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Page 8 of 13 Yang et al. Hepatoma Res 2020;6:37 I http://dx.doi.org/10.20517/2394-5079.2020.09

splenectomy for cirrhosis does not increase the risk of postoperative bleeding and can effectively prevent
PVT. At the same time, antiplatelet drugs should be used until PLT has fallen to normal levels. The specific
application methods are described as follows. Anticoagulation should be applied at 72 h after surgery for
safety concerns. Either LMWH-calcium or LMWH-sodium can be used. Taking enoxheparin (0.4 mL,
4000 AXa IU, ih, qd) as an example, the duration of treatment is 5 days. After discontinuation of enoxaparin,
oral warfarin is used for continuous anticoagulation for 6 months. INR should be maintained between 2
9
and 3. When platelets exceed 400 × 10 /L, antiplatelet drugs, such as aspirin, ticlopidine or dipyridamole
should be used. After the platelets have returned to normal values, they should be discontinued. PLT and
coagulation states of patients should be monitored every other day in the first week, and then monthly in
the first year after surgery. Color Doppler ultrasound should be repeated monthly in the first year. It is worth
noting that for PVT patients with mild to moderate renal dysfunction, the dose of enoxaparin should be
halved, and liver and kidney function should be closely monitored. In patients with severe renal dysfunction
or renal failure, enoxaparin must be used with caution according to the specific situation.

[41]
Warfarin inhibits the synthesis of vitamin K-dependent coagulation factors II, VII, IX, and X . Studies have
shown that prophylactic anticoagulation is effective and safe in patients undergoing splenectomy, and that
warfarin is effective in patients undergoing LS [41,97] . But warfarin can also inhibit the synthesis of proteins C
[98]
and S, and thus, it has the potential to increase thrombosis . Rivaroxaban and Dabigatran are approved for
clinical use, and these drugs are widely used since there is no need for dose adjustment. Rivaroxaban has
been successfully used to treat PVT according to some reports [99,100] . Studies have shown that for patients
with cirrhosis, the anticoagulant effect of dabigatran is very considerable, while the anticoagulant effect of
rivaroxaban is slightly weaker [101] .

However, some researchers warn that considering that the rethrombosis rate after anticoagulation therapy
is still high (52%), long-term anticoagulation should be applied more carefully [102] . At present, most of the
research on the prevention of PVT focuses on LMWH because it has a good anticoagulant effect, but to date,
there is no uniform standard for applying LMWH to PVT [103] .

Surgery and interventional treatment
For PVT after splenectomy, when non-invasive treatment of thrombosis fails and causes portal vein stenosis,
invasive treatment can be considered: surgery and interventional treatment.

Surgical treatments are mostly performed with clear serious complications, but there is still no unified
standard for the indications, surgical choices, contraindications and complications of surgery. There are three
main types of interventional therapies for PVT: TIPS, percutaneous transhepatic portal vein thrombolysis or
thrombectomy. One of the most common treatments is TIPS, where it can improve portal vein hemodynamics
and dissolve fluid clot [104] . Portal vein flow increases more than 5 times after TIPS [105] . Moreover, PVT can
also be treated directly by intravascular techniques (balloon angioplasty, stent placement, thrombectomy,
[106]
and thrombolytic drugs) when the catheter is inserted into the portal vein . TIPS can play an active role
[107]
in resolving portal hypertension and preventing the recurrence of blood clots by creating venous shunts .
Portal recanalization can be achieved in 87% to 100% of patients by TIPS [106,108] . However, the timing of TIPS
treatment is a tough issue. A complete occlusion of the thrombus will significantly increase the technical
[109]
difficulty and surgical risk of TIPS . Futher studies are required to solve this problem.

In addition, some researchers have proposed autologous spleen transplantation combined with esophageal
transection anastomosis to treat cirrhotic portal hypertension. After 2 months of operation, patients with
autologous spleen transplantation had significantly higher levels of tuftsin and IgM than splenectomy patients,
and there was no significant difference in liver function, which proves that autologous spleen transplantation
combined with esophageal transection anastomosis is a safe and effective treatment strategy for the treatment