Тромбоз воротной вены при циррозе печени. Часть 2: лечение, первичная и вторичная профилактика

В большинстве случаев тромбоз воротной вены прогрессирует без лечения, спонтанная реканализация воротной вены развивается у 42 % больных циррозом печени. Существующие стратегии лечения включают назначение антикоагулянтов, проведение интервенционных мероприятий, таких как трансъюгулярное внутрипеченочное портосистемное шунтирование или эндоваскулярный фибринолиз. Антикоагулянтная терапия имеет определенные трудности у пациентов с циррозом печени из-за сложного профиля гемостаза, склонности как к геморрагиям, так и к гиперкоагуляции. Помимо традиционных антикоагулянтов (препараты гепарина, фондапаринукс, антагонисты витамина К) в последние годы при тромбозе воротной вены широко используются прямые оральные антикоагулянты. Ранее тромбоз воротной вены считался противопоказанием к выполнению трансъюгулярного внутрипеченочного портосистемного шунтирования, в настоящее время метод часто применяется с целью восстановление портального кровотока через шунт и предотвращения повторного тромбоза. Эндоваскулярный фибринолиз по-прежнему остается опцией специализированных центров для «сложных» больных. В случаях повышенного риска венозных тромбоэмболий пациентам с циррозом печени рекомендуется профилактика препаратами низкомолекулярного гепарина или прямыми оральными антикоагулянтами, однако дальнейшие исследования должны уточнить их эффективность в этом аспекте. В обзоре освещены данные об особенностях терапии, первичной и вторичной профилактики тромбоза воротной вены у больных циррозом печени. Несмотря на существующие клинические рекомендации по ведению больных цирротическим тромбозом воротной вены, выбор той или иной стратегии, прежде всего, зависит от индивидуализированной оценки рисков и преимуществ каждого из методов лечения.

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