4 Indeed,

in the present extended EN-Vie study, surviving patients were followed up more than 3 additional years, and during this additional period, 8 patients received TIPS, 2 OLT, and 7 died. Thus, the present study was able to evaluate long-term outcome of BCS patients (median follow-up of almost 5 years, with a minimum of 43 months). Our updated data confirm that, in Western countries, a step-wise therapeutic strategy confers good long-term survival in patients with BCSurvival score. Most of our patients (88.5%) received long-term anticoagulation. Interestingly enough, the rate of bleeding complications in patients receiving anticoagulation was lower than that previously reported.15 This is most likely the result of more adequate prevention of PH complications as well as careful management of anticoagulation during selleck chemicals invasive procedures.15 Only 22 patients (14%) underwent angioplasty/thrombolysis as primary invasive therapy, and only 8 of them did not require further intervention, such as TIPS, surgical shunt, and/or OLT. It seems that angioplasty/stenting, although an attractive, minimally invasive technique with the potential of

restoring physiological sinusoidal flow, has low applicability in the treatment of our BCS patients. These results contrast with a recent retrospective study from China showing a great applicability and efficacy of angioplasty/stenting in a large cohort of patients with BCS.16 In our opinion, these differences could be most likely explained by different pathogenic mechanisms of hepatic venous outflow obstruction,8 because hepatic vein stenoses are less frequent in the Western world than in Eastern countries. Therefore, angioplasty/stenting remains a potentially valuable treatment of the BCS subtype with short-length stenosis and investigation of the patients’ suitability for this approach is mandatory, because the benefits are Thalidomide potentially significant. Strikingly, no additional patient

received a surgical shunt during the extended follow-up period, and thus only 3 patients (2%) received this therapeutic modality. TIPS has emerged as the preferred derivative treatment in Europe. The fact that two recent small retrospective studies from North America have shown excellent outcomes of BCS patients after surgical shunts does, in our opinion, not change the trend in current practice to prefer less-invasive over more-invasive procedures.17, 18 Moreover, we would like to emphasize that previous multicenter retrospective studies were unable to demonstrate a solid survival advantage in BCS patients treated with surgical shunts.7, 19-22 The low number of patients treated with surgical shunting in our data set precludes shedding more light on this issue. Sixty-two patients required TIPS as rescue therapy after failures of medical or minimally invasive treatments (angioplasty/stenting/thrombolysis).