Anticoagulant therapy for splanchnic vein thrombosis: recent updates for patients with liver cirrhosis

ABSTRACT

Introduction

Liver cirrhosis is accompanied by several hemostatic alterations, which contribute to the current theory of “rebalanced hemostasis.” Splanchnic vein thrombosis (SVT) is a frequent complication of liver cirrhosis (17–26% of the cirrhotic patients), and liver cirrhosis is a common risk factor for SVT (24–28% of SVT cases).

Areas covered

This narrative review aims to describe the current state of the art on the anticoagulant treatment of cirrhotic SVT, with a particular focus on the possible role of the direct oral anticoagulants (DOACs) and recent guidelines on this topic.

Expert opinion

Early anticoagulant therapy is recommended in cirrhotic patients with acute SVT, to obtain vessel recanalization and decrease the rates of portal hypertension-related complications. Gastroesophageal varices do not represent a contraindication to anticoagulation, if adequate prophylaxis of variceal bleeding is established, and varices band ligation can be safely performed without the need to stop the anticoagulant treatment. The conventional treatment of cirrhotic SVT consisted of low molecular weight heparin, as initial treatment of choice, eventually followed by vitamin K antagonists, but the DOACs can be considered as a reasonable alternative in patients with compensated liver cirrhosis.

KEYWORDS:

• Direct Oral Anticoagulants
• Liver Cirrhosis
• Low Molecular Weight Heparin
• Splanchnic vein thrombosis
• Venous thromboembolism
• Vitamin K Antagonists

Article highlights

• Splanchnic vein thrombosis (SVT) occurs frequently in patients with liver cirrhosis.

• Early anticoagulation is recommended in cirrhotic patients with acute SVT. A cautious risk-benefit evaluation is required.

• The use of direct oral anticoagulants (DOACs) in cirrhotic patients is slowly increasing in clinical practice.

• Emerging evidence suggests the DOACs as a reasonable alternative in patients with compensated liver cirrhosis.

Declaration of interest

W Ageno reports research support from Bayer Healthcare and participation in advisory boards for Bayer Healthcare, BMS-Pfizer, Leo Pharma, Norgine, Sanofi, and Viatris. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.