Portal vein thrombosis: yes or no on anticoagulation therapy

To describe portal vein thrombosis (PVT) in the setting of cirrhosis especially in relation to its potential impact on liver transplantation. In addition, the safety and efficacy of anticoagulation is reviewed.

PVT in cirrhosis occurs in up to 26% of patients awaiting liver transplantation. Different studies have suggested that PVT impacts negatively post-liver transplantation survival, particularly in first year post-liver transplantation and when PVT is complete involving the porto-mesenteric confluence and not allowing physiological anastomosis. Anticoagulation is effective in preventing PVT progression and may achieve partial or complete PVT recanalization. Its use in patients with cirrhosis seems not to be associated with increased bleeding risk.

The goal of anticoagulation is to prevent thrombus extension to the superior mesenteric vein and/or favor recanalization if previously affected, allowing physiological anastomosis during liver transplantation and therefore improving outcome. Low-molecular-weight heparin and vitamin K antagonist have a similar safety profile without specific data in favor of any of them. Treatment with direct anticoagulants cannot be recommended yet because of limited experience in cirrhosis. Transjugular intrahepatic portosystemic shunt could be an alternative particularly if thrombosis progresses despite satisfactory anticoagulation and/or when PVT is associated with severe portal hypertension complications. However, careful consideration of potential risks and benefits of anticoagulation is recommended until further studies are conducted.