[Special features of anticoagulant treatment in vascular liver diseases]

Anticoagulants play a major role in the management of vascular liver diseases (VLD). However, their use is challenging due to portal hypertension and thrombocytopenia, frequently observed in these conditions. Moreover, when the disease is associated with hepatic insufficiency, hemostatic abnormalities further complicate the use of anticoagulants. Finally, in cases of digestive resection following mesenteric ischemia, the absorption and pharmacokinetics of oral anticoagulant therapies raise numerous concerns. The benefit-risk balance regarding bleeding and thrombosis must therefore be carefully assessed. Nevertheless, anticoagulant therapy in VLD is crucial to prevent thrombus extension, improve recanalization, and reduce the risk of severe complications such as portal hypertension and mesenteric ischemia. It must be initiated as early as possible. Acute-phase treatment generally relies on low-molecular-weight heparin (LMWH), switch to Direct oral anticoagulants (DOACs) are increasingly used, however, vitamin K antagonists (VKAs) remain indicated in certain situations. Screening and management of esophageal varices should be systematic when initiating and managing anticoagulant therapy. Thrombocytopenia is most often moderate and should not lead to modification or discontinuation of anticoagulation. Severe thrombocytopenia < 50 G/L requires close monitoring and management in a specialized center. In Budd-Chiari syndrome, hepatic insufficiency may lead to reduced synthesis of coagulation factors as well as major coagulation inhibitors, allowing a degree of rebalancing of the hemostatic system. Prolonged coagulation times (aPTT) and decreased PT do not accurately reflect these changes and should not contraindicate or delay anticoagulant therapy. Women of childbearing age must be informed of the risks associated with anticoagulant therapy during pregnancy and breastfeeding. Menorrhagia is common and may require appropriate management. All patients should participate in a treatment education program, enabling them to understand the characteristics and risks of their treatment.