Recent guidelines on the treatment of splanchnic vein thrombosis in cirrhotic patients
| Guideline (year) . | Indication . | Timing . | Drug . | Duration . |
|---|---|---|---|---|
| AASLD (2020)6 | • Anticoagulation is essential in recent PVT and concern for intestinal ischemia • In cirrhotic patients with PVT without ischemic symptoms, consider treatment on a case-by-case basis • Cirrhotic patients with recent thrombosis of small intrahepatic subbranches of PV or minimally occlusive thrombosis of the main PV (<50% lumen): observation with serial imaging is reasonable; anticoagulant treatment if clot progression • Cirrhotic patients with recent occlusive or partially occlusive thrombosis of the main PV (>50% lumen): antithrombotic therapy should be considered | • Anticoagulation should be initiated as soon as possible (not delayed until variceal eradication or adequate beta-blockade is achieved) | • Choice of anticoagulant drug (LMWH, VKA, DOAC) should be individualized, in consultation with a hematologist and/or hepatologist • Limited data on DOAC, use with caution in cirrhotic patients with advanced portal hypertension | Not mentioned |
| ACG (2020)22 | • Anticoagulation recommended for: ○ acute complete main PVT ○ MVT ○ PVT extension into MV • Risk of bleeding must be weighted against benefits (eg, low platelet counts <50 × 109/L, or hepatic encephalopathy at risk of falls) | • Initiation of anticoagulation delayed if active bleeding | • Initial treatment with UFH or LMWH • UFH preferred if renal insufficiency • LMWH preferred if thrombocytopenia • Maintenance with oral anticoagulants or LMWH • Limited experience with DOAC | • 6 months for cirrhotic patients with acute PVT or MVT • Continue beyond 6 months in patients on the waiting list for liver transplant |
| ISTH (2020)23 | • Anticoagulation recommended for cirrhotic patients with SVT, if no active bleeding or other contraindications | • Early anticoagulant treatment | • Start with therapeutic dose LMWH • Switch to VKA or DOAC, if not contraindicated by severe liver dysfunction • Reduced doses of LMWH or DOAC may be used for longer/indefinite duration | • At least 3-6 months • Longer or indefinite duration if: ○ thrombosis progression ○ recurrence after anticoagulant discontinuation ○ unprovoked SVT ○ persistent risk factors |
| AGA (2021)25 | • Anticoagulation suggested for cirrhotic patients with acute or subacute nontumoral PVT | Not mentioned | • No data to support the use of 1 anticoagulant over another | Not mentioned |
| Baveno VII (2022)24 | • Anticoagulation recommended in cirrhotic patients with: ○ recent complete or partial occlusion (>50%) of the PV trunk ○ symptomatic PVT ○ PVT in candidates for liver transplant • Anticoagulation should be considered in cirrhotic patients with minimally occlusive (<50%) thrombosis of the PV trunk if: ○ thrombus progression at 1-3 months follow-up ○ involvement of superior MV • Case-by-case basis if low platelet count (<50 × 109/L) | Not mentioned | • Initial treatment with LMWH • Maintenance with LMWH, VKA, DOAC • Monitoring VKA can be challenging in cirrhotic patients • Regarding DOAC: ○ no major safety concern with Child-Pugh A; ○ use with caution in Child-Pugh B for possible accumulation; ○ not recommended in Child-Pugh C | • Anticoagulation should be: ○ maintained for at least 6 months and until PV recanalization; ○ continued after recanalization in candidates for liver transplant; ○ considered after recanalization in all patients, balancing risks and benefits |
| Guideline (year) . | Indication . | Timing . | Drug . | Duration . |
|---|---|---|---|---|
| AASLD (2020)6 | • Anticoagulation is essential in recent PVT and concern for intestinal ischemia • In cirrhotic patients with PVT without ischemic symptoms, consider treatment on a case-by-case basis • Cirrhotic patients with recent thrombosis of small intrahepatic subbranches of PV or minimally occlusive thrombosis of the main PV (<50% lumen): observation with serial imaging is reasonable; anticoagulant treatment if clot progression • Cirrhotic patients with recent occlusive or partially occlusive thrombosis of the main PV (>50% lumen): antithrombotic therapy should be considered | • Anticoagulation should be initiated as soon as possible (not delayed until variceal eradication or adequate beta-blockade is achieved) | • Choice of anticoagulant drug (LMWH, VKA, DOAC) should be individualized, in consultation with a hematologist and/or hepatologist • Limited data on DOAC, use with caution in cirrhotic patients with advanced portal hypertension | Not mentioned |
| ACG (2020)22 | • Anticoagulation recommended for: ○ acute complete main PVT ○ MVT ○ PVT extension into MV • Risk of bleeding must be weighted against benefits (eg, low platelet counts <50 × 109/L, or hepatic encephalopathy at risk of falls) | • Initiation of anticoagulation delayed if active bleeding | • Initial treatment with UFH or LMWH • UFH preferred if renal insufficiency • LMWH preferred if thrombocytopenia • Maintenance with oral anticoagulants or LMWH • Limited experience with DOAC | • 6 months for cirrhotic patients with acute PVT or MVT • Continue beyond 6 months in patients on the waiting list for liver transplant |
| ISTH (2020)23 | • Anticoagulation recommended for cirrhotic patients with SVT, if no active bleeding or other contraindications | • Early anticoagulant treatment | • Start with therapeutic dose LMWH • Switch to VKA or DOAC, if not contraindicated by severe liver dysfunction • Reduced doses of LMWH or DOAC may be used for longer/indefinite duration | • At least 3-6 months • Longer or indefinite duration if: ○ thrombosis progression ○ recurrence after anticoagulant discontinuation ○ unprovoked SVT ○ persistent risk factors |
| AGA (2021)25 | • Anticoagulation suggested for cirrhotic patients with acute or subacute nontumoral PVT | Not mentioned | • No data to support the use of 1 anticoagulant over another | Not mentioned |
| Baveno VII (2022)24 | • Anticoagulation recommended in cirrhotic patients with: ○ recent complete or partial occlusion (>50%) of the PV trunk ○ symptomatic PVT ○ PVT in candidates for liver transplant • Anticoagulation should be considered in cirrhotic patients with minimally occlusive (<50%) thrombosis of the PV trunk if: ○ thrombus progression at 1-3 months follow-up ○ involvement of superior MV • Case-by-case basis if low platelet count (<50 × 109/L) | Not mentioned | • Initial treatment with LMWH • Maintenance with LMWH, VKA, DOAC • Monitoring VKA can be challenging in cirrhotic patients • Regarding DOAC: ○ no major safety concern with Child-Pugh A; ○ use with caution in Child-Pugh B for possible accumulation; ○ not recommended in Child-Pugh C | • Anticoagulation should be: ○ maintained for at least 6 months and until PV recanalization; ○ continued after recanalization in candidates for liver transplant; ○ considered after recanalization in all patients, balancing risks and benefits |
AASLD, American Association for the Study of Liver Diseases; ACG, American College of Gastroenterology; AGA, American Gastroenterological Association; DOAC, direct oral anticoagulant; INR, international normalized ratio; ISTH, International Society on Thrombosis and Haemostasis; LMWH, low-molecular-weight heparin; MV, mesenteric vein; MVT, mesenteric vein thrombosis; PV, portal vein; PVT, portal vein thrombosis; SVT, splanchnic vein thrombosis; UFH, unfractionated heparin; VKA, vitamin K antagonist; VTE, venous thromboembolism.