Anticoagulant therapy for splanchnic vein thrombosis: an individual patient data meta-analysis

Abstract

Robust evidence on the optimal management of splanchnic vein thrombosis (SVT) is lacking. We conducted an individual patient meta-analysis to evaluate the effectiveness and safety of anticoagulation for splanchnic vein thrombosis (SVT). MEDLINE, EMBASE, and clincaltrials.gov., were searched up to June 2021 for prospective cohorts or randomized clinical trials including patients with SVT. Data from individual datasets were merged, and any discrepancy with published data was resolved by contacting study authors. Three studies for a total of 1635 patients were included. Eighty-five percent of patients received anticoagulation for a median duration of 316 days (range 1 to 730 days). Overall, incidence rates for recurrent VTE, major bleeding, and mortality were 5.3/100 patients-years (p-y) (95% CI, 5.1 to 5.5), 4.4/100 p-y (95% CI, 4.2 to 4.6), and 13.0/100 p-y (95% CI, 12.4 to 13.6), respectively. The incidence rates of all outcomes were lower during anticoagulation and higher after treatment discontinuation or when anticoagulation was not administered. In multivariable analysis, anticoagulant treatment appeared to be associated with a lower risk of recurrent VTE (Hazard Ratio [HR] 0.42; 95% CI, 0.27 to 0.64), major bleeding (HR 0.47; 95% CI, 0.30 to 0.74), and mortality (HR 0.23; 95% CI, 0.17 to 0.31). Results were consistent in patients with cirrhosis, solid cancer, myeloproliferative neoplasms, unprovoked SVT, and SVT associated with transient or persistent non-malignant risk factors. In patients with SVT the risk of recurrent VTE and major bleeding is substantial. Anticoagulant treatment is associated with reduced risk of both outcomes.

A 10-year Australian experience of rare intraabdominal venous thrombosis with comparison to deep vein thrombosis and pulmonary embolism

“…In our study, cirrhotic patients were more likely to receive no anticoagulation compared to noncirrhosis patients with a nonsignificant shorter median duration of anticoagulation (3.0 vs. 6.0 months, P = 0.13). This finding is consistent with a recent meta-analysis by Candeloro et al [30], which found a nonnegligible proportion of patients with SVT being untreated (15%) or under-treated. Importantly, cirrhotic patients had a higher composite rate of VTE recurrence and clot progression compared to noncirrhotic patients (HR 4.7, 95% CI 1.2–18.9, P = 0.030) with no significant differences in clinically significant major bleeding rates (HR 3.5, 95% CI 0.5–26.0, P = 0.22).…”

“…An increasingly important clinical question given the widespread use of DOAC is the safety of DOAC in SVT treatment. Early data suggests that DOAC may be safe [1,27–30], with one randomized controlled trial showing rivaroxaban to be more effective and safer than VKA in cirrhosis-related PVT [29]. Eighteen patients (including five patients with cirrhosis) were treated with DOAC in this study, none of which reported thrombotic or bleeding complications while on anticoagulation although there is a potential for selection bias.…”

“…This suggests that selective extension of anticoagulation with careful assessment of bleeding and recurrence risk may be a prudent strategy. It has been postulated by several studies [30,35,36] that risk of bleeding complications may be reduced in anticoagulated patients through venous recanalization decreasing intravascular pressure in the splanchnic circulation.…”

Acute mesenteric ischemia secondary to superior mesenteric vein thrombosis in a patient with liver cirrhosis: A case report

“…[3] The optimal type and dose of anticoagulant therapy for splanchnic venous thrombosis remain uncertain, as most evidence is primarily based on observational studies. [4] In cases of reversible etiology, it is recommended to continue anticoagulation for 3 to 6 months, whereas for underlying thrombophilia, anticoagulation should be indefinite. [5] Meta-analyses have shown comparable low bleeding risk for vitamin K antagonists, LMWH, and direct oral anticoagulants.…”

Acute Mesenteric Ischemia Secondary to Superior Mesenteric Vein Thrombosis

“…Another study reported that 80% of patients with splanchnic vein thrombosis (SVT) were treated with anticoagulants, of which treatment with LMVH and vitamin K antagonists accounted for 31.9% and 25.4% of cases, respectively. Direct oral anticoagulants (DOAC) were used in only 1.7% of cases [ 7 ].…”