Anticoagulation Favors Thrombus Recanalization and Survival in Patients With Liver Cirrhosis and Portal Vein Thrombosis: Results of a Meta-Analysis

Abstract

Introduction: Benefit and risk of anticoagulation in cirrhotic patients with portal vein thrombosis (PVT) remain controversial, especially in those with asymptomatic PVT and in non-liver transplant candidates. Furthermore, the predictors of portal vein recanalization and bleeding events after anticoagulation are critical for making clinical decisions, but still unclear. We conducted a meta-analysis to investigate the outcomes of anticoagulation for PVT in liver cirrhosis and explore the predictors of portal vein recanalization and bleeding events after anticoagulation. Methods: All studies regarding anticoagulation for PVT in liver cirrhosis were searched via PubMed, EMBASE, and Cochrane Library databases. Thrombotic outcomes, bleeding events, and survival were compared between anticoagulation and non-anticoagulation groups. Predictors of portal vein recanalization and bleeding events were pooled. Risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (CIs) were calculated. Results: Thirty-three studies including 1696 cirrhotic patients with PVT were included. Anticoagulation significantly increased portal Electronic supplementary material The online version of this article (

Controversies in the Management of Portal Vein Thrombosis in Liver Cirrhosis

“…Indeed, if the benefit-to-risk ratio of anticoagulation therapy in other contexts, such as atrial fibrillation, was evaluated in trials that included several thousand patients, the results differed [26][27][28][29][30][31][32][33][34][35]. Similar results and limitations were recently reported in a systematic review with a meta-analysis from China [24]. The above data cast doubt on the negative role of PVT in the natural history of cirrhosis.…”

“…Recently, a meta-analysis of 33 studies, which included 1696 cirrhotics, reported that anticoagulation (AC) therapy significantly improved overall survival without influencing overall bleeding [24]. However, the surveyed studies included heterogeneous populations and were predominantly retrospective; some were presented only in an abstract form, and none were randomized or controlled.…”

“…However, the surveyed studies included heterogeneous populations and were predominantly retrospective; some were presented only in an abstract form, and none were randomized or controlled. In the absence of randomization, combining data from cohorts in which the primary option was treatment with those in which it was no treatment exacerbates the risk of bias in the selection of patients [24].…”

Treatment of direct oral anticoagulants in patients with liver cirrhosis and portal vein thrombosis

“…54 A recent meta-analysis of 33 studies (n=1,696 patients with cirrhotic PVT who received conventional anticoagulants) reported that decompensated cirrhosis may be associated with lower PV recanalization rates in patients who are administered anticoagulants. 55 Early anticoagulation initiation (risk ratio [RR] 1.58, 95% CI 1.21-2.07, P<0.001) significantly increased PV recanalization. Furthermore, decompensated cirrhosis (RR 0.77, 95% CI 0.62-0.95, P=0.02) and higher MELD scores (mean difference -1.48, 95% CI -2.20-0.76, P<0.001) were significantly associated with low PV recanalization rates.…”

“…Furthermore, decompensated cirrhosis (RR 0.77, 95% CI 0.62-0.95, P=0.02) and higher MELD scores (mean difference -1.48, 95% CI -2.20-0.76, P<0.001) were significantly associated with low PV recanalization rates. 55 Bleeding, one of the most common complications of anticoagulation therapy, occurred in 5% of patients with cirrhosis and PVT who received anticoagulants. 54 A meta-analysis of six studies that included 257 patients with cirrhosis and PVT reported no difference in total bleeding rates between the anticoagulation and no-anticoagulation groups (11% in both groups).…”