Clinical Impact and Safety of Anticoagulants for Portal Vein Thrombosis in Cirrhosis

Abstract

Objectives: Portal vein thrombosis (PVT) is a frequent complication of cirrhosis. Benefit, safety, and duration of anticoagulant treatment in this setting are controversial issues. The aim of this study was to analyze the course of PVT in a large cohort of cirrhotic patients undergoing or not anticoagulation therapy. Methods: The data of 182 patients who presented between January 2008 and March 2016 with cirrhosis and PVT with at least 3 months of follow-up after the first PVT detection were analyzed. Eighty-one patients received anticoagulants and 101 were untreated per physician discretion. Results: The extension of the thrombosis decreased by >50% in 46 (56.8%, with complete recanalization in 31/46) patients under anticoagulation and in 26 (25.7%) untreated patients. Of the 46 patients who underwent recanalization, 17 (36%) suffered recurrent thrombosis after stopping anticoagulation therapy. Kaplan–Meier analysis showed a higher survival rate in the treated group (p = 0.010). At multivariate analysis, anticoagulation was an independent factor associated with longer survival (HR:0.30, CI:0.10–0.91, p = 0.014). The Child–Turcotte–Pugh classes B/C negatively influenced survival (hazard ratio, (HR):3.09, confidence interval (CI):1.14–8.36, p = 0.027 for Child–Turcotte–Pugh B and HR:9.27, CI:2.67–32.23, p < 0.001 for Child–Turcotte–Pugh C). Bleeding complications occurred in 22 (21.8%) untreated and 16 (19.7%) treated patients, but in only four cases was it judged to be related to the anticoagulant treatment. No death was reported as a consequence of the bleeding events. Conclusions: Anticoagulant treatment is a safe and effective treatment leading to partial or complete recanalization of the portal venous system in 56.8% of cases, improving the survival of patients with cirrhosis and PVT. Discontinuation of the therapy is associated with a high rate of PVT recurrence.

Recent developments in the field of vascular liver diseases

“…34 Finally, an increasing number of studies have evaluated the most important issue, which is the impact of recanalization on survival and the need for liver transplantation. None of these studies except one 28 found any influence, 29,30,32,35,64,67 although univariate analyses often suggested that recanalization was favourable. On the other hand, several studies have suggested that anticoagulation therapy has an independently positive effect, regardless of recanalization or the severity of liver disease.…”

“…Results on analyses to identify predictors for recanalization on anticoagulation therapy have been varied. The delay in initiating anticoagulation is the only consistent factor …”

“…Not surprisingly multivariate analyses in these retrospective observational studies showed significant differences between patients who received anticoagulants and those who did not. In particular, a lower proportion of past variceal bleeding or cavernoma, lower blood urea levels, a smaller proportion of alcoholics, severe liver disease or cavernoma were found as well as an increased proportion of women or non‐specific beta‐blockers and a higher proportion of involvement of the superior mesenteric vein or multiple venous sites . These factors were not taken into account in the 2017 meta‐analysis …”

“…The delay in initiating anticoagulation is the only consistent factor. [30][31][32][34][35][36] Two low-powered studies evaluated recurrence after spontaneous resolution, which was found to occur in 9 out of 20 patients 12 and 19 out of 89 patients 13…”

“…Since this paper was published, a dozen, mainly retrospective studies have been published, largely confirming these findings in a total of 653 patients receiving anticoagulation, and including 312 patients who received anticoagulants compared to 251 patients who did not. [28][29][30][31][32]35,[64][65][66][67] These recent studies show the high risk of recurrence following discontinuation of anticoagulation (43% in 219 patients at risk). Even more interestingly, these studies provide data on additional points that are important for the interpretation of mainly morphological data.…”