Outcomes of long‐term anticoagulant treatment for the secondary prophylaxis of splanchnic venous thrombosis

Abstract

Background Splanchnic vein thrombosis (SVT) is an uncommon but potentially life‐threatening disease usually related to different underlying clinical conditions. The risk of SVT recurrences is high over time in patients with an underlying permanent prothrombotic condition. Vitamin K antagonists (VKA) represent the mainstay of treatment for SVT. Data about the efficacy and safety of direct oral anticoagulants (DOACs) are reported in the literature for the treatment of acute SVT, but less is known about their application for the secondary prophylaxis of venous thromboembolism (VTE). The aim of this study was to assess the efficacy and safety of long‐term DOACs therapy in patients at high‐risk of thrombosis, compared to VKA. Methods This is a retrospective single‐centre study including 70 patients with SVT on long‐term anticoagulant treatment with VKA followed‐up at our Units between January 2017 and December 2019. All the patients were at high thrombotic risk defined as the presence of a permanent prothrombotic condition requiring long‐term anticoagulation. During follow‐up, 28 patients were shifted to DOACs and their clinical outcomes were compared to those of the patients who continued VKA therapy. All the arterial and venous thrombotic events of the splanchnic and extra‐splanchnic districts as well as the haemorrhagic adverse events occurring during follow‐up were recorded. Results Of the seventy patients enrolled in the study, 36 patients (51.4%) had a single‐segment involvement thrombosis (28.5% of portal vein, 7.1% of superior mesenteric vein, 4.3% of splenic vein, 11.5% of hepatic veins) and 34 patients (48.6%) had multi‐segment involvement at the time of diagnosis. 42 patients (60%) continued VKA therapy and 28 (40%) were switched to DOACs. Median follow‐up was 6 years (range 2‐8) during VKA and 1.9 years (range 1‐5.2) during DOACs. The incidence of thrombotic events was similar between patients on VKA and those on DOACs. Patients on VKA developed deep vein thrombosis (DVT), and of the patients on DOACs 1 developed NSTEMI and 1 DVT. No major haemorrhagic events occurred. Minor bleedings occurred in 26% of patients on VKA and in none of the DOACs patients (P: 0.09). Conclusions Our results highlight that DOACs could represent an effective and safe alternative to the VKA for secondary prophylaxis in SVT patients at high risk of thrombosis.

Real-life experience of secondary prophylaxis with DOACs in splanchnic venous thrombosis during COVID-19 pandemic

“…The second patient, a 38-year-old female without known risk factors and with no evidence of cavernomatosis and esophageal varices, presented a recurrence of portal vein thrombosis 2 years and 5 months after the resolution of the previous one. In literature, several retrospective reports stated the feasibility of DOAC treatment in SVT [ 3 , 4 ], but only one report so far, by Serrao et al [ 5 ], in a cohort of 70 patients, described a safety and efficacy profile not inferior to VKA in long-term prophylaxis, obtaining results similar to ours.

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The effect of venoplasty and stent implantation in patients with chronic venous symptoms following deep vein thrombosis in iliofemoral segment

“…The overall results of DVT as a disorder of venous physiology are highly dependent on the anatomical position of the thrombosed venous segment [20,28,29]. In recent years, the therapies of acute DVT have become more widespread, but there is still much debate about the priority of treatment in terms of the lowest risk and the best prevention of complications [30]. PTS is still a recurring complication in DVT and leads to significant complications, suffering, and high health costs [17].…”

Evidence-Based Minireview: Should warfarin or a direct oral anticoagulant be used in patients presenting with thrombosis in the splanchnic or cerebral veins?

“…12 Riva and Ageno 9 sum ma rize most of the remaining evi dence reporting on the use DOACs in SVT, which con sists mostly of small obser va tional tri als, the major ity ret ro spec tive in nature. Serrao et al 13 describe a recent pro spec tive study of 28 patients with SVT and ongo ing risk fac tors maintained on chronic treatment with war fa rin who were switched to DOACs and com pared out comes to 42 patients remaining on war fa rin. There was no dif fer ence in throm botic events between the groups.…”

“…No major bleed ing events occurred in either group, while minor bleed ing did not occur in the DOAC group but was documented in 26% of war fa rin-treated patients (P = .09). 13 In the larg est of the ret ro spec tive tri als, Naymagon et al 14 in Blood Advances reported on 93 patients with noncirrhotic portal vein treated with apixaban (n = 20), rivaroxaban (n = 65), and dabigatran (n = 8) com pared with low molec u lar weight hep a rin (LMWH) (n = 70) and war fa rin (n = 108). 14 Seventy-three per cent of patients had predisposing fac tors for PVT.…”