Usage of Direct Acting Oral Anticoagulants in Cirrhotic and Non-Cirrhotic Portal Vein Thrombosis: A Systematic Review.

Sachin Gupta,Yang Yang,Sorab Gupta,Sandeep Singh,Alexandra Short,Aditya Iyer,Jessica Hidalgo,Harshil Bhatt,Balraj Singh

doi:10.7759/cureus.16922

Abstract

Thrombosis of the portal vein (PVT) is generally seen in the setting of liver cirrhosis and to a lesser extent in the absence of cirrhosis. There is no clear guidance in relation to approaching treatment with anticoagulation in this condition. The professional societies and guidelines recommend treatment with traditional anticoagulation like low-molecular-weight heparin and vitamin-K antagonists in patients presenting with acute portal vein thrombosis. There is no clarity in relation to treatment in the setting of chronic PVT and in patients with cirrhosis. Also, the role of direct-acting oral anticoagulants (DOACs) that are becoming a preferred choice for anticoagulation for various other indications is not clear in the case of PVT. There are a very few studies in the medical literature that have investigated the role of DOACs in patients with PVT in different settings. Thus, we performed a systematic review of the literature to study the use of DOACs in PVT in patients with and without cirrhosis. The results of the available studies show that DOACS appears to be a promising choice for the treatment of patients with PVT. The availability of more data in the future along with better availability of the approved reversal agents for various DOACs is expected to make DOACS a preferred choice for the clinicians to treat patients with PVT.

Highlights

BackgroundThrombosis of the portal vein (PVT) is common in patients with cirrhosis with prevalence ranging from 5% to 24% in studies that utilized ultrasonography to 6-64% in autopsy series [1]
The new guidelines and published expert opinions have remained conservative regarding the use of direct-acting oral anticoagulants (DOACs), advising continued reliance on low molecular weight heparin (LMWH) and vitamin K antagonists
A study using a large database suggests that anticoagulation increases the chances of bleeding in patients with cirrhosis and PVT but in general newer anticoagulants have a lower incidence of bleeding compared to traditional anticoagulants like warfarin and LMWH [20]

Summary

Introduction

Thrombosis of the portal vein (PVT) is common in patients with cirrhosis with prevalence ranging from 5% to 24% in studies that utilized ultrasonography to 6-64% in autopsy series [1]. Besides inherited or acquired prothrombotic states which are the major risk factors for PVT in both patients with previously healthy liver and cirrhosis [4,5,6,7], other risk factors include primary and secondary hepatobiliary malignancies, intra-abdominal infectious or inflammatory diseases, and myeloproliferative disorders [8]. Patients with acute onset of PVT may have sudden onset of partial or complete occlusion of the portal vein leading to presentation with a wide spectrum from being silent or mild abdominal pain to catastrophic events like variceal bleeding and intestinal ischemia and infarction [9]. As patients with chronic PVT generally develop collateral blood vessels bypassing the area of obstruction such patients are generally asymptomatic and discovered incidentally or may present with symptoms and sequelae related to chronic complications of chronic PVT including portal hypertension and portal cholangiopathy [10,11,12]

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