Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Dec 18, 2015; 7(29): 2906-2912
Published online Dec 18, 2015. doi: 10.4254/wjh.v7.i29.2906
Therapeutic and clinical aspects of portal vein thrombosis in patients with cirrhosis
Massimo Primignani, Giulia Tosetti, Vincenzo La Mura
Massimo Primignani, Giulia Tosetti, U.O. Gastroenterologia ed Epatologia, IRCCS-Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milano, Italy
Vincenzo La Mura, U.O. Medicina Interna, IRCCS-San Donato, Dipartimento di Scienze Biomediche per la Salute, Università degli studi di Milano, 20097 Milan, Italy
Author contributions: Primignani M contributed to review concept and design; all authors contributed to drafting of the manuscript.
Conflict-of-interest statement: No potential conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Massimo Primignani, MD, PhD, U.O. Gastroenterologia ed Epatologia, IRCCS-Ca’ Granda, Ospedale Maggiore Policlinico, via F. Sforza 35, 20122 Milano, Italy.
Telephone: +39-02-55035432 Fax: +39-02-50320410
Received: July 3, 2015
Peer-review started: July 9, 2015
First decision: August 25, 2015
Revised: November 8, 2015
Accepted: December 1, 2015
Article in press: December 2, 2015
Published online: December 18, 2015

Portal vein thrombosis (PVT) is a frequent complication in cirrhosis, particularly in advanced stages of the disease. As for general venous thromboembolism, risk factors for PVT are slow blood flow, vessel wall damage and hypercoagulability, all features of advanced cirrhosis. Actually, the old dogma of a hemorrhagic tendency in cirrhosis has been challenged by new laboratory tools and the clinical evidence that venous thrombosis also occurs in cirrhosis. The impaired hepatic synthesis of both pro- and anticoagulants leads to a rebalanced hemostasis, more liable to be tipped towards thrombosis or even bleeding. Conventional anticoagulant drugs (low molecular weight heparin or vitamin K antagonists) may be used in cirrhosis patients with PVT, particularly in those eligible for liver transplantation, to prevent thrombosis progression thus permitting/facilitating liver transplant. However, several doubts exist on the level of anticoagulation achieved as estimated by coagulation tests, on the efficacy of treatment monitoring and on the correct timing for discontinuation in non-transplant candidates, while in transplant candidates there is expert consensus on continuing anticoagulation until transplantation. The recent introduction of direct acting oral anticoagulant drugs (DOACs) in other clinical settings generates much interest on their possible application in patients with cirrhosis and PVT. However, DOACs were not evaluated yet in patients with liver disease and cannot be recommended for the present time.

Keywords: Portal vein thrombosis, Coagulopathy, Hypercoagulopathy, Direct acting oral anticoagulant drugs, Cirrhosis

Core tip: Impaired liver synthesis of both pro- and anticoagulants maintains a haemostatic balance in advanced liver disease, but this balance is more unstable than in healthy subjects and can be easily tipped towards thrombosis or bleeding. Portal vein thrombosis (PVT) frequently occurs in advanced stages of cirrhosis and, if occlusive or extensive, may complicate or impede liver transplant. Therefore, prevention and treatment of PVT are frequent issues in cirrhosis patients, particularly in those eligible to liver transplant. Current treatments are with low molecular weight heparin or vitamin K antagonists and should be continued until transplantation in liver candidates, whereas no consensus exists regarding the duration of anticoagulation in non-transplant candidates.