Efficacy and Safety of Direct Oral Anticoagulants Versus Vitamin K Antagonist for Portal Vein Thrombosis in Cirrhosis: A Systematic Review and Meta-analysis

Introduction And Aim: Portal vein thrombosis (PVT) is associated with a higher risk of liver-related complications. Recent guidelines recommend direct-acting anticoagulants (DOAC) in patients with cirrhosis and non-tumoral PVT. However, data on the efficacy and safety of DOAC in these patients remain limited. We aim to investigate the efficacy and safety of DOAC compared to vitamin K antagonists (VKA) to treat non-tumoral PVT in patients with cirrhosis.

Methods: We performed a systematic search of six electronic databases using MeSH term and free text. We selected all studies comparing the use of DOACs with vitamin K antagonist to treat PVT in cirrhosis. The primary outcome was PVT recanalization. Secondary outcomes were and PVT progression, major bleeding, variceal bleeding and death.

Results: From 944 citations, we included 552 subjects from a total of 11 studies (10 observational and 1 randomized trial) that fulfilled the inclusion criteria. We found that DOAC were associated with a higher pooled rate of PVT recanalization (RR = 1.67, 95%CI: 1.02, 2.74, I = 79%) and lower pooled risk of PVT progression (RR = 0.14, 95%CI: 0.03-0.57, I = 0%). The pooled risk of major bleeding (RR = 0.29, 95%CI: 0.08-1.01, I = 0%), variceal bleeding (RR = 1.29, 95%CI: 0.64-2.59, I = 0%) and death (RR = 0.31, 95%CI: 0.01-9.578, I = 80%) was similar between DOAC and VKA.

Conclusion: For the treatment of PVT in patients with cirrhosis, the bleeding risk was comparable between DOAC and VKA. However, DOAC were associated with a higher pooled rate of PVT recanalization. Dedicated randomized studies are needed to confirm these findings.