Portal Vein Thrombosis in the Setting of Cirrhosis: Evaluation and Management Strategies

Evidence from meta-analyses and scientific society guidelines clearly support the use of anticoagulation in patients with cirrhosis and symptomatic acute PVT. Currently, anticoagulation is initiated with LMWH (in the absence of impaired renal function) and then transitioned to warfarin. However, DOACs are increasingly used in this population. Anticoagulation is associated with higher rates of PV recanalization, lower rates of variceal bleeding, and decreases in all-cause mortality. Interventional radiological procedures are indicated in patients in whom the thrombus extends into the SMV despite anticoagulation, especially if there is a risk of bowel ischemia. Endoscopic therapy is required for control of variceal bleeding. In patients with chronic PVT, there is the risk of ectopic variceal bleeding and biliary complications from portal hypertensive cholangiopathy. The patient in this clinical vignette was initiated on UFH and then underwent EGD, which revealed large varices without high-risk stigmata of bleeding. He was initiated on a NSBB to prevent variceal bleeding. He was transitioned to warfarin at hospital discharge. He remains clinically stable, symptom free, and without extension of his thrombus. He will later undergo evaluation for LT. At transplantation, if the portal vein has not completely recanalized, an attempt at thrombectomy will be made, taking great care not to damage the vein so as to carry out a successful anastomosis between the donor and recipient portal vein. If thrombectomy is unsuccessful, a jump graft to the side of the SMV will be carried out using a segment of the iliac vein that is usually recovered from the donor. In the unlikely event that neither the portal vein nor the SMV can be used, the donor portal vein will be anastomosed to a large collateral vein that may be present, usually the dilated coronary vein.