Direct oral anticoagulants in portal vein thrombosis in patients with cirrhosis: a systematic review and meta-analysis.

The optimal anticoagulant strategy for portal vein thrombosis (PVT) in patients with cirrhosis remains uncertain, particularly regarding the role of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs), low-molecular-weight heparin, or no anticoagulation. We conducted a systematic review and meta-analysis of studies evaluating DOAC therapy in patients with cirrhosis with PVT. Random-effects models were used to estimate pooled risk ratios (RRs). A total of 21 studies including 21 506 patients with cirrhosis with PVT were analyzed. Among them, 2099 patients were treated with DOACs. Compared with VKAs, DOAC therapy was associated with higher rates of complete PVT recanalization (RR, 3.49; 95% confidence interval [CI], 2.06-5.93) and lower risk of PVT progression (RR, 0.19; 95% CI, 0.04-0.78), with no significant difference in major bleeding (RR, 1.09; 95% CI, 0.79-1.51). DOACs were also associated with a lower risk of intracranial hemorrhage (ICH; RR, 0.49; 95% CI, 0.30-0.80). Compared with no anticoagulation, DOAC therapy was associated with lower mortality (RR, 0.77; 95% CI, 0.71-0.84) without increased bleeding risk. DOAC benefit on recanalization was more pronounced in studies including only patients with Child-Pugh class A or B, whereas safety outcomes remained consistent across cirrhosis severity strata. In patients with cirrhosis with PVT, DOAC therapy is associated with improved complete recanalization and reduced PVT progression compared with VKAs, without increased bleeding risk and with lower risk of ICH. These findings support the use of DOACs in select patients, although randomized trials are needed to confirm these results.