Clinical management of portal vein thrombosis in cirrhosis: an evidence‑based narrative review.

Portal vein thrombosis (PVT) complicates up to a third of patients with cirrhosis and is associated with variceal bleeding, refractory ascites, and challenges at liver transplantation. Management has evolved from selective anticoagulation to broader use of endovascular therapies, especially transjugular intrahepatic portosystemic shunt (TIPS) and portal vein recanalisation strategies. In this narrative review, we summarise the current evidence for anticoagulation, thrombolysis, TIPS, and surgery, and compare major society guidelines. Meta-analyses in cirrhosis show that anticoagulation increases recanalisation and reduces thrombus progression without increasing major bleeding and may lower variceal bleeding risk. Endovascular meta-analysis demonstrates high feasibility of TIPS for PVT (~ 95%) with a 12-month portal vein recanalisation around 80% and shunt patency ~ 84% with major complications observed in ~ 10%. Additional catheter-directed thrombolysis during TIPS may increase severe complications and is not routinely recommended in patients with cirrhosis. Guidelines broadly recommend anticoagulation for recent, clinically significant PVT and reserve TIPS for patients with portal hypertension complications, failure of anticoagulation, or transplantation candidacy.