Direct Oral Anticoagulants for Portal Vein Thrombosis in Cirrhosis: From Pharmacology to Clinical Practice.

BackgroundHemostasis in cirrhosis is a dynamic, "rebalanced" state rather than a simple bleeding diathesis. Portal vein thrombosis (PVT) is a frequent complication linked to variceal bleeding, hepatic decompensation, and mortality. Anticoagulation can prevent thrombus progression, promote recanalization, and improve survival without a major increase in bleeding risk.ObjectivesTo summarize the safety, efficacy, and pharmacologic considerations of direct oral anticoagulants (DOACs) for PVT in cirrhosis.MethodsThis narrative review is informed by a systematic literature search (Ovid Medline, Ovid EMBASE, Cochrane Central, Cochrane Database of Systematic Reviews, and Scopus) from 2010 to 17 July 2025. We included cohort, interventional, and meta-analytic studies evaluating DOACs in adults with cirrhosis and PVT, and synthesized these with pharmacokinetic data and international guidance.ResultsFixed-dose oral DOACs, with generally favorable safety profiles, are promising alternatives to vitamin K antagonists (VKAs) and low-molecular-weight heparins. Regulatory guidance supports DOAC use in Child-Turcotte-Pugh (CTP) class A, recommends cautious use in selected CTP class B patients, and generally discourages use in CTP class C. Apixaban and edoxaban show relatively stable pharmacokinetics in compensated cirrhosis. Observational cohorts and network meta-analyses suggest that DOACs achieve at least comparable, and often higher, rates of portal vein recanalization than VKAs, with similar risks of major and variceal bleeding.ConclusionsOverall, DOACs represent an effective and convenient anticoagulation option for carefully selected cirrhotic patients with PVT. Treatment should be individualized according to liver and renal function, variceal status, and transplant candidacy. High-quality prospective studies are still needed, particularly in CTP classes B/C cirrhosis.