DAY 2 - Should portal vein thrombosis be anticoagulated?

Fadi Francis, MD, from the American University of Beirut Faculty of Medicine, in Pittsburgh, Pennsylvania, argued that PVT should be anticoagulated, and focused specifically in patients with cirrhosis. He noted that while PVT contributes to liver decomposition, the associated mortality risk is unclear. But it is clear that loss of portal blood flow leads to reduction in liver function, and Dr. Francis cited several retrospective studies and meta-analyses showing increased risk of various outcomes with PVT, including progression of portal vein hypertension, anastomoses in transplantation, and worse post-transplantation survival, and well as the positive effects of anticoagulation on reducing the risk of progression and bleeding, and improving transplantation-free survival rates. He noted that direct oral anticoagulants have been shown to be safe for chronic PVT in cirrhosis. He also cited Guerrero et al. a meta-analysis of 5 studies including 500 patients, 205 of whom were anticoagulated, showing that all-cause mortality was reduced. He recommended that PVT should be screened in patients with decompensated cirrhosis, PVT is indicated in certain patients including those listed for transplant, that delays in PVT should be avoided in patients waiting for EGD, and DOACs have been increasingly used in Child A and Child B cirrhosis.

Joseph K. Lim, MD, from Yale University School of Medicine in New Haven, Connecticut, took the opposing stance, that PVT should not be anticoagulated. He argued that VTE/PVT are common in cirrhosis, affecting 10-25% of patients over the course of the disease, and trying to rebalance coagulation in cirrhosis is delicate. He also described PVT as a thickening of the PV wall that causes stenosis, rather than a clot caused by hypercoagulation. Dr. Lim argued that there are only a few patients for which anticoagulation is unequivocally recommended, and that a selective, individualized approach is needed to identify those who benefit. He cited Davis et al. (Gastroenterology. 2025), and recommendations for initial evaluation to include cross sectional imaging and evaluate PVT timing, symptoms, location, percent occlusion, presence of cancer, liver transplant candidate, bleeding risk, and known thrombophilia. The only patients for whom there is a benefit of anticoagulation would be those with PVT at the time of transplantation Dr. Lim listed seven reasons why anticoagulation is usually not required:

1.    PVT often spontaneously resolves, in 40-70% range, so monitoring and waiting is usually warranted
2.    PVT is a marker of disease severity rather than a causal factor in liver events
3.    Anticoagulation increases bleeding risk up to 24%
4.    The clinical benefit is uncertain, and recanalization rates are incomplete and suboptimal (see Cheloff et al. Clin Gastro Hepatol. 2025)
5.    There are no alternatives to anticoagulation
6.    Adherence is an issue to hepatic meds in general and to anticoagulation specifically, which can cause harm
7.    Anticoagulation for PVT is not recommended by any society 

Dr. Lim concluded by sharing the guidelines algorithm for patient selection for PVT anticoagulation (see Davis et al. Gastroenterology. 2025) and noting that more research is needed to inform evidence-based practice and the role of DOACs. 

The audience poll and the end of the debate showed that 81% agreed that PVT should not be anticoagulated and 20% felt that PVT should be anticoagulated.