How to manage splanchnic vein thrombosis in patients with liver disease

Liver cirrhosis and splanchnic vein thrombosis (SVT) are strictly correlated. Portal vein thrombosis, the most common loca tion of SVT, is fre quently diag nosed in liver cir rho sis (pooled inci dence 4.6 per 100 patient- years), and liver cir rho sis is a common risk factor for SVT (reported in 24%-28% of SVT patients). In cirrhosis-associated SVT, anticoagulant treatment reduces mor tal ity rates, throm bo sis exten sion, and major bleed ing, and increases the rates of recan a li za tion, com pared to no treatment. Achieving vessel recanalization improves the prognosis of cirrhotic patients by reducing liver-related complications (such as variceal bleeding, ascites, hepatic encephalopathy). Anticoagulation should be therefore routinely pre scribed to cir rhotic patients with acute SVT unless contraindicated by active bleed ing asso ci ated with hemody namic impair ment or by exces sively high bleed ing risk. Of note, early treat ment is asso ci ated with higher prob a bil ity of achieving vessel recanalization. The standard treatment consists of low-molecular-weight heparin, followed by oral anti co ag u lants (eg, vita min K antag o nists or direct oral anti co ag u lants), if not contraindicated by severe liver dys function. Cirrhotic patients with SVT should be treated long- term (espe cially if can di date for liver trans plan ta tion) since liver cir rho sis is a per sis tent risk fac tor for recur rent throm bo sis. In this review, we dis cuss the man age ment of SVT in patients with liver cir rho sis, with a focus on the anti co ag u lant treat ment in terms of indi ca tions, tim ing, drugs, dura tion, and partic ular scenarios, such as gastroesophageal varices and thrombocytopenia.