Sequential anticoagulation with LMWH and DOACs in cirrhotic portal vein thrombosis

BACKGROUND: Portal vein thrombosis (PVT) is a common complication in patients with liver cirrhosis. While anticoagulation improves outcomes, the optimal treatment strategy, including the role of direct oral anticoagulants (DOACs), remains unclear. METHODS: In this retrospective cohort study, patients with liver cirrhosis and PVT were analyzed according to anticoagulation strategy (low-molecular-weight heparin [LMWH], DOACs, sequential LMWH/DOAC therapy, or no anticoagulation). Outcomes included bleeding events, portal vein recanalization, mortality, and event-free survival (EFS). Time-to-event analyses and multivariable regression models were applied. RESULTS: Anticoagulated patients showed significantly improved survival compared with non-anticoagulated patients. No significant differences in bleeding events, recanalization rates, or mortality were observed between anticoagulation strategies. Sequential LMWH/DOAC therapy was consistently associated with more favorable clinical outcomes, including lower mortality and improved EFS, (mortality HR ≈ 0.4-0.5; EFS log-rank p = 0.01), compared with LMWH monotherapy, although statistical significance was not reached. DOAC therapy was not associated with increased bleeding risk. Portal vein recanalization was associated with increased bleeding risk, and PVT recurrence was linked to higher mortality. CONCLUSIONS: Anticoagulation is associated with improved survival in patients with cirrhosis and PVT. DOACs appear safe in carefully selected patients, and sequential LMWH/DOAC therapy may offer clinical benefit, warranting confirmation in prospective studies.