Prevention and treatment of thrombosis in patients with decompensated cirrhosis

Patients with decompensated cirrhosis commonly have indications for anticoagulation, including stroke prevention in atrial fibrillation and the prevention and treatment of venous thromboembolism, particularly portal vein thrombosis. While the rates of anticoagulation in those with indications for therapy have improved over time, the concern for bleeding due to altered hepatic elimination of anticoagulants and exclusion of patients with cirrhosis from pivotal randomized trials of direct oral anticoagulants and warfarin continue to create challenges in defining best practices for anticoagulation in patients with cirrhosis, especially in decompensated disease. In this review, we present 3 commonly encountered clinical scenarios in patients with decompensated cirrhosis requiring consideration of anticoagulation: a patient with atrial fibrillation and elevated baseline international normalized ratio, a patient with atrial fibrillation and recurrent bleeding while on anticoagulation, and a patient with portal vein thrombosis and thrombocytopenia. For each scenario, we discuss the available literature and propose a management approach.