Continuous versus intermittent anticoagulation during endoscopic treatment of esophageal varices in cirrhosis: a randomized controlled trial

Background: Endoscopic variceal treatment (EVT) in cirrhotic patients carries a risk of periprocedural bleeding, making anticoagulation management challenging in those with acute portal vein thrombosis (PVT). Objectives: The first randomized controlled trial to evaluate the safety and efficacy of continuous versus intermittent anticoagulation during EVT in cirrhotic patients with acute PVT. Methods: In this trial, cirrhotic patients with acute PVT and esophageal varices requiring EVT were assigned to either a continuous or intermittent anticoagulation group. In the continuous anticoagulation group, anticoagulation began immediately after PVT diagnosis and continued during EVT. In the intermittent group, anticoagulation was resumed 1 week post-procedurally. Incidences of post-procedural bleeding and hepatic decompensation events were observed during a 1-year follow-up period. Potential confounders were adjusted for using multivariable binary logistic regression. Results: Among 120 enrolled patients, 112 were analyzed (continuous anticoagulation group, n = 55; intermittent anticoagulation group, n = 57). The rate of early rebleeding within 6 weeks did not differ between groups ( p > 0.99). However, continuous anticoagulation significantly reduced the incidence of late rebleeding ( p = 0.037) and all-cause bleeding ( p = 0.020). The cumulative incidences of late rebleeding (hazard ratio (HR) = 0.386, 95% confidence interval (CI): 0.150–0.994; log-rank p = 0.041) and all-cause bleeding (HR = 0.396, 95% CI: 0.173–0.904; log-rank p = 0.023) were significantly lower in the continuous anticoagulation group. The continuous anticoagulation group had significantly lower incidences of hepatic decompensation events ( p = 0.006), and ascites ( p = 0.015). After adjustment for liver function, indications for EVT, and history of splenectomy, continuous anticoagulation remained significantly associated with superior outcomes compared with intermittent anticoagulation. Conclusion: Continuous anticoagulation during EVT in cirrhotic patients with acute PVT is safe and does not increase early rebleeding risk. It significantly reduces late and overall bleeding events and may improve long-term outcomes. Trial registration: Chinese Clinical Trial Registry, ChiCTR1800017430.