Analysis of the clinical characteristics of direct oral anticoagulants-associated atraumatic splenic rupture

Objective: Atraumatic splenic rupture (ASR), though rare, is an adverse event linked to direct oral anticoagulants (DOACs). Given their widespread use and potentially fatal consequences if undiagnosed, heightened clinical awareness of DOAC-associated ASR is crucial. Our aim was to analyze the occurrence and clinical characteristics of ASR induced by DOACs. Methods: We conducted a retrospective analysis of all reported DOAC-associated ASR cases through 15 April 2025, without language restrictions. Results: A total of 27 patients (11 males and 16 females) were included with a median age of 64 years. Among them, apixaban (n = 17) was the most common DOAC, followed by rivaroxaban (n = 8) and dabigatran (n = 2), with atrial fibrillation (81.5%, n = 22) being the primary indication. The comorbidities observed among patients with DOAC-associated ASR risk included hypertension (25.9%), coronary heart disease (18.5%), malignancy (18.5%), and infections (18.5%). Among 27 patients, 11 (40.7%) received concomitant medications that may potentiate DOAC effects, with 5 patients taking four interacting drugs simultaneously. Only 4 of the 11 patients had documented anticoagulant dosages, half of which were full-dose regimens. Management included immediate DOAC cessation (100.0%), transfusion (77.8%), splenic artery embolization (44.4%), and splenectomy (70.4%) - with 31.6% of splenectomies representing salvage procedures following failed embolization. All patients were successfully discharged with no mortality. Conclusion: ASR is a potentially life-threatening but preventable DOAC complication. Early recognition-particularly in elderly patients with comorbidities and polypharmacy-and urgent imaging for abdominal pain are crucial for improving clinical outcomes.