Comparative Effectiveness and Safety of Various Anticoagulation Regimens for Portal Venous Thrombosis in Cirrhosis: A Systematic Review and Network Meta-Analysis

BackgroundPortal venous thrombosis (PVT) is a serious complication in cirrhosis, with management debated due to differing anticoagulant guidelines. This network meta-analysis assessed various anticoagulants for PVT in cirrhotic patients.MethodsPubMed, Cochrane Central, and ScienceDirect were searched till May 2025. A frequentist network meta-analysis was conducted in RStudio version 4.3.3. The ranking was based on P-scores.ResultsNineteen studies were included in the analysis. Direct oral anticoagulants (DOACs) (RR = 2.38; 95%CI:[1.17, 4.85]; p = 0.02), fondaparinux (RR = 18.16; 95%CI:[2.09, 158.13]; p = 0.009), low-molecular-weight heparin (LMWH) (RR = 11.96; 95%CI:[1.58, 90.79]; p = 0.01), LMWH-Warfarin sequential therapy (RR = 2.32; 95%CI:[1.01, 5.31]; p = 0.04), and Vitamin K antagonists (VKA) (RR = 1.71; 95%CI:[1.03, 2.83]; p = 0.04) showed a significant increase in complete recanalization, with fondaparinux ranked highest (P-score = 0.94). DOACs (RR = 0.23;95%CI:[0.07, 0.71]; p = 0.01), LMWH (RR = 0.24;95%CI:[0.11, 0.52]; p = 0.0003), LMWH-Warfarin sequential therapy (RR = 0.40;95%CI:[0.21, 0.77]; p = 0.006) demonstrated a significant reduction in PVT progression, with Antithrombin-III ranked highest (P-score = 0.87). Fondaparinux was ranked highest (P-score = 0.90) for reducing esophageal variceal bleeding, while LMWH was ranked highest (P-score = 0.72) for decreasing overall bleeding. DOACs significantly decreased mortality (RR = 0.74; 95% CI: [0.67, 0.81]; p < 0.0001), with LMWH ranked highest (P-score = 0.80) for mortality.ConclusionDOACs, LMWH, and LMWH-Warfarin sequential therapy significantly improved recanalization and reduced PVT progression. LMWH was ranked highest in reducing bleeding and mortality, while fondaparinux ranked highest regarding esophageal bleeding and complete recanalization.

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This network meta-analysis of 19 studies compared anticoagulants for portal vein thrombosis in cirrhosis. Direct oral anticoagulants reduced mortality, fondaparinux ranked highest for complete recanalization and reducing variceal bleeding, and LMWH ranked highest for reducing overall bleeding.

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