Timing of anticoagulation for the management of portal vein thrombosis in liver cirrhosis

Portal vein thrombosis (PVT) represents a not uncommon complication of liver cirrhosis with an impact on patients’ morbidity and, possibly, patients’ mortality. The prevalence of PVT is associated to the severity of liver disease and ranges from about 1% in patients with compensated liver cirrhosis to 8% in patients with decompensated liver cirrhosis and up to 40% in patients who developed a hepatocellular carcinoma. Despite recent evidence, thrombus localization and extension as well as the perceived increase in bleeding risk due to both hemostatic abnormalities (e.g., defective platelet number or function) and portal hypertension (e.g., high-risk gastroesophageal varices) may complicate the decision of which patients should be treated and when anticoagulant treatment should be started. A recent guidance paper from the International Society of Thrombosis and Haemostasis suggested that the stage of thrombosis (i.e., acute or chronic) rather than the presence or absence of symptoms at diagnosis should guide therapeutic decision. Anticoagulant therapy is suggested for patients with acute symptomatic or incidentally-detected PVT without active bleeding or other contraindications. Conversely, a careful evaluation of the risks and benefits of anticoagulation is suggested in patients with chronic thrombosis. The aims of this narrative review are to discuss the available data and to identify the correct timing for anticoagulant therapy in patients with liver cirrhosis and PVT.