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Antithrombotic Therapy and Liver Disease

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Vascular Disorders of the Liver

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Abstract

In this chapter, the authors discuss the current knowledge on antithrombotic therapy, with either the classical anticoagulants heparins and vitamin K antagonists, or the direct oral anticoagulants (DOAC) in patients with thrombotic involvement of the liver vasculature with or without prior parenchymal liver disease. The role of anticoagulation in the former is well established, particularly so in the Budd-Chiari syndrome (BCS) and in acute/recent extrahepatic portal vein obstruction (EHPVO). BCS requires long-term anticoagulation, irrespective of the recognition of prothrombotic risk factors. Acute/Recent extrahepatic portal vein obstruction requires anticoagulation for at least 6 months, as portal vein recanalization does not occur beyond the sixth month of anticoagulation treatment. Nonetheless, long-term anticoagulation is recommended if an underlying persistent prothrombotic defect is identified. The role of anticoagulation is less settled in chronic EHPVO, idiopathic non-cirrhotic portal hypertension/porto-sinusoidal vascular disease (INCPH/PSVD) and sinusoidal obstruction syndrome (SOS), particularly in the absence of persistent prothrombotic conditions. Finally, anticoagulation treatment is controversial in liver cirrhosis complicated by portal vein thrombosis. Though recent data suggest a favourable benefit/risk ratio of anticoagulation for preventing or treating PVT in cirrhosis patients, large randomized clinical trials are needed. At present, anticoagulant treatment in cirrhosis, with LMWH or VKA is recommended for patients with PVT listed for liver transplantation or symptomatic and progressive PVT. Anticoagulation does not appear to increase the risk of portal hypertensive bleeding, if patients receive adequate prophylaxis of variceal hemorrhage. However, patients with low platelet count (e.g. <50 × 109/L) are at higher risk of both PVT and bleeding complications under anticoagulation. Direct oral anticoagulants (DOAC) which, at variance with heparins or VKA, target activated coagulation factors without intermediation from antithrombin or carboxylation, are in principle more suitable than LMWH or VKA in patients with liver disease. However, DOAC are not licensed yet for the treatment of splanchnic vein thrombosis and cirrhosis patients were excluded from the DOAC registration trials. Nonetheless, a growing amount of clinical data suggest that DOAC are equally effective in cirrhotic patients, with decreased occurence of bleeding events. Large clinical trials on DOAC in patients with splanchnic vein thrombosis with/without cirrhosis and more data on the preferable DOAC and optimal DOAC dose according to the severity of liver disease are still awaited.

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Authors and Affiliations

  1. Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, Milan, Italy

    Massimo Primignani

  2. Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy

    Armando Tripodi

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  1. Massimo Primignani
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  2. Armando Tripodi
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Correspondence to Massimo Primignani .

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Editors and Affiliations

  1. CRI, UMR 1149, Université de Paris and Inserm, Paris, France

    Dominique Valla

  2. Hospital Clinic, Hepatic Hemodynamic Lab Hospital Clinic, Barcelona, Spain

    Juan Carlos Garcia-Pagan

  3. Gastroenterology and Hepatology, Ente Ospedaliero Cantonale, Lugano, Switzerland

    Andrea De Gottardi

  4. Université de Paris, Paris, France

    Pierre-Emmanuel Rautou

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Primignani, M., Tripodi, A. (2022). Antithrombotic Therapy and Liver Disease. In: Valla, D., Garcia-Pagan, J.C., De Gottardi, A., Rautou, PE. (eds) Vascular Disorders of the Liver . Springer, Cham. https://doi.org/10.1007/978-3-030-82988-9_16

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