The optimal anticoagulant strategy for portal vein thrombosis (PVT) in patients with cirrhosis remains uncertain, particularly regarding the role of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs), low-molecular-weight heparin (LMWH), or no anticoagulation. We conducted a systematic review and meta-analysis of studies evaluating DOAC therapy in cirrhotic patients with PVT. Random-effects models were used to estimate pooled risk ratios (RRs). A total of 21 studies including 21,506 cirrhotic patients with PVT were analyzed. Among them, 2,099 subjects were treated with DOACs. Compared with VKAs, DOAC therapy was associated with higher rates of complete PVT recanalization (RR 3.49, 95% CI 2.06-5.93) and lower risk of PVT progression (RR 0.19, 95% CI 0.04-0.78), with no significant difference in major bleeding (RR 1.09, 95% CI 0.79-1.51). DOACs were also associated with a lower risk of intracranial hemorrhage (ICH) (RR 0.49, 95% CI 0.30-0.80). Compared with no anticoagulation, DOAC therapy was associated with lower mortality (RR 0.77, 95% CI 0.71-0.84) without increased bleeding risk. DOAC benefit on recanalization was more pronounced in studies including only Child-Pugh A-B patients, while safety outcomes remained consistent across cirrhosis severity strata. In cirrhotic patients with PVT, DOAC therapy is associated with improved complete recanalization and reduced PVT progression compared with VKAs, without increased bleeding risk and with lower risk of ICH. These findings support the use of DOACs in selected patients, although randomized trials are needed to confirm these results.
Boccatonda et al. (2026) studied this question.