Antiplatelet therapy in anticoagulated cirrhotic patients with chronic portal vein thrombosis: A retrospective multicenter study

Abstract Background: Treatment of chronic portal vein thrombosis (PVT) in cirrhotic patients can be complicated, mainly because there is no clear consensus or solid evidence to guide therapy. Clinicians struggle to strike the right balance between preventing clot progression and avoiding bleeding, especially in this fragile group. While anticoagulation is typically used, the role of adding antiplatelet therapy (APT) is not well defined. In practice, some patients with coexisting heart disease have received treatment for both, but we still do not know much about how this combination affects outcomes in cirrhosis. Methods: We conducted a retrospective study of 163 patients treated with cirrhosis and chronic portal vein thrombosis between January 2021 and December 2022. We divided the patients into four groups based on their anticoagulation approach: DOAC alone, DOAC combined with antiplatelet therapy (APT), warfarin alone, and warfarin with APT. We looked at imaging reports to evaluate thrombus resolution and tracked any hospital readmissions related to bleeding over one year. Secondary outcomes were also evaluated, including gastrointestinal bleeding and overall mortality during that timeframe. Results: Of the total cohort, 111 patients (68%) received DOAC monotherapy, 16 (10%) received DOAC + APT, 33 (20%) were on warfarin alone, and 3 (2%) received warfarin + APT. Complete thrombus resolution occurred most frequently in the DOAC + APT group (50%), followed by warfarin alone (45%), DOAC alone (29%), and warfarin + APT (0%). Bleeding-related readmissions occurred in 1 patient (3%) from the warfarin-only group. Notably, none of the patients on DOAC with or without APT had a bleeding-related admission. While the results did not reach statistical significance, the trend suggests that adding APT to anticoagulants did not worsen bleeding risk and may be associated with improved thrombus resolution. Conclusions: In patients with cirrhosis and chronic portal vein thrombosis, adding antiplatelet therapy, particularly alongside DOACs, did not seem to raise bleeding risk and was associated with a higher rate of thrombus resolution. Although this was a retrospective study with limitations, the results suggest that combining anticoagulation with antiplatelet therapy might benefit carefully selected cases. Further prospective studies will be important to clarify the safety and effectiveness of this approach.