Acute portal vein thrombosis arising in the context of liver cirrhosis requires a targeted approach. Cirrhosis is both a major risk factor for portal vein thrombosis and a key determinant of how treatment is selected and sequenced.
This protocol addresses acute portal vein thrombosis in patients with established liver cirrhosis. The severity of underlying liver disease shapes the treatment options available, and patients who are potential liver transplant candidates represent an especially important subgroup — portal vein patency directly influences transplant feasibility and outcomes.
Management centres on anticoagulation therapy. The choice of anticoagulant is guided by the degree of liver dysfunction — not every agent is appropriate across the full spectrum of cirrhosis severity. The complete evidence-based regimen, including specific agent selection, sequencing, and patient eligibility criteria, is in the full protocol.
DOI: 10.1016/j.jhep.2025.08.001
In patients with cirrhosis and PVT who are potential LT candidates, anticoagulation should be used regardless of degree of occlusion or extension of PVT, to improve feasibility and outcomes of LT.
LMWH has been shown to be more effective than warfarin with regard to complete PVT resolution.
Direct oral anticoagulants can be used in patients with PVT and Child-Pugh A or B cirrhosis; however, owing to insufficient evidence, they cannot be recommended over vitamin K antagonists or low-molecular-weight heparin to reduce morbidity and mortality. In patients with Child-Pugh C cirrhosis, direct oral anticoagulants are not recommended.
Anticoagulation is most effective if started within 6 months of diagnosis of PVT.
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