S1167 Non-Vitamin K Antagonist Oral Anticoagulation vs Standard of Care for the Treatment of Portal Venous Thrombosis in Cirrhotic Patients; A Systematic Review with Meta-Analysis

Introduction: There remains hesitancy among practitioners with using non-vitamin K antagonist oral anticoagulants (NOACs) to treat portal venous thrombosis (PVT) in the setting of cirrhosis due to their unclear safety profile in this patient population. Methods: A systematic review of Medline and Embase was conducted from inception-March 2021. Studies comparing NOACs to the current standard of care (SOC; vitamin-K antagonist oral anticoagulant or no anticoagulation) for the treatment of PVT in cirrhosis were included. A meta-analysis yielding risk ratios (RR) was performed using a random effects model for safety and efficacy outcomes of interest. Influence analysis was also conducted to assess robustness of any significant signals identified herein. Findings are reported as pooled effect sizes with their corresponding 95% confidence intervals. Results: We found 7 non-randomized and one randomized study. Most patients had HCV-associated cirrhosis and Child Pugh Class B disease (Table 1). Esophageal varices were reported in 74% and 66% of patients in the NOAC and SOC arm, respectively. Rivaroxaban and Apixaban were the most commonly used NOACs. Complete vessel recanalization was reported in 54% and 12% of patients in the NOAC and SOC arms, respectively; NOACs were associated with a higher complete recanalization rate (RR 2.75; 95% CI 1.75-4.34; P = 0.00; Figure A); this finding remained significant throughout the influence analysis (Figure B). NOACs were associated with a decreased risk of clot progression (RR 0.23; 0.08-0.66; P = 0.01); this finding remained significant upon removal of three of the four studies in the influence analysis. There was no significant difference in the risk of overall adverse events (AEs), bleeding events, need for hospitalization, surgery, or endoscopy due to AEs the NOAC and SOC arms (Table 1). There was no significant difference in the need for anticoagulation discontinuation in the two groups. Conclusion: NOAC are associated with a higher rate of complete recanalization in the setting of PVT in cirrhosis, with no significant increase in bleeding risk compared to SOC. Although some patients may require discontinuation of NOAC due to AEs, the difference in the need for discontinuation compared to SOC is not significant. These findings do not apply to patients with Child Pugh Class C disease or patients with CKD. The current body of evidence, although promising, is very limited. The relative safety documented herein may set the premise for future randomized clinical trials.Table 1.: Pooled Baseline Characteristics – NOACs vs Standard of Care for Portal Venous Thrombosis in Patients with Cirrhosis.Figure 1.: Comparative meta-analysis of NOAC vs Standard of Care for the treatment of PVT in cirrhosis