Li Hui-Jun, Yin Fu-Qiang, Ma Yu-Tong, Gao Teng-Yu, Tao Yu-Ting, Liu Xin, Shen Xian-Feng, Zhang Chao
Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China.
Hepatobiliary and Pancreatic Research Center, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China.
Front Pharmacol. 2025 Jan 6;15:1462338. doi: 10.3389/fphar.2024.1462338. eCollection 2024.
Evidences for anticoagulation strategies in cirrhotic with portal vein thrombosis (PVT) are still insufficient. This study aims to comprehensively compare the therapeutic effects of different therapeutic therapeutic measures in individuals suffering from cirrhosis with PVT, with the ultimate goal of providing evidence-based recommendations for thrombolytic therapy in this population.
Starting from 20 October 2023, a comprehensive search about therapeutic strategies for portal vein thrombosis in cirrhosis was conducted on PubMed, EMBASE, and Cochrane Library.
19 studies were eventually incorporated into this study. Comparison with control in network meta-analysis, direct oral anticoagulants (DOACs) (RR = 2.15, 95%CI: 1.33, 3.48), LMWH (RR = 1.41, 95%CI: 1.01, 1.99), TIPS (RR = 5.68, 95%CI: 2.63, 12.24), warfarin (RR = 2.16, 95%CI: 1.46, 3.21), EBL propranolol (RR = 2.80, 95%CI: 1.18, 6.60), LMWH-DOACs sequential (RR = 7.92, 95%CI: 2.85, 21.99) and LMWH-warfarin sequential (RR = 2.26, 95%CI: 1.16, 4.42) significantly improved the incidence of complete recanalization. The anticoagulation drugs were ranked based on their SUCRA values, with the LMWH-DOACs sequential (92.7%), TIPS warfarin (91.3%), and TIPS (80.3%) emerging as the top three effective treatments.
In this study, active anticoagulants were recommended for cirrhosis with PVT. The TIPS warfarin, LMWH-DOACs sequential, and TIPS improved the complete recanalization rate most effectively, and the EBL propranolol, heparin DOACs warfarin, and DOACs were highly recommended for increasing the incidence of partial recanalization. Warfarin and TIPS were recommended for reducing the frequency of bleeding events, while LMWH warfarin and DOACs proved to be most effective in decreasing the rate of major bleeding events. Warfarin, heparin DOACs warfarin, and DOACs demonstrated the most significant reduction in mortality rates, highlighting its potential as an effective intervention. TIPS warfarin, LMWH-DOACs sequential, and TIPS were recommended for reducing the occurrence of PVT expansion. Heparin DOACs warfarin was recommended for reducing the occurrence of hepatic encephalopathy, and protocols that involve TIPS were generally associated with a higher risk of hepatic encephalopathy. However, a longer follow-up period is necessary to comprehensively evaluate the efficacy of active anticoagulants therapy in patients with PVT in cirrhosis.
肝硬化合并门静脉血栓形成（PVT）的抗凝策略证据仍不充分。本研究旨在全面比较不同治疗措施对肝硬化合并PVT患者的治疗效果，最终目的是为该人群的溶栓治疗提供循证建议。
从2023年10月20日开始，在PubMed、EMBASE和Cochrane图书馆对肝硬化门静脉血栓形成的治疗策略进行全面检索。
最终纳入本研究的有19项研究。在网络荟萃分析中与对照组比较，直接口服抗凝剂（DOACs）（RR = 2.15，95%CI：1.33，3.48）、低分子肝素（LMWH）（RR = 1.41，95%CI：1.01，1.99）、经颈静脉肝内门体分流术（TIPS）（RR = 5.68，95%CI：2.63，12.24）、华法林（RR = 2.16，95%CI：1.46，3.21）、内镜下硬化剂注射联合普萘洛尔（EBL propranolol）（RR = 2.80，95%CI：1.18，6.60）、低分子肝素 - DOACs序贯治疗（RR = 7.92，95%CI：2.85，21.99）和低分子肝素 - 华法林序贯治疗（RR = 2.26，95%CI：1.16，4.42）显著提高了完全再通率。根据表面排序曲线下面积（SUCRA）值对抗凝药物进行排序，低分子肝素 - DOACs序贯治疗（92.7%）、TIPS联合华法林（91.3%）和TIPS（80.3%）成为前三种有效治疗方法。
在本研究中，推荐对肝硬化合并PVT患者采用积极的抗凝治疗。TIPS联合华法林、低分子肝素 - DOACs序贯治疗和TIPS最有效地提高了完全再通率，强烈推荐内镜下硬化剂注射联合普萘洛尔、肝素联合DOACs联合华法林以及DOACs以增加部分再通率。推荐华法林和TIPS以降低出血事件的发生率，而低分子肝素联合华法林和DOACs在降低大出血事件发生率方面被证明是最有效的。华法林、肝素联合DOACs联合华法林以及DOACs在降低死亡率方面表现出最显著的效果，突出了其作为有效干预措施的潜力。推荐TIPS联合华法林、低分子肝素 - DOACs序贯治疗和TIPS以减少PVT扩展的发生。推荐肝素联合DOACs联合华法林以减少肝性脑病的发生，涉及TIPS的方案通常与肝性脑病的较高风险相关。然而，需要更长的随访期来全面评估积极抗凝治疗对肝硬化合并PVT患者的疗效。
