Practice guidance addresses vascular liver disorders, portal vein thrombosis, procedural bleeding

Among other statements, the American Association for the Study of Liver Diseases said that modifiable risk factors for bleeding, such as use of antithrombotic drugs, should be identified and corrected before procedures in patients with cirrhosis.


The American Association for the Study of Liver Diseases (AASLD) recently issued guidance on vascular liver disorders, portal vein thrombosis, and procedural bleeding. An expert panel developed the practice guidance, which provides guidance statements that are based on review and analysis of the literature.

Regarding procedural bleeding in patients with cirrhosis, there is no data-driven, specific international normalized ratio (INR) or platelet cutoff at which risk is reliably increased, the guidance said. It recommended identification and correction of modifiable risk factors for bleeding (e.g., use of antithrombotic drugs) before procedures, especially high-risk elective procedures. The INR should not be used to gauge procedural bleeding risk in patients with cirrhosis who are not taking vitamin K antagonists (VKAs), the guidance said. Measures to reduce the INR are not recommended before procedures in patients with cirrhosis who are not taking VKAs, according to the guidance.

In patients with cirrhosis, the guidance said, it is mandatory to rule out malignant venous obstruction due to hepatocellular carcinoma with appropriate contrast-enhanced imaging studies. An extensive evaluation for thrombophilic conditions is not needed unless family history or routine laboratory testing raises other concerns, according to the guidance. A complete investigation for myeloproliferative disorders or another thrombophilic condition is warranted, usually in consultation with a hematologist, in patients without cirrhosis who have thrombosis of the portal venous system but no clear provoking factor, the guidance said. Local or systemic thrombolytic therapy should be considered only in very select patients with recent portal vein thrombosis who have persistent intestinal ischemia despite anticoagulation, according to the guidance.

The choice of agent for anticoagulant therapy–low-molecular-weight heparin, VKAs, or direct oral anticoagulants (DOACs)—should be individualized in patients with portal vein thrombosis, in consultation with a hematologist and/or expert hepatologist, the guidance said. It noted that DOACs are becoming a common therapy for general medical patients with thrombosis but that portal vein thrombosis data remain limited regarding safety and efficacy in patients with and without cirrhosis. “In patients with cirrhosis, caution is advised in patients with advanced portal hypertension, and expert consultation is recommended,” the guidance said.

The practice guidance, which also covers hepatic vein thrombosis (Budd-Chiari syndrome), sinusoidal obstruction syndrome, liver vascular malformations and hereditary hemorrhagic telangiectasia, idiopathic noncirrhotic portal hypertension, and hepatic and splenic artery aneurysms, was published Nov. 20 by Hepatology and is available online.