Abstract Introduction Portal vein thrombosis (PVT) is a common sequela of advanced cirrhosis and often reflects worsening portal hypertension. Anticoagulation may prevent thrombus propagation and reduce the risk of intestinal ischemia but introduces significant bleeding risk in patients with thrombocytopenia, varices, and coagulopathy. This case highlights the therapeutic dilemma of managing extensive PVT in a patient with severe thrombocytopenia and concurrent evaluation for combined liver-lung transplantation. Case Description A 58-year-old man with combined pulmonary fibrosis and emphysema (CPFE) was admitted with acute-on-chronic hypoxemic respiratory failure requiring high-flow nasal cannula oxygen (Figure 1A). Laboratory testing revealed platelet count 52 × 109/L, and imaging showed cirrhotic liver morphology. Platelets fluctuated during hospitalization, reaching a nadir of 29 × 109/L. Workup excluded heparin-induced thrombocytopenia, autoimmune disease, and nutritional deficiencies. Abdominal CT revealed extensive nonocclusive PVT (5 cm) extending into the superior mesenteric vein (SMV), portal hypertension, and a 4.2-cm hepatic lesion concerning for hepatocellular carcinoma (Figure 1B). Esophagogastroduodenoscopy demonstrated variceal esophagitis without active bleeding. Following multidisciplinary discussion, dose-reduced enoxaparin was initiated, later transitioned to full-dose apixaban after platelet recovery to 70 × 109/L. The patient remained stable without bleeding events but was ultimately declined for combined liver-lung transplantation due to high surgical risk and comorbid organ dysfunction. Discussion This case underscores the competing risks of thrombosis progression and hemorrhage in cirrhotic patients with severe thrombocytopenia. Extension of PVT into the SMV carries significant risk of mesenteric ischemia and hepatic decompensation, often necessitating anticoagulation despite bleeding concerns. Individualized risk assessment, multidisciplinary input, and close monitoring of platelet counts are essential when initiating therapy. In this patient, cautious stepwise anticoagulation prevented thrombus extension without bleeding complications. Nonetheless, advanced CPFE and hepatic failure precluded dual-organ transplantation, illustrating the broader challenges of managing patients with concurrent end-stage pulmonary and hepatic disease. Optimal care requires balancing thrombosis control with hemostatic stability through collaborative, multidisciplinary decision-making. This abstract is funded by: None
Zaiem et al. (Fri,) studied this question.