Viscoelastic Tests in Cirrhotic Patients Undergoing Invasive Procedures: A Systematic Review and Meta‐Analysis of RCTs

Background and Aims Bleeding risk in cirrhotic patients undergoing invasive procedures is traditionally assessed using conventional coagulation tests, which poorly reflect the rebalanced haemostatic state of cirrhosis and often lead to unnecessary transfusions. Viscoelastic testing (VET) provides a global assessment of coagulation and may enable more rational transfusion strategies. We performed a systematic review and meta‐analysis of randomised controlled trials (RCTs) to evaluate the efficacy and safety of VET‐guided transfusion strategies in this setting. Methods We systematically searched PubMed, Embase and Scopus from inception to 10 April 2026. RCTs comparing VET‐guided versus standard‐of‐care transfusion strategies in cirrhotic patients undergoing invasive procedures were included. Primary outcome was procedure‐related bleeding; secondary outcomes included transfusion requirements. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using the Mantel–Haenszel method. Results Six RCTs including 296 patients were analysed. Procedure‐related bleeding was rare and did not differ between groups (RR 0.74, 95% CI 0.24–2.31; I 2 = 0%). In contrast, VET‐guided strategies significantly reduced transfusion requirements, including any blood product transfusion (RR 0.33, 95% CI 0.26–0.44; I 2 = 56%), platelet transfusion (RR 0.20, 95% CI 0.13–0.32; I 2 = 40%), any fresh frozen plasma (FFP) exposure (RR 0.40, 95% CI 0.28–0.57; I 2 = 63%) and FFP‐only transfusion (RR 0.22, 95% CI 0.10–0.46; I 2 = 81%). Conclusions VET‐guided transfusion strategies significantly reduce blood product utilisation without increasing bleeding risk in cirrhotic patients undergoing invasive procedures. These findings support a shift towards a physiology‐based approach to haemostasis, with potential benefits for patient safety and resource optimisation. Trial Registration: ClinicalTrials.gov identifier: CRD420261382437.