Splanchnic Vein Thrombosis in Cirrhosis - Areas Still in the Shadow

Dear Editor: We read with great interest the recent article by Senzolo et al.1 aiming to describe the clinical presentation, bleeding incidence, thrombotic events, and mortality in cirrhotic patients with splanchnic vein thrombosis (SVT). This is a complete study on splanchnic vein thrombosis in cirrhotic patients and the largest of its kind, shedding light on a very debated subject matter regarding the longterm clinical outcomes of SVT and the safety and the efficacy of the anticoagulant treatment in cirrhotic patients. Although this is a very well conducted multicenter study, we would like to address some issues that deserve further consideration. Firstly, the study was centred on Child-Pugh A and B patients, with only 10.2% Child-Pugh C patients. We think that it is very important to make a clear distinction between patients with compensated and decompensated liver cirrhosis, as the influence of each risk factor in the development of SVT could be different, with an immediate effect on the therapeutic approach and patient outcome. New studies including Child-Pugh C population are needed in order to establish the best therapeutic approach in this difficult to treat (special) population. Secondly, the authors reported that only 25% and 33.7% of the patients received beta-blockers prophylaxis or endoscopic treatment, respectively. Although, this could be considered an inappropriate variceal bleeding prophylaxis, the rate of variceal bleeding events in the treated group is maintained low, which could be explained by the beneficial effects of anticoagulant treatment on portal hypertension, as it has already been demonstrated by Villa et al.2 Finally, with regard to acute portal vein thrombosis, we are still missing a clear definition. Until now the definitions proposed were based on anatomic findings only, lacking any clinically significant consequences of portal vein thrombotic occlusion such as portal hypertension and ascites. In our view, it is important to have a description of PVT pattern of evolution (spontaneous recanalization, extended or stable) with or without anticoagulant treatment, and the status of the liver cirrhosis (compensated or decompensated) in order to achieve a personalized therapeutic approach. To conclude, the study by Senzolo et al.1 provides the opportunity to highlight some aspects regarding SVT in cirrhotic patients, though the subject remains a matter of debate in the scientific community and should be cautiously considered, primarily because the definitions of acute/chronic thrombosis are not clearly stated3–5 and, until now the anticoagulant treatment is not strongly support by randomized control clinical trials6.