Portal vein thrombosis (PVT) is a challenging complication of cirrhosis, associated with adverse outcomes. Clinical management of PVT remains complex and demanding.

We performed a retrospective study involving 1562 cirrhotic patients from six medical centers, among whom 222 were diagnosed with chronic non-tumoral PVT. These PVT patients were categorized into four primary treatment groups: watch-and-wait follow-up alone (n=38), anticoagulation monotherapy (n=85), isolated TIPS creation (n=32), and TIPS combined with postoperative warfarin anticoagulation (n=67). For secondary efficacy analyses, the anticoagulation group was further divided into three medication subgroups (warfarin, LMWH, rivaroxaban), resulting in five analytical subgroups in total. Risk factors for PVT were analyzed in the entire cirrhotic cohort. Therapeutic efficacy and safety were compared across subgroups. Outcomes were evaluated between patients with and without PVT, TIPS-treated PVT patients with and without post-TIPS anticoagulation, and PVT patients receiving different anticoagulants.

Ascites, variceal disease, and the Model for End-Stage Liver Disease (MELD) score were associated with the development of chronic PVT. No significant differences in recanalization or rethrombosis rates were observed among patients receiving different anticoagulants. Adjunctive postoperative anticoagulation significantly improved early portal venous recanalization compared with TIPS monotherapy. The MELD score, but not anticoagulant use, was associated with an increased bleeding risk. After adjusting for confounding factors, PVT, anticoagulant type, and post-TIPS anticoagulation were not associated with poor outcomes.

The severity of cirrhosis is linked to PVT development. Individualized PVT therapy enables safe and high-probability recanalization. TIPS expands therapeutic options for decompensated cirrhotic patients with PVT.