Splanchnic vein thrombosis associated with high risk of bleeding and recurrent thrombosis

1. Amongst a multi-center, international cohort of patients diagnosed with splanchnic vein thrombosis (SVT), the risk of recurrent thrombotic events, while lower during the period of time on anticoagulation, was substantial during the discontinuation phase and equally high amongst those who never received any anticoagulation treatment.

2. Patients with SVT in the setting of cirrhosis had the highest risk of bleeding and recurrent thrombotic events, so the risks versus benefits of anticoagulation in this particular cohort remained unclear.

Evidence Rating Level: 2 (Good)

Study Rundown: Splanchnic vein thrombosis (SVT) is a rare, but often troublesome disease. While the mainstay of treatment is anticoagulation, there is little information regarding the prognosis for these patients. This is perhaps complicated by the fact that a relatively heterogeneous set of comorbidities predisposes patients to this disease, rather than one unifying illness. This study was conducted to determine the long-term clinical outcomes in patients with SVT. The results of the study showed that the risk of recurrent thrombotic events, while lower during the period of time on anticoagulation, was substantial during the discontinuation phase and equally high amongst those who never received any anticoagulation treatment. Patients with SVT in the setting of cirrhosis had the highest risk of bleeding and recurrent thrombotic events, so the risks versus benefits of anticoagulation in this particular cohort remained unclear.

The major strength of the study was the inclusion of multiple centers around the world. Additionally, no particular exclusion criteria were used, so the results are applicable to any patient diagnosed with SVT. Weaknesses of the study included the relatively small number of patients in the study, which was difficult to change since the condition is relative rare, as well as significant variations in management amongst the patients.

Click to read the study, published today in JAMA Internal Medicine

Click to read an invited commentary in JAMA Internal Medicine

Relevant Reading: Survival and recurrence in patients with splanchnic vein thromboses

In-Depth [prospective cohort]: This was a multi-center, international prospective cohort study promoted through the International Society on Thrombosis and Hemostasis (ISTH). Inclusion criteria were objectively diagnosed SVT within six months of initiation in the study. There were no exclusion criteria. The study was conducted from 2008 to 2012, with follow up ending in 2014. Major endpoints evaluated were duration of antithrombotic therapy, major bleeding episodes and thrombosis events.

There were 604 patients in the study, of whom 465 received anticoagulation therapy. The mean duration of treatment was 13.9 months, with a standard deviation of 9.2 months. The rate of major bleeding for those on anticoagulation was 3.9 per 100 patient-years (95%CI 2.6-6.0), which reduced to 1.0 per 100 patient-years (95%CI 0.3-4.2) when therapy was discontinued. None of these bleeds were fatal. Amongst patients who never received anticoagulation, the rate of major bleeding was 5.8 per 100 patient-years (95%CI 3.1-10.7). The risk of bleeding was highest amongst patients with liver cirrhosis (10 per 100 patient-years) compared to all other comorbidities. In regards to thrombotic events, for patients on anticoagulation therapy, the rate was 5.6 per 100 patient-years (95%CI 3.9-8.0). This increased to 10.5 per 100 patient-years (95%CI 6.8-16.3) during the discontinuation phase. By comparison, for those who never received anticoagulation, thrombotic rate was 9.2 per 100 patient-years (95%CI 5.7-15.1). Again, the rate of thrombotic events was highest amongst those with liver cirrhosis (11.3 per 100 patient-years).

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