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This review provides an updated and comprehensive overview of the diagnosis and management of splanchnic venous thrombosis (SVT), a rare but clinically important manifestation of venous thrombosis involving the portal, mesenteric, splenic, and hepatic veins. The aim of this article is to summarize and critically appraise recent advances in the evidence base for anticoagulant therapy, prognosis, and clinical decision-making across the diverse clinical settings in which SVT occurs, including the most important subgroups of liver disease, myeloproliferative neoplasms, and solid malignancy. The review integrates findings from prospective studies, meta-analyses, and registry data and highlights the evolving role of direct oral anticoagulants (DOACs) as an alternative to vitamin K antagonists and low-molecular-weight heparins. Meta-analyses demonstrate that anticoagulation increases the likelihood of vessel recanalization and improves survival in cirrhotic portal vein thrombosis (PVT) without increasing major bleeding. Pooled data suggest that DOACs achieve at least comparable efficacy to conventional anticoagulant drugs, with lower rates of thrombus growth and major bleeding, while low-dose rivaroxaban has proven effective for secondary prevention in chronic non-cirrhotic PVT. In cancer-associated SVT, anticoagulation reduces recurrence with acceptable bleeding risk, and in Budd-Chiari syndrome, DOACs show promising safety and efficacy in selected patients. Despite major progress in recent years, most evidence still remains observational, and randomized trials, pediatric data, and studies on long-term secondary prevention are urgently needed to further refine and standardize SVT management.