Safety of Anticoagulation When Undergoing Endoscopic Variceal Ligation: A Systematic Review and Meta-Analysis.

Introduction: The safety of continuing anticoagulation therapy during endoscopic variceal ligation (EVL) remains controversial. We performed a systematic review and meta-analysis to evaluate the safety of anticoagulation therapy in EVL.

Methods: We systematically searched four electronic databases from their inception until 1 June 2024, for studies that evaluated anticoagulation use and risk of rebleeding among patients undergoing EVL. The primary endpoint was rebleeding after EVL. The secondary endpoints were post-banding ulcer bleeding (PBUB) and variceal eradication rate. The PROSPERO registration number is CRD42024556094.

Results: A total of 5617 participants from nine studies (eight cohort studies and one randomised trial) were included. The most common type of anticoagulation is low-molecular-weight heparin, followed by warfarin and direct oral anticoagulants (DOAC). The pooled risk of rebleeding was 10.9% (95%CI: 6.3-16.5; I² = 65.5%). Concurrent anticoagulation during EVL did not increase the risk of overall rebleeding (OR, 1.10; 95%CI: 0.85-1.42, I² = 0%), PBUB (OR, 1.04; 95%CI, 0.48-2.24; I² = 24%) or severe bleeding (OR, 0.94; 95%CI, 0.31-2.85; I² = 0%). Variceal eradication rates were similar, regardless of the use of anticoagulation therapy during EVL.

Conclusion: Anticoagulation did not increase the risk of rebleeding in patients who underwent EVL. Since the certainty of evidence is low, these findings should be confirmed in future randomised trials.