Inferior vena cava (IVC) filter placement is indicated; this patient cannot safely undergo anticoagulation because of his recent major gastrointestinal bleed. He is at increased risk for bleeding owing to the presence of a coagulopathy, likely secondary to his liver disease, and thrombocytopenia, likely due to hypersplenism from an enlarged spleen resulting from portal hypertension. Despite having prolonged coagulation parameters, patients with liver disease are not “autoanticoagulated” and may experience venous thromboembolism (VTE), because procoagulant and anticoagulant protein production is deficient in unpredictable ratios, making it nearly impossible to predict if the patient is most at risk for bleeding or thrombosis. Because of this, anticoagulation in patients with liver disease should be undertaken with caution because of the risk for bleeding. This patient's bleeding risk is very high because of the recent episode of bleeding varices. When IVC filters are necessary, retrievable filters are strongly recommended rather than permanent filters. Whether IVC filters are beneficial for patients with pulmonary embolism (PE) despite appropriate therapeutic anticoagulation is unclear; a possible indication is massive PE with poor cardiopulmonary reserve. No evidence supports the use of IVC filters in the primary prophylaxis of VTE. If the bleeding risk resolves, a conventional course of anticoagulant therapy is recommended with consideration of filter removal.

Considering this patient's risk for bleeding, no anticoagulant (such as heparin, argatroban, rivaroxaban) can safely be given. Additionally, rivaroxaban and argatroban are partially cleared by the liver and are contraindicated in severe liver disease.