Combined transhepatic and transjugular approach for mechanical thrombectomy of massive TIPS thrombosis

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-validated decompressive therapy option to manage ascites and variceal bleeding secondary to portal hypertension. Complications following TIPS procedures include hepatic encephalopathy, liver failure, and TIPS dysfunction. TIPS dysfunction is due to occlusion or stenosis of the TIPS shunt and can be caused by acute or chronic thrombosis. TIPS thrombosis is often treated with mechanical thrombectomy or catheter-directed thrombolytic therapy. Most cases of in-stent occlusion can be treated via a transjugular approach with recanalization or placement of additional stents. We present a case of a 72-year-old female who presented with worsening ascites 17 months after initial TIPS procedure; she was found to have a large thrombus completely occluding the TIPS stent. In our case, a combined transhepatic and transjugular approach was required for TIPS revision given the extent of well-organized clot located near the hepatic venous end of the stent, resulting from prolonged stent occlusion. This was an extremely challenging scenario with two overlapping covered stents and a bare metal stent at the hepatic venous end in the setting of chronic thrombosis and a well-organized fibrous cap. The case highlights the need for optimal initial placement of the primary TIPS shunt to avoid the need for subsequent complex interventions to maintain TIPS shunt patency.

Keywords: Portal hypertension; TIPS; Thrombectomy; Thrombolysis; Thrombosis; Transjugular intrahepatic portosystemic shunt.

Fig. 1

Duplex ultrasound images of the TIPS stent showing no blood flow within the TIPS shunt.

Fig. 2

Portal angiography at an outside hospital showing occluded TIPS, patent main portal venous system, 2 covered stents (green arrow), one extension uncovered stent (blue arrow) and a malpositioned portal end stent (red arrow).

Fig. 3

Venous phase of a contrast-enhanced CT of the abdomen showing thrombus within the TIPS stent extending to the superior mesenteric vein inflow. Both axial (Fig. 3A) and coronal images (Fig. 3B) are shown.

Fig. 4

Spot fluoroscopy image showing “flossed” access after combined transhepatic and transjugular approaches, to perform thrombectomy within the mesenteric venous system.

Fig. 5

Large thrombus measuring 31 cm in length removed from TIPS stent with the Penumbra System Lighting12. The hepatic venous end fibrous cap can be seen (Orange arrow).

Fig. 6

Final portal angiogram showing functioning TIPS shunt, with chronic mural based thrombus within the portal end and within the stent. Extension stent within the main portal vein to displace portal end of the malpositioned stent. Residual stenosis is seen despite angioplasty at the hepatic venous end (blue arrow).