Recurrent TIPS dysfunction and variceal bleeding: A combined, staged, use of large-bore aspiration thrombectomy and partial splenic artery embolization-A case report

Abstract

A 51-year-old man, with a history of cirrhotic portal hypertension and recurrent transjugular intrahepatic portosystemic shunt (TIPS) stenoses, presented with an acute gastro-esophageal variceal hemorrhage in the setting of an acute and massive thrombotic TIPS shunt occlusion. The clinical presentation was complicated by patient's severe, chronic thrombocytopenia which had precluded empiric anticoagulation previously for recurrent TIPS dysfunction. Following endoscopic treatment of the variceal bleeding, the CAT 12 Indigo aspiration system (Penumbra) was used to remove a large burden of thrombus from the TIPS, allowing successful re-stenting and restoration of blood flow through the TIPS. A staged partial splenic artery embolization was performed a few days later to reduce hypersplenism and treat the thrombocytopenia. The patient was then therapeutically anticoagulated to prevent future TIPS occlusion.

Keywords: Covered stent; Splenic artery embolization; Splenomegaly; TIPS.

Fig. 1

Coronal CT image shows thrombotic occlusion of the TIPS shunt and massive splenomegaly. Note hepatic dome hypodense lesion which represents post ablation changes related to a hepatocellular carcinoma.

Fig. 2

DSA images from the TIPS thrombectomy procedure. (A) demonstrates residual thrombus (arrow) in the TIPS shunt after a few passes of suction thrombectomy. Relining the TIPS shunt was successful after thrombectomy, and a stenosis in the hepatic vein just cephalad to the TIPS shunt can be seen (arrows) (B). 10 mm Balloon angioplasty was therefore performed (C). After the procedure, the shunt is widely patent with improved caliber of the hepatocaval junction stenosis (D).

Fig. 3

4 days after the TIPS thrombectomy, partial splenic artery embolization was successfully performed with particles and coils to treat hypersplenism (arrows).