Ultrasound-assisted thrombolysis of an occluded transjugular portosystemic shunt

Transjugular intrahepatic portosystemic shunt (TIPS) insertion is commonly performed for refractory ascites or variceal bleeding. However, TIPS dysfunction can be seen in both early and late settings, with shunt thrombosis a particular problem. Treatment of shunt dysfunction commonly involves angioplasty and re-lining, with or without embolectomy, mechanical thrombectomy, or thrombolysis. Ultrasound-assisted thrombolysis has been shown to be successful for treatment of pulmonary embolism, deep vein thrombosis, and peripheral arterial thromboembolism, but has not been described before for TIPS occlusion. Ultrasound is theorized to lead to a shortened duration of thrombolysis due to thinning of the fibrin clot and exposing plasminogen receptor sites. In this technical report, we describe the first published use of ultrasound-assisted thrombolysis in the declotting of an occluded TIPS. We found that the use of ultrasound-assisted thrombolysis allowed a relatively short duration of thrombolytic therapy, with removal of thrombus extending into the portal vein, facilitating stent re-lining. No complications were observed, in particular no bleeding complications. The TIPS remains patent at 8 months postprocedure.