Clot Out, Flow Back: Large-Bore Aspiration Thrombectomy for Symptomatic Early Transjugular Intrahepatic Portosystemic...

Thrombotic occlusion of a transjugular intrahepatic portosystemic shunt (TIPS) returns the patient to the portal-hypertensive state prior to shunt creation and requires early recognition and intervention. We describe a 45-year-old woman with metabolic dysfunction-associated steatohepatitis (MASH) cirrhosis who underwent TIPS placement for refractory ascites with subsequent clinical improvement. Approximately two months later, she presented with progressive anasarca, bilateral lower-extremity edema, abdominal distension, and diffuse abdominal pain. Computed tomography (CT) and Doppler ultrasound demonstrated complete in-stent shunt thrombosis, cirrhotic morphology, and moderate ascites. She was started on therapeutic heparin and underwent transjugular TIPS recanalization with large-bore mechanical aspiration thrombectomy followed by balloon angioplasty directed at the hepatic venous outflow segment. Completion venography demonstrated restored flow through the shunt without residual stenosis or obstruction; the portosystemic pressure gradient decreased from 21 to 13 mmHg. Her abdominal pain and manifestations of volume overload improved, and she was discharged on apixaban. This case demonstrates that single-session large-bore aspiration thrombectomy combined with balloon angioplasty can achieve technical, hemodynamic, and early clinical success in symptomatic early TIPS occlusion. Further studies are needed to determine its long-term efficacy and optimal role in TIPS revision.