IVUS-Guided TIPS Thrombectomy for Acute Non-Cirrhotic Portomesenteric Thrombus: Case Series and Review of Literature

• Transjugular intrahepatic portosystemic shunt (TIPS) placement with Intravascular ultrasound (IVUS) guidance and mechanical thrombectomy via a TIPS approach are both well described techniques  
  


• Combined IVUS-guided TIPS creation and mechanical thrombectomy is a novel technique which may reduce complications and increase technical success in treating acute portomesenteric thrombus

Acute portomesenteric venous thrombosis (PMVT) is a clinical entity carrying severe morbidity, with sequelae including bowel ischemia, cavernous transformation of the portal venous system and portal hypertension, as well as significant mortality risk. The mainstay of the treatment of acute PMVT involves initiation of therapeutic-dose anticoagulation. However, patients with characteristics of severe disease including extensive and occlusive thrombus, bowel ischemia, symptomatic portal hypertension, or with contraindications to anticoagulation, may require interventional treatment to rapidly clear clot burden and restore portal venous flow.  
 

 

 

 

 

 

 

 

 

Clinical Findings/Procedure Details:

Six patients underwent intravascular ultrasound (IVUS)-guided TIPS creation and large-bore aspiration thrombectomy with either 12 Fr or 16 Fr Penumbra Lightning vacuum thrombectomy catheters. Of the patients included, none had a history of cirrhosis or malignancy. Two patients were undergoing hematologic workup for comorbid clotting disorders. Technical success was observed in all patients, with complete clearance of portomesenteric venous thrombus in four patients and partial clearance of thrombus in two patients. One patient underwent small bowel resection after intervention for bowel necrosis identified prior to procedure; no procedure-related complications were encountered. IVUS guidance was beneficial in confirming needle trajectory and avoidance of extracapsular puncture. Follow up imaging was obtained at 1 month and 3 month intervals. Primary and secondary patency rates will be presented. Current literature regarding the use of IVUS guidance in TIPS creation suggests potential reductions in rates of liver capsule injury and bleeding events, and potential benefits in procedure time, radiation dose, and technical success rates {1,2}. 
 

 

 

 

 

 

 

 

 

Conclusion and/or Teaching Points:

IVUS-guided large-bore mechanical thrombectomy is a feasible and potentially efficacious technique for the treatment of acute portomesenteric venous thrombus with a low rate of complications and durable short to medium term patency rates. Current evidence suggests additive benefits in combining the two techniques.