785 - Management of Portomesenteric Thrombosis in TIPS: Patient Selection, Endovascular Strategies, and Outcomes

Learning Objectives:

• Review contemporary strategies for managing portomesenteric venous thrombosis.


• Highlight the role of TIPS creation and recanalization techniques in acute and chronic thrombosis.


• Provide a stepwise framework for access, thrombectomy, thrombolysis, and stent strategies in complex portomesenteric cases.

Background: Portomesenteric venous thrombosis, involving the portal, superior mesenteric, and splenic veins, is a clinically significant condition. In cirrhotic patients, it complicates portal hypertension management and can preclude transplantation. In noncirrhotic patients, it risks bowel ischemia and chronic portal hypertension. While systemic anticoagulation is first-line, extensive clot burden, failure of medical therapy, or urgent indications for decompression necessitate intervention. Transjugular intrahepatic portosystemic shunt (TIPS) with recanalization has emerged as a pivotal therapy, allowing both clot clearance and durable portal decompression.

Clinical Findings/Procedure Details: Patient selection relies on imaging to assess thrombus acuity, extent, and transplant candidacy. Interventional therapy is indicated for progressive occlusion, bowel ischemia, or when TIPS is otherwise required. Standard techniques include transjugular or transhepatic access for wire traversal, angioplasty, and catheter-directed thrombolysis, followed by covered-stent TIPS to secure inflow and decompression. In more complex anatomy, transsplenic or hybrid access improves feasibility, and sharp recanalization or ultrasound-assisted thrombolysis may serve as adjuncts. Recent advances have expanded options: portal vein recanalization with TIPS is now a widely adopted reconstructive strategy, IVUS guidance enhances accuracy, and large-bore aspiration or mechanical thrombectomy devices provide rapid clot debulking in acute cases. Outcomes are favorable in acute or subacute thrombosis, while chronic cavernous transformation remains challenging. Post-procedure anticoagulation, surveillance, and timely TIPS revision are essential to sustain long-term patency.

Conclusion and/or Teaching Points: Management of PMVT in the TIPS setting requires integration of patient selection, technical expertise, and evolving device technologies. While anticoagulation remains standard therapy, endovascular recanalization with TIPS creation is now central to care, improving feasibility in both acute and chronic disease. Familiarity with these strategies allows for improvement of outcomes, retention of transplant options, and prevention of life-threatening consequences.