Aspiration Thrombectomy of a Completely Thrombosed Transjugular Intrahepatic Portosystemic Shunt Stent using the INARI Flow Triever Device: A Case Report

Abstract

This report details the use of the INARI FlowTriever aspiration thrombectomy device to successfully declot a thrombosed transjugular intrahepatic portosystemic shunt (TIPS) stent in a 50-year-old man with history of cirrhosis with portal hypertension. Patient presented with abdominal pain and worsening ascites, and the TIPS was found to be completely thrombosed on computed tomography imaging. The stent was recanalized with aspiration thrombectomy, portal venogram after balloon venoplasty showed brisk antegrade flow with no residual stenosis. Patient's symptoms resolved immediately postprocedure. This case underscores the importance of routine TIPS follow-up and highlights the efficacy of aspiration thrombectomy, contributing to the evolving strategies for managing TIPS complications.

Keywords

TIPS - thrombectomy - portal hypertension

Introduction

Transjugular intrahepatic portosystemic shunt (TIPS) placement is a well-established method for alleviating portal hypertension in patients with conditions such as ascites or esophageal varices.[1] Shunt dysfunction often arise from stenosis or occlusion, necessitating revision.[2] For thrombosed TIPS stents, mechanical thrombectomy using large-bore aspiration catheters has rarely been reported. This case report presents the use of the INARI FlowTriever large-bore aspiration catheter to successfully declot a thrombosed TIPS stent.

Case Report

A 50-year-old man with history of alcoholic cirrhosis complicated by portal hypertension with recurrent ascites necessitating TIPS placement 26 months prior presented with abdominal pain and worsening ascites for 2 weeks. Computed tomography with contrast timed to the portal venous phase revealed complete in-stent thrombosis extending to the portal vein ([Fig. 1]). Interventional radiology was consulted for TIPS declot and revision.

Fig. 1 Contrast-enhanced computed tomography scan of the abdomen in a 50-year-old man with indwelling stent who presented with acute abdominal pain and recurrent, worsening ascites. (A) Axial and (B) coronal images showing complete thrombosis of the TIPS stent with the thrombus extending into the main portal vein (arrow). TIPS, transjugular intrahepatic portosystemic shunt.

The internal jugular vein was accessed under ultrasound guidance and a 10 Fr sheath was placed. The right hepatic vein was selected using an MPA catheter (Angiodynamics, Latham, New York, United States), and the thrombosed TIPS stent was carefully crossed with a stiff Glidewire (Terumo, Tokyo, Japan). Once the uncovered portion was reached, a J-tipped wire (Merit, South Jordan, Utah, United States) was used to cross into the main portal vein. Portal venography using a marker pigtail catheter showed complete thrombosis within the TIPS stent, with opacification of numerous esophageal and gastric varices, including a distended coronary vein ([Fig. 2]).

Fig. 2 TIPS Declot procedure. (A) Portal venography prior to thrombectomy showing complete thrombosis of the TIPS stent with numerous variceal collaterals (arrowheads). (B) Postaspiration thrombectomy venography showing significantly improved flow through the TIPS shunt with focal area of in-stent stenosis, with persistence of the coronary vein (arrow). (C) Venogram after balloon venoplasty using a 10-mm balloon, showing improved flow and fewer collaterals. (D) Final venogram after venoplasty using 12-mm Conquest balloon showing brisk flow with minimal opacification of the coronary vein (arrow). TIPS, transjugular intrahepatic portosystemic shunt.

The 10-Fr sheath was replaced with a 16-Fr Protrieve Sheath (INARI, Irvine, California, United States), and the INARI FlowTriever 16 Aspiration Catheter (INARI, Irvine, California, United Sates) was used to perform mechanical thrombectomy through the occluded TIPS stent. One pass was made, performing four separate aspirations from the superior aspect of the TIPS stent to the main portal vein, revealing mixed acute and subacute thrombus. Postaspiration portal venogram showed a mostly patent TIPS stent with a focal area of moderate–severe in-stent stenosis. It was noted that the TIPS stent, a VIATORR 8 to 10 mm (Gore, Flagstaff, Arizona, United States) was dilated to 10 mm at initial placement. Balloon venoplasty through the TIPS stent was performed twice, using a 10-mm then a 12-mm Conquest balloon, with final postvenoplasty portal venogram showing brisk antegrade flow through the TIPS stent with no residual stenosis or filling defects. Portosystemic gradient was decreased from 16 mm Hg predeclot to 12 mm Hg after thrombectomy, 10 mm Hg after first venoplasty, then finally to 6 mm Hg after second venoplasty. The procedure lasted 1 hour 31 minutes and fluoroscopy time was 17 minutes. The patient's symptoms resolved immediately postintervention, with no further issues with TIPS malfunction as of his most recent follow-up at 8 months. As the thrombus burden was cleared and area of stenosis was treated with no presumed residual area of thrombogenesis, no anticoagulation was recommended upon patient's discharge.

Discussion

There is a strong emphasis on the need for routine TIPS follow-ups and timely revisions, when necessary, with a meta-analysis showing that reintervention to maintain shunt patency is required in 70 to 90% of patients within 2 years of creation.[3] In this case, the patient experienced complete stent thrombosis at 26 months, likely precipitating from the focal in-stent stenosis that was seen after initial aspiration thrombectomy.

TIPS shunt thrombosis is usually treated by balloon angioplasty, but depending on degree and chronicity of thrombus, balloon venoplasty alone is often not sufficient to fully clear the TIPS stent.[4] In some cases, catheter thrombolysis may be necessary as an adjunct to declot and revise the stent, whereas other options include mechanical thrombectomy or systemic anticoagulation. Mechanical thrombectomy includes multiple approaches; mechanical, hydrodynamic, and rheolytic methods have all been described. A case series published by Sullivan et al. showed successful recanalization of portal vein thrombosis using the Inari FlowTriever aspiration thrombectomy device.[5] This case demonstrates that the use of the same device to perform recanalization and declot of a thrombosed TIPS stent can be feasible. The acute to subacute timeframe of the patient's stent thrombosis likely contributed to the success and ease mechanical thrombectomy using the Inari device, as experience from pulmonary embolism aspiration thrombectomy shows that the Inari device is ideal for quickly removing acute and subacute clots.

Conclusion

Prompt and tailored interventions are essential for managing TIPS thrombosis. This case suggests that mechanical thrombectomy using the INARI FlowTriever device can be a feasible option in quickly declotting thrombosed TIPS stents. Further clinical investigations with larger patient cohorts can verify the safety and efficacy of this procedure.

Conflict of Interest

None declared.

• References

• 1 Tripathi D, Stanley AJ, Hayes PC. et al. Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension. Gut 2020; 69 (07) 1173-1192
• 2 Gravel G, Artru F, Gonzalez-Quevedo M. et al. Shunt dysfunction patterns after transjugular intrahepatic portosystemic shunt creation using a combination of a generic stent-graft and bare-stents. CVIR Endovasc 2024; 7 (01) 7
• 3 ter Borg PC, Hollemans M, Van Buuren HR. et al. Transjugular intrahepatic portosystemic shunts: long-term patency and clinical results in a patient cohort observed for 3-9 years. Radiology 2004; 231 (02) 537-545
• 4 Darcy M. Evaluation and management of transjugular intrahepatic portosystemic shunts. AJR Am J Roentgenol 2012; 199 (04) 730-736
• 5 Sullivan IW, Fonseca A, Brown M. et al. Large bore portal vein thrombectomy: an Inari FlowTriever case series. Cardiovasc Intervent Radiol 2023; 46 (01) 136-141

Publication History

Article published online:
17 February 2026