Portal vein thrombosis after occlusion of a transjugular intrahepatic portosystemic stent shunt (TIPSS): Shunt dilatation with subsequent local and systemic thrombolysis

History and clinical findings: A transjugular intrahepatic portosystemic stent shunt (TIPSS) had been implanted to lower the portal hypertension in a 56-year-old man with alcoholic liver cirrhosis and several bleedings from fundal varices. A shunt revision with dilatation became necessary one year later. Recently the patient had gained 8 kg in weight in 3 weeks and his abdomen had become distended. The patient's general condition (height 179 cm, weight 82.9 kg) was clearly reduced. He had marked ascites, the liver was enlarged to 17 cm below the costal margin and the right lung base was dull on percussion. Investigations: Abdominal sonography detected marked ascites and liver cirrhosis with splenomegaly. Duplex sonography failed to demonstrate any flow in the shunt, indicating its occlusion. Treatment and course: At retrograde dilatation of the stent a fresh thrombosis was noted in the Fight branch of the portal vein and a partial one in the main trunk. Recanalization was achieved locally 10 mg and systemically 100 mg recombinant tissue plasminogen activator (r-tPA). Hepatic vein pressure measurements before and after the thrombolysis demonstrated a significantly lower hepatic venous occlusion gradient, and the portal hypertension had been reduced by about 45%. The ascites gradually resolved. Conclusion: Combined local and systemic thrombolysis was successful in recanalizing portal vein thrombosis after TIPSS.