What is the best course of action for a adult patient with a history of cirrhosis and a Transjugular Intrahepatic Portosystemic Shunt (TIPS) who develops thrombus after 2 years of proper functioning?

Management of TIPS Thrombosis After Two Years of Function

For a cirrhotic patient with TIPS thrombosis after 2 years of proper functioning, proceed directly to invasive TIPS revision with mechanical thrombectomy or catheter-assisted thrombolysis, combined with restenting as needed, after excluding active infection, liver failure, cardiac failure, and severe hepatic encephalopathy. 1

Diagnostic Confirmation

Initial assessment with Doppler ultrasound is mandatory to confirm TIPS dysfunction, which demonstrates sensitivity of 0.96 and specificity of 1.0 for complete TIPS occlusion, showing stop-flow or hepatofugal blood flow with reduced vein compressibility. 1

• Contrast-enhanced portal-venous CT angiography should follow to provide anatomical visualization of the portal-venous vascular axis and confirm the extent of thrombosis. 1
• Clinical symptoms prompting evaluation include recurrent variceal bleeding, worsening or new-onset ascites, or other signs of portal hypertension recurrence occurring more than 3 months after initial TIPS creation. 1

Pre-Intervention Exclusion Criteria

Before proceeding with TIPS revision, you must exclude the following contraindications:

• Active uncontrolled infection 1
• Acute liver failure or severe hepatic decompensation 1
• Cardiac failure 1
• Severe or medically unresponsive hepatic encephalopathy 1

Intervention Strategy for Complete Occlusion

The 2025 EASL guidelines provide clear direction for complete TIPS occlusion:

• Mechanical thrombectomy or catheter-assisted thrombolysis with or without stent implantation are the primary approaches for complete TIPS tract occlusion. 1
• If the standard transjugular approach fails, alternative techniques include the pull-through technique or trans-splenic approach combined with a rendezvous procedure transjugularly, though these are reserved for selected cases. 1
• In cases where recanalization proves impossible, parallel new TIPS insertion can be evaluated as an alternative. 1

Technical Considerations During Revision

Venography with hemodynamic assessment is essential during the procedure:

• Perform pressure measurement with a withdrawal curve to document the exact location and hemodynamic significance of any stenosis or obstruction. 1
• A portocaval pressure gradient >12 mmHg indicates hemodynamically significant dysfunction requiring intervention. 2
• If stent misalignment or stenosis at the venous end is identified, extend the TIPS tract by overlapping implantation of additional stents/stent grafts up to the vena cava opening to achieve proper alignment and unobstructed flow. 1

Additional Interventions

If the patient presents with active variceal bleeding, particularly from ectopic varices:

• Embolization of the varices should be performed in addition to TIPS revision, especially when persistent variceal filling is demonstrated, as ectopic varices can bleed even at low portal pressures. 1

Role of Anticoagulation

Anticoagulation after TIPS revision is NOT routinely indicated in cirrhotic patients:

• Randomized controlled trial data demonstrate no significant difference in complete portal system recanalization rates when anticoagulation was continued versus discontinued after TIPS creation (84% vs. 72%). 1, 3
• The French guidelines explicitly state that continuing anticoagulation after TIPS does not confer benefits in cirrhotic patients. 1, 3
• Exceptions where anticoagulation IS indicated: underlying prothrombotic disorder (myeloproliferative disease, antiphospholipid syndrome), Budd-Chiari syndrome component, or extensive pre-existing portal vein thrombosis extending into the superior mesenteric vein. 3

Understanding Late TIPS Dysfunction

The mechanism of thrombosis after 2 years differs from early dysfunction:

• Progressive neointimal hyperplasia developing within the TIPS stent over time is the dominant mechanism of late dysfunction, causing gradual luminal narrowing rather than acute thrombotic occlusion. 2
• Modern covered stents have significantly reduced but not eliminated this complication compared to bare metal stents used historically. 2
• This gradual hyperplastic response takes months to years to reach hemodynamically significant stenosis, explaining why dysfunction occurs after an initial period of good function. 2

Common Pitfalls to Avoid

Critical errors in management include:

• Delaying intervention once TIPS dysfunction is confirmed—revision should be performed as soon as possible, especially with bleeding complications. 1
• Attempting TIPS revision in patients with severe uncontrolled hepatic encephalopathy or acute liver failure, which significantly increases mortality risk. 1
• Routine anticoagulation after successful revision in standard cirrhotic patients, which increases bleeding risk without proven benefit for TIPS patency. 1, 3
• Failing to assess for and embolize competing collaterals or ectopic varices during the revision procedure, which can lead to persistent symptoms despite technically successful TIPS revision. 1