a 41-year - old woman with a history of liver cirrhosis presented with recurrent portal hypertension and bleeding from esophageal varices .
three months prior to this admission , a tips was created with a 10 mm  7 cm wallgraft ( boston scientific , natick , ma ) . however , the stent 's anticoagulation was inadequate ( international normalized ratio [ inr ] : 1.02 - 1.21 ) after placement .
the initial attempts at recanalization of the completely occluded stent via the transjugular approach were unsuccessful .
therefore , a percutaneous transsplenic approach guided by ultrasound was used to gain entry to the splenic vein and portal vein for catheterization of the occluded stent . to perform the
ultrasound guided puncture of the splenic vein through the spleen , we used a skater introducer set ( angiotech , pbn medicals , denmark ) .
a 22-guage chiba needle was introduced into the splenic vein , then a 0.018 inch guide wire was placed through the chiba needle into the splenic vein , and a 6-fr dilator system was placed over the wire .
we then exchanged the 0.018 inch guide wire with a 0.035 inch guide wire , followed by a 5-fr introducer sheath and a 4-fr kmp catheter ( cook medical inc . ,
however , residual thrombosis of the stent was noted in combination with occlusion of the hepatic vein ( fig .
so , we performed catheter - directed intrathrombus thrombolysis with urokinase ( taiwan green cross co. , taipei , taiwan ) . in brief , the distal end of a 4 fr rc1 catheter ( cook medical inc . , bloomington , in ) with home - made side holes (
n = 10 , made by needle - sticks into the distal 5-cm segment of the catheter ) was wedged into the thrombosed tips stent . then , catheter - directed intrathrombus thrombolysis with a solution of 48 vials of urokinase ( 60,000 u / vial ) in 500 ml normal saline at a drip rate of 21 ml / hr ( i.e. , 2 vials / hr = 2,000 u
recanalization was performed in the following day and a wallstent endoprosthesis ( 14 mm  9 cm , boston scientific , natick , ma ) was placed , resulting in the successful opening of the shunt ( fig .
the catheters were removed and the transsplenic tract was embolized with 4 serial coils ( mwce-35 - 8/4-tornado , cook medical inc . ,
she is doing well five months after discharge and an ultrasound study indicates that the stent remains patent .
transjugular intrahepatic portosystemic shunt is now considered the procedure of choice for accessing the portal system for management of refractory variceal bleeding .
certain complications , including a high reintervention rate due to occlusion of the stent , have raised concerns regarding its application ( 2 , 3 ) . yet
recent reports have suggested that using a covered prosthesis improves the tips patency to longer than two years ( 4 , 5 ) .
although a covered stent had been employed in the patient presented here , thrombosis occurred early ( i.e. , within 3 months ) .
transjugular intrahepatic portosystemic shunt failure requires recanalization of the stent or placement of serial or parallel stents ( 6 , 7 ) .
neointimal hyperplasia at the ends of the stent may completely occlude the outflow hepatic venous tract ( 1 ) and this can make reintervention difficult . as in this case , an alternative route is needed when attempts at recanalization via a conventional transjugular approach fail .
the splenic vein drains directly to the portal vein , and its size and straight route make this approach an ideal option ( 5 , 8) .
the transsplenic approach has been used for other indications , as reviewed by tuite et al .
( 8) , but we are unaware of any other report of using the percutaneous transsplenic approach to recanalize an occluded tips stent .
additionally , we believe that the overnight infusion of a thrombolytic agent contributed to successful recanalization in our case ( 9 ) . concerns regarding post - procedural splenic bleeding and the reported difficulty some clinicians have experienced negotiating the pathway have limited the use of the transsplenic route . a cautious , image - guided approach reduces the risk of splenic hemorrhage ( 5 , 8) and obliteration of the transsplenic tract with coils upon completion of the procedure also assists in preventing post - procedural bleeding ( 8) .
no significant splenic bleeding occurred in our patient , despite her liver impairment , during or following the intervention .
subtherapeutic anticoagulation ( inr < 2 ) probably contributed to the thrombosis and subsequent occlusion in this patient . there is no routine anticoagulation protocol to follow for tips patients .
we prescribe anticoagulation for only the patients with tips dysfunction ; however , there is no reference available for the effectiveness of this regime . as a general rule for preventing thromboembolism , chronic oral anticoagulant therapy with a vitamin k antagonist
is administered and the dose is adjusted to achieve an inr of 2.0 to 3.0 ( 10 ) . in summary
, we have reported on a rare case of using the transsplenic approach for recanalization of a tips stent by thrombolysis .
transsplenic entry to the portal system is useful in recanalizing a stent that is difficult to reach through the usual transjugular route .
 a 41-year - old woman with liver cirrhosis had recurrent portal hypertension and bleeding from esophageal varices due to complete occlusion of a previously inserted transjugular intrahepatic portosystemic shunt stent . because recanalization of the stent by the transjugular approach was unsuccessful , ultrasound - guided entry to the splenic vein and portal vein was used . after catheter - directed intrathrombus thrombolysis , successful opening of the stent 
 was achieved and a stent was placed . 
 we herein report a rare case in which thrombolysis and recanalization of a tips stent were performed via a percutaneous transhepatic approach . 