Endovascular stent placement for severe post-transplant portal vein anastomotic stenosis following an unsuccessful TIPS attempt

Portal vein anastomotic stenosis after liver transplantation is an uncommon but clinically important complication that can lead to portal hypertension, ascites, and impaired graft inflow. We present a case of a liver transplant recipient with persistent ascites in whom Doppler ultrasound and CT angiography suggested a focal narrowing of a complex anastomosis between portal vein and mesenteric varicose veins. An attempted TIPS procedure was unsuccessful because the stenotic segment could not be safely traversed; however, venography provided additional clues supporting a hemodynamically relevant obstruction. On the following day, a percutaneous transhepatic approach enabled definitive visualization of a short, high-grade stenosis, which was successfully treated with balloon-assisted stent placement. Early Doppler ultrasound demonstrated restored hepatopetal portal flow. This case highlights the value of a staged percutaneous stent placement technique when TIPS is technically unfeasible.