Rescue transsplenic thrombectomy for portal remnant thrombosis after ALPPS stage 1

BACKGROUND: This report describes a critical complication following the first stage of an unplanned ALPPS procedure (Associating Liver Partition and Portal vein Ligation for Staged hepatectomy). While ALPPS is designed to induce rapid hypertrophy of the future liver remnant (FLR), the development of portal vein thrombosis (PVT) in the remnant liver can be catastrophic, jeopardizing the success of the second stage. This report highlights the novelty of using a rescue transsplenic mechanical thrombectomy and balloon dilation to restore flow, demonstrating a successful interventional radiology approach to salvage a complex surgical plan. CASE PRESENTATION: A 68-year-old male with a history of rectal adenocarcinoma was diagnosed with a 6 cm hepatic lesion (pancreatobiliary origin) infiltrating the right portal vein. During an intended right hepatectomy, intraoperative tumor progression prompted conversion to the first stage of a tourniquet ALPPS procedure. Ten days post-surgery, CT imaging revealed a partially occlusive thrombosis of the main portal vein and insufficient FLR growth. A transsplenic portography was performed, confirming stenosis at the left portal branch. The medical team intervened using Alteplase instillation followed by mechanical thrombectomy and balloon dilation of the stenotic area and embolization of the splenic tract. This approach restored portal flow and allowed completion of hepatectomy after adequate hypertrophy. CONCLUSIONS: Transsplenic mechanical thrombectomy performed by interventional radiology represents an effective option for the treatment of portal vein thrombosis following the first stage of an ALPPS procedure. In our case, it enabled portal recanalization and promoted the growth of the future liver remnant.