26 May 2026
: Case report 
Glue Embolus-Induced Portosplenic Thrombosis in Transjugular Intrahepatic Portosystemic Shunt: A Novel Finding During Liver Transplantation
Unusual or unexpected effect of treatment
Mayank S. Kotadia
BDEF 1, David Saulino BD 2, Daiki Soma DE 3, Asad H. Bashir ABDEF 1*
DOI: 10.12659/AJCR.952418
Am J Case Rep 2026; 27:e952418
Table 1 Chronological overview of key interventions, anticoagulation changes, and hematologic indices from pretransplant thrombectomy to discharge, highlighting how anticoagulation was repeatedly adjusted in response to evolving thrombotic and bleeding risks during orthotopic liver transplantation.
| POD | Key event/intervention | Anticoagulation regimen* | INR/aPTT** | Hgb (g/dL−1) | Imaging/surgical finding | Outcome/ next action |
|---|---|---|---|---|---|---|
| −104 | IR suction thrombectomy of occluded TIPS stent | UFH infusion → enoxaparin 1 mg/kg SC q12h (POD 103) then bridged back to warfarin 2.5 mg qd | 1.8/− | 9.5 | Postthrombectomy venogram: patent TIPS; CT POD 99: patent TIPS, small thrombus at IVC junction, chronic nonocclusive PVT → SV; ascites and splenomegaly | Residual clot monitored; discharged on warfarin + oral antibiotics |
| −1 | Admit for OLT; preoperative evaluation | Warfarin 2.5 mg qd (last dose POD −2) | 3.8/46 s | 8.9 | CT POD −1: clot from splenic vein traversing patent TIPS into IVC | Plan PCC reversal at induction; proceed to OLT |
| 0 | Orthotopic liver transplant + portal thrombectomy; PCC 25 IU/kg IV | UFH drip 12 IU kg/h, antiXa 0.3–0.7 | 1.7/36 s | 10.6 | Intraoperative US/TEE: stable flows; US 15: 26 and CT 17: 01 – thrombus at portal anastomosis, intrahepatic PV patent | Extubated in OR; fullintensity UFH in SICU |
| 1 | Reexploration, washout, portal revision, SMV/SV thrombectomy | UFH continued intraoperatively | 2.7/− | 6.8 | CT POD 2: similar SMV clot, new 11.6×6 cm perihepatic hematoma | Heparin paused after hematoma identified |
| 3 | Thirdlook laparotomy; hematoma washout | Anticoagulation held | 1.4/− | 7.7 | CT POD 5: evolving perihepatic hematoma, active bleed; PV patent; small subsegmental PE | Delay UFH restart until Hgb stable |
| 11 | Lowintensity UFH restarted (500 IU/h) | UFH 500 IU/h (flat rate) | 0.9/26 s | 8 | US POD 8 and 10: sluggish but patent portal flow | Daily CBC, antiXa monitoring |
| 21 | First upper GI bleed; EGD banding; octreotide infusion | UFH paused ×72 h | 1.1/− | 9.2 | CT GIbleed protocol POD 21: no active extravasation; US Doppler unchanged | UFH restarted lowdose POD 23 |
| 31 | Recurrent UGIB; EGD + gastric varix banding; splenic artery embolization | UFH paused → restart 250 IU h on POD 34 | 1.2/34 s | 8.4 | IR angiogram POD 31: successful splenic embolization; CT POD 31: no active bleed | Escalated to highintensity UFH by POD 33 |
| 34 | Right femoral pseudoaneurysm treated with thrombin injection | UFH highintensity (antiXa 0.4–0.5) | 1.0/57 s | 9.4 | US: pseudoaneurysm thrombosed; CT POD 34: persistent nonocclusive PVT, perihepatic hematoma improving | Continue systemic UFH |
| 43 | Triphasic CT shows improved PVT; anticoagulation switched to DOAC | Apixaban 5 mg PO bid | 1.0/−# | 9.4 | CT POD 43: PVT reduced to 1.4×0.2 cm; SMV patent; splenic infarcts increased | Plan repeat CT in 3 months after discharge |
| 47 | Discharge to inpatient rehabilitation | Apixaban 5 mg PO bid | 1.3/33 s## | 9.8 | Bedside Doppler: patent portal flow; reference CT POD 44 | Outpatient transplant clinic followup |
| * Doses reflect best available documentation; ** aPTT is shown when UFH was active; anti-Xa levels were # DOAC therapy renders INR unreliable; value provided for completeness; ## aPTT performed for bleeding screen, not for monitoring apixaban. aPTT – activated partial thromboplastin time; CBC – complete blood count; CT – computed tomography; DOAC – direct oral anticoagulants; EGD – esophagogastroduodenoscopy; GI – gastrointestinal; Hgb – hemoglobin; INR – international normalized ratio; IR – interventional radiology; IV – intravenous; IVC – inferior vena cava; OLT – orthotopic liver transplantation; OR – operating room; PCC – prothrombin complex concentrate; PE – pulmonary embolism; PO – per os; POD – postoperative day; PV – portal vein; PVT – portal vein thrombosis; SICU – surgical intensive care unit; SMV – superior mesenteric vein; SV – splenic vein; TEE – transesophageal echocardiogram; TIPS – transjugular intrahepatic portosystemic shunt; UFH – unfractionated heparin; UGIB – upper gastrointestinal bleeding; US – ultrasound. | ||||||