Pyrrolizidine alkaloid–induced hepatic sinusoidal obstruction syndrome (PA-HSOS) is highly prevalent in Asia, primarily due to the widespread use of traditional herbal medicines containing hepatotoxic pyrrolizidine alkaloids. This condition poses significant clinical challenges, including diagnostic difficulties and limited therapeutic options, frequently leading to severe liver damage and portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) treatment has emerged as a key intervention for managing complications associated with PA-HSOS, such as refractory ascites and variceal bleeding, by reducing portal pressure and supporting liver function recovery. However, TIPS has not been widely accepted as a salvage therapy for severe PA-HSOS unresponsive to anticoagulation therapy, mainly due to concerns about post-TIPS complications, particularly hepatic encephalopathy. Consequently, careful patient selection and risk stratification are critical. This review synthesizes the current evidence on PA-HSOS in Asia, evaluates the clinical utility of TIPS, and discusses strategies to optimize outcomes while minimizing adverse effects. Specifically, we review the epidemiology, pathophysiology, and diagnostic advancement of PA-HSOS, with a particular focus on the evolving role of TIPS in its management.

Acute SVC syndrome caused by extensive thrombosis requires prompt endovascular intervention. We report a 48-year-old female with colon cancer presenting with massive chemoport-related thrombosis involving the SVC, right atrium (RA), and bilateral brachiocephalic veins. Due to the lack of an embolic protection filter landing zone, we performed a novel plug-assisted thrombectomy (PAT) technique. A 20-mm vascular plug was positioned at the RA-SVC junction as a temporary tethered filter without detachment. Following mechanical thrombectomy, plug retrieval, and adjunctive balloon dilatation, the patient recovered and was discharged on day 12. This case demonstrates the technical feasibility of PAT as a proof-of-concept approach for embolic protection in patients with extensive SVC thrombosis where conventional filter placement is anatomically precluded.