Acute synthetic portal graft thrombosis post–living donor liver transplantation (LDLT) is a rare, life-threatening complication. A 32-year-old woman with Budd-Chiari syndrome and chronic Yerdel grade IV portal thrombosis underwent LDLT using an expanded polytetrafluoroethylene jump graft from the superior mesenteric vein to the donor portal vein. Five months post-transplant, she developed acute graft failure and contrast-enhanced computed tomography confirmed complete occlusion with absent portal flow. Due to prohibitive surgical risk and lytic bleeding hazards, emergency transhepatic percutaneous mechanical thrombectomy with balloon angioplasty restored immediate portal flow without lytics. Liver function rapidly normalized, and the graft remained patent on Doppler ultrasound at 12-month follow-up. Emergency mechanical thrombectomy with angioplasty offers a feasible, effective endovascular salvage strategy for acute synthetic portal graft failure.

Hemodialysis vascular access dysfunction remains a major cause of morbidity and repeated interventions. Stenosis related to neointimal hyperplasia and altered hemodynamics leads to access flow limitation and thrombosis, particularly in AVFs. While percutaneous transluminal angioplasty is the standard first-line treatment, durability is often limited, resulting in frequent reinterventions. Drug-coated balloons, most commonly paclitaxel-based, have been introduced to inhibit restenosis and have demonstrated improved target lesion patency compared with conventional balloon angioplasty in several randomized trials, though outcomes vary by lesion location and study design. This narrative review summarizes the current evidence for drug-coated balloon angioplasty in dysfunctional arteriovenous access, discusses key trial endpoints, reviews safety and practical considerations, and highlights ongoing controversies and future directions.