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Background Acute non-malignant portomesenteric venous thrombosis (PMVT) is associated with high morbidity and mortality in a young patient population. Chronically it can result in portal hypertension (PHT), pain and poor nutrition. We report 24-month outcomes of a series of patients presenting with this condition who acutely received a stepwise therapeutic protocol consisting of systemic thrombolysis with low-dose tissue plasminogen activator (L-tPa) +/- Transjugular Intrahepatic Portosystemic Shunt (TIPSS) with thrombectomy and catheter-directed thrombolysis if indicated.Method We conducted a retrospective analysis of clinical records of patients with acute PMVT who were transferred to a tertiary centre for stepwise management between 2014–2024 and thereafter followed up at 3 months (3M), 6 months (6M), 12 months (12M) and 24 months (24M) post-discharge.Results 99 patients were included, 65 (65.7%) were male. Mean age was 47 years (SD=15). All patients had thrombosis of the superior mesenteric vein (SMV) on cross-sectional imaging and had persistent abdominal pain despite standard anticoagulation prior to the initiation of L-tPa. 8/99 (8.1%) patients had underlying chronic liver disease. Median time to initiation was 12 (IQR=13) days of symptoms. Follow-up post-discharge at 3M (n=63), 6M (n=49), 12M (n=50) and 24M (n=30) of these patients were reviewed. Findings are summarised in table 1.The majority of patients (see table) received warfarin as long-term anticoagulation. 92.9% were pain-free at discharge which was maintained in 72% of the patients followed up at 12 months. 93.3% of patients at 24M were maintaining adequate nutrition. Further surgical or vascular intervention was not required in 93.3% of patients at 24M. 16.3% required readmission to hospital at 6M, 26% at 12M and 20% at 24M. 86% and 83.3% of patients followed-up at 12M and 24M respectively did not develop any clinical features of PHT. TIPSS was inserted in 48 patients of which 41 (85.4%) remained patent on discharge; 16/21 (76.2%) and 9/11 (81.8%) were still patent at 12M and 24M respectively.Abstract O5 Table 1Clinical outcomes over 24 months following discharge of patients who received low-dose systemic thrombolysis ± TIPSS for acute portomesenteric thrombosis Discharged (Total) 3 months 6 months 12 months 24 months n = 99 63 49 50 30 Patients with TIPSS 48 (48.5%) 21 (33.3%) 15 (30.6%) 21 (42%) 11 (36.7%) Patent TIPSS 41 (85.4%) 15 (71.4%) 11 (73.3%) 16 (76.2%) 9 (81.8%) Warfarin 26 (26.3%) 45 (71.4%) 39 (79.6%) 37 (74%) 25 (83.3%) DOAC 15 (15.2%) 6 (9.5%) 6 (12.2%) 6 (12%) 4 (13.3%) No pain 92 (92.9%) 36 (57.1%) 24 (49%) 36 (72%) 20 (66.7%) No further surgical or vascular intervention required 59 (93.7%) 41 (83.7%) 43 (86%) 28 (93.3%) Re-admission 8 (16.3%) 13 (26%) 6 (20%) Adequate nutrition 45 (90%) 28 (93.3%) No features of portal hypertension 43 (86%) 25 (83.3%) Oesophageal Varices 4 (8%) 2 (6.7%) Gastric varices 1 (2%) 0 (0%) Splenomegaly 0 (0%) 2 (6.7%) Ascites 3 (6%) 1 (3.3%) Conclusion Our stepwise protocol achieved good recanalization and patency rates. Most patients had sustained symptom control over a 24M period. Few patients developed features of PHT (<17% at 24 months). This contrasts with recently presented data in patients with recent thrombosis and no intervention which showed 39% of patients developed PHT (and over half of these patients had milder presentation with incomplete portal vein thrombosis and no SMV thrombosis) 1. Readmission and further intervention were avoided in the majority.Reference GS-004 Development of portal hypertension after non-cirrhotic non-tumoral recent portal vein thrombosis (RPVT). A long-term follow-up study. Alabau B, et al. Journal of Hepatology. May 2025;82:S3–S4.