In Budd–Chiari presenting with acute liver failure (ascites/encephalopathy) but a technically amenable short-segment hepatic vein lesion, how do you decide between urgent decompression (TIPS/DIPS or recanalization) versus prioritizing expedited transplant listing?

I would work up this patient for transplant because the presence of encephalopathy is very concerning. If a proper transplant candidate, without contraindications, and not meeting criteria for status 1a, I would plan for the TIPS. The patient is likely already on rifaximin and lactulose.