Fifth seed Matteo Berrettini survived an early scare on his return from a thigh injury to progress in the second round of the Western and Southern Open in Cincinnati over Albert Ramos-Vinolas on Tuesday.

The Italian world number eight, making his ATP Tour return since losing the Wimbledon final to Novak Djokovic in July, won 6-7 (5-7) 6-3 7-5.

The Spaniard claimed the first set in a tie-break but Berrettini hit back, sending down 25 aces for the match, winning 84 per cent on his first serve.

"I'm happy for the win. I think I served really well," Berrettini said. "My strokes from the baseline weren't working the way I wanted them to, but I knew from the beginning it's been a long time since I played a match, especially on hard, so I expected to feel a little bit weird."

The match extended to two hours and 20 minutes, with the Italian utilizing his backhand slice in the final set to get the edge.

Berrettini, who has a 33-7 record for the season, will face 12th seed Felix Auger-Aliassime or Karen Khachanov in the third round.

"I'm really happy that I'm going to have the chance to play another match because that's what I need," Berrettini said. "I need to play matches. I need to get in the best shape possible."

Canadian sixth seed Denis Shapovalov suffered a shock early upset, going down to France's Benoit Paire 6-3 4-6 7-5 in the Round of 64.

Former US Open, Wimbledon and Australian Open semi-finalist Grigor Dimitrov toppled 13th seed Roberto Bautista Agut 6-3 6-4 in one hour and 21 minutes.

Fellow seed Cristian Garin also bowed out, losing 4-6 6-3 6-4 to qualifier Tommy Paul, while ninth seed Hubert Hurkacz defeated Alejandro Davidovich Fokina 6-1 6-7 (3-7) 6-1.

Marin Cilic, John Isner, Sebastian Korda, Gael Monfils, Reilly Opelka, Lorenzo Sonego and Frances Tiafoe were the other Tuesday winners.

Isner sent down his 13,000th career ace in his three-set win over Briton Cam Norrie.