A case of congenital stenosis of the inferior vena cava with portal hypertension

Congenital systemic venous drainage obstruction: A case report

BACKGROUND

Vena cava anomalies are rare congenital defects due to incorrect development during fetal life, ranging from minor asymptomatic anatomic variations to complex life-threatening abnormalities. Echocardiography plays a fundamental role in the diagnosis, with advanced imaging techniques allowing detailed anatomic delineation. Invasive cardiology techniques are a promising therapeutic approach, but surgery is probably the best option when diffuse compromise of the systemic veins is present.

CASE REPORT

An 8-month-old infant presenting episodes of labial cyanosis and a failure to thrive was diagnosed with severe superior vena cava (SVC) stenosis at the right atrium ostium, with decompression via azygos vein and mild inferior vena cava (IVC) stenosis. The patient was referred for surgery, with IVC enlargement and removal of a fibromuscular tissue band on the anterior aspect of the SVC ostium. At a 6-month follow-up, the patient is asymptomatic, with excellent surgical outcome. To the authors' knowledge, only two cases of congenital SVC stenosis have been previously described.

Membranous obstruction of the inferior vena cava (obliterative hepatocavopathy, Okuda)

Confusion prevails throughout the world regarding the definition and classification of the Budd-Chiari syndrome. The original patients (Budd and Chiari) described had hepatic vein thrombosis, but this syndrome now encompasses various hepatic venous outflow blocks, of which membranous obstruction of the inferior vena cava (IVC) is the most common. This author has been suggesting that the classical Budd-Chiari syndrome or hepatic vein thrombosis and membranous obstruction of IVC or primary thrombosis of IVC at its hepatic portion are epidemiologically, pathologically and clinically different, and that they should be treated as two clinical entities that are not to be mixed. The two diseases have a different onset, different clinical manifestations and a different natural history. Whereas hepatic vein thrombosis is a severe disease with an acute onset, IVC thrombosis presents mildly at onset, but it recurs and eventually turns into a fibrous occlusion of IVC of varying thickness or stenosis of a various degree. The fibrous IVC occlusion is found as a mysterious thin membrane, but is more often much thicker than a membrane, and therefore 'membrane' is a misnomer. Although the genesis is not established, formation of a thin membrane may be an outcome of recurrent thrombosis. The past congenital vascular malformation theory no longer holds, because the disease occurs mostly in adulthood, and transformation of thrombosis into a membrane has now been well documented pathologically as well as clinically. This author suggests that a term 'obliterative hepatocavopathy' replace membranous obstruction of IVC, the term 'Budd-Chiari syndrome' be abandoned, and that primary hepatic venous outflow block be divided into primary hepatic vein thrombosis and primary IVC thrombosis (obliterative hepatocavopathy).

Pre-operative and post-operative ultrasound evaluation of Budd Chiari syndrome due to coarctation of the inferior vena cava

Coarctation of the inferior vena cava (IVC) is being increasingly recognised as a congenital and operable cause for chronic Budd Chiari syndrome. It is necessary to distinguish this entity from other causes of Budd Chiari syndrome because of a more favourable outcome after surgery. Early diagnosis would result in surgical intervention before irreversible liver damage and also possibly avoid the onset of hepatocellular carcinoma. Real time ultrasound has proved valuable in pre-operative diagnosis in nine patients with coarctation of the IVC. It has also been found useful to confirm patency of dorsal cavo-atrial bypass using polytetrafluoroethylene grafts in five patients and isthmusplasty of the IVC in one patient. Ultrasound is recommended for routine screening of high risk population.

Transformation of inferior vena caval thrombosis to membranous obstruction in a patient with the lupus anticoagulant

A 24-yr-old woman with hemolytic anemia developed multiple thrombosis of the hepatic vein and inferior vena cava. She was found to have circulating lupus anticoagulant that could have been causally related to the thrombosis and hence the Budd-Chiari syndrome. On her first admission to the hospital vena cava and hepatic vein catheterizations revealed partial thrombotic occlusion of the cava at the level of the diaphragm, which was subsequently transformed into complete membranous obstruction. The right hepatic vein, which was patent on the first admission, was also completely occluded. These observations support the theory that membranous obstruction of the inferior vena cava is a sequela to inferior vena caval thrombosis rather than a congenital anomaly.

Diagnostic value of combined transhepatic venography and inferior vena cavography in chronic Budd-Chiari syndrome

In a series of 19 patients with Budd-Chiari syndrome, transhepatic venography and inferior vena cavography were used to localize the site of hepatic outflow obstruction. Classification into two types was made on the basis of the site of obstruction. Four cases were grouped as type I, in which obstruction was localized in the hepatic vein alone, and the inferior vena cava (IVC) was patent. Fifteen cases were of type II, in which there was a well-defined obstruction in the intrahepatic portion of the IVC or ostium of a hepatic vein. This study highlights the frequent occurrence of IVC obstruction as a cause of chronic Budd-Chiari syndrome in northern India and the utility of transhepatic venography in its diagnosis.