Efficacy and Safety of Endovascular Intervention for the Management of Primary Entire-Inferior Vena Cava Occlusion

Feasibility and long-term outcomes of hepatic vein recanalization in Budd-Chiari syndrome through intrahepatic collateral pathways

BACKGROUND AND AIMS

To investigate the feasibility and long-term outcomes of hepatic vein (HV) recanalization using intrahepatic collateral pathways in patients with Budd-Chiari syndrome (BCS) with HV obstruction.

METHODS

Clinical data of 29 BCS patients with HV obstruction and intrahepatic collateral pathways were reviewed. All patients underwent HV recanalization through the intrahepatic collaterals. Follow-up was performed at 1, 3, 6, and 12 months after treatment and annually thereafter. Cumulative patency and survival rates were assessed using Kaplan-Meier curves. The independent predictors of patency were determined using a Cox regression model.

RESULTS

HV recanalization was successful in 28 of the 29 patients (96.6%), with no complications. Of the 28 cases, simultaneous recanalization of the accessory HV and right HV was achieved in 11 patients, accessory HV and middle HV in six, accessory HV and left HV in three, right HV and middle HV in five, and left HV and middle HV in three. Twenty-eight patients were followed from 4 to 87 (mean, 53.6 ± 26.7) months after treatment, and six patients developed reocclusion. The overall cumulative 1-, 3-, 5-, and 7-year primary HV patency rates were 96.3, 82.9, 74.6, and 59.7%, respectively. The cumulative 1-, 3-, 5-, and 7-year survival rates were 100, 95.8, 95.8, and 86.3%, respectively.

CONCLUSION

Interventional treatment of HV obstruction in BCS patients through intrahepatic collateral approaches is well tolerated and feasible and can result in excellent long-term patency and survival rates.

Total Iliocaval Reconstruction in a Complex Palliative Patient with Malignant Inferior Vena Cava Syndrome

Inferior vena cava (IVC) compression secondary to mass effect is accompanied by edema, ascites, back and abdominal pain, and central nervous system symptoms. Most IVC syndrome cases described in the literature focus on the focal treatment of IVC lesions, and reports of complete iliocaval reconstructions secondary to malignant IVC syndrome in the palliative context are limited. In this case report, we describe the clinical presentation, technical approach, and symptomatic outcomes of a patient with extensive malignant compression and invasion of the iliofemoral venous system. An 82-year-old male with metastatic lung cancer invading the right upper quadrant of the abdomen presented with scrotal and bilateral lower extremity edema, as well as anasarca. Computed tomography (CT) demonstrated an 11 cm right adrenal metastasis and extensive retroperitoneal lymphadenopathy resulting in the compression of the IVC and iliac veins. Femoral venography demonstrated extensive collateral venous pathway formation with the opacification of the para-lumbar and vertebral veins, in addition to the vertebral/sacral venous plexus. Iliocaval reconstruction was performed using venous-dedicated stents. This case report highlights a technically successful total iliocaval reconstruction in a complex palliative patient with diffuse metastatic disease resulting in IVC compression and syndrome.

Establishment and validation of a prediction model for the first recurrence of Budd-Chiari syndrome after endovascular treatment: a large sample size, single-center retrospective study

OBJECTIVE

To investigate the independent risk factors for the first recurrence after endovascular management in patients with Budd-Chiari syndrome (BCS), and to establish a prediction model for predicting recurrence in target patients.

METHODS

BCS patients who underwent endovascular treatment in the Affiliated Hospital of Xuzhou Medical University from January 2010 to December 2015 were retrospectively examined, with their clinical, laboratory test, and imaging data collected and analyzed. Independent risk factors for recurrence were identified, and a prediction model was established and validated.

RESULTS

A total of 450 patients met the filtering criteria, and 102 recurred during the follow-up. The median follow-up time was 87 months, ranging from 1 to 137 months. The 1-, 3-, 5- and 10-year cumulative recurrence rate was 9.11% (6.41-11.73%), 17.35% (13.77-20.78%), 20.10% (16.30-23.72%), and 23.06% (18.86-27.04%), respectively. Liver cirrhosis, ascites, thrombosis, and all the main intrahepatic drainage veins obstructed (obstructed HV + AHV) are independent risk factors, while age is an independent protective factor. The prediction model was named MRBET. Based on the model, the risk score of each patient equals (-0.385981 * Age/10) + (0.0404184 * PT) + (0.0943423 * CRE/10) + (0.0157053 * LDH/10) + (0.592179 * LC) + (0.896034 * Ascites) + (0.691346 * Thrombosis) + (0.886741 * obstructed HV + AHV), and those in the high-risk group (risk score ≥ 1.57) were more likely to recur than those in the low-risk group (HR = 6.911, p < 0.001). The MRBET model is also available as a web tool at https://mrbet.shinyapps.io/dynnomapp .

CONCLUSION

Liver cirrhosis, ascites, thrombosis, and obstructed HV + AHV are independent risk factors for the first recurrence; age is an independent protective factor. The prediction model can effectively and conveniently predict the risk of recurrence and screen out patients at a high recurrence risk.

Long-term outcomes of interventional treatment for Budd-Chiari syndrome with chronic accessory hepatic vein obstruction

OBJECTIVE

Interventional treatment is the main therapy for Budd-Chiari syndrome (BCS) with hepatic vein obstruction. The aim of this study was to investigate the long-term outcomes of endovascular management for BCS with chronic accessory hepatic vein (AHV) obstruction.

METHODS

In total, 68 patients with primary BCS who underwent AHV dilation with or without stenting from January 2008 to December 2018 were included in this retrospective study. The technical success rate and complications were recorded. Cumulative patency rates were estimated by the Kaplan-Meier curves and compared using the log-rank test.

RESULTS

Technical success was achieved in all 68 patients, and AHV patency was confirmed by postoperative angiography. Fifty-two patients underwent balloon dilation alone and 16 underwent adjunctive stent implantation. During a mean follow-up period of 60.2 ± 30.5 months, AHV reocclusion occurred in 14 patients in the balloon group and four patients in the stent group (χ2 = 0.034, P = 0.855). The overall cumulative 1-, 3-, 5-, and 7-year primary and secondary AHV patency rates were 90.6, 76.6, 72.0, and 68.2% and 98.4, 91.4, 89.2, and 89.2%, respectively. The cumulative 1-, 3-, 5-, and 7-year primary patency rates of the AHV were 89.8, 73.8, 71.2, and 71.2% in the balloon group and 93.3, 86.2, 75.4, and 60.3% in the stent group, respectively. There was no statistically significant difference between the two groups (P = 0.934).

CONCLUSION

Interventional treatment of BCS with chronic AHV obstruction has good long-term outcomes. Both balloon dilation alone and adjunctive stent implantation can be used for AHV recanalization.

Percutaneous sharp recanalization of a membranous IVC occlusion with an occlusion balloon as a needle target

A 50-year-old male with right upper quadrant symptoms and hepatic dysfunction was found to have multiple dilated hepatic veins (HVs) with intrahepatic collateralization and membranous occlusion of the intrahepatic inferior vena cava (IVC) consistent with primary Budd–Chiari syndrome. Venacavograms depicted drainage of the intrahepatic collaterals through a left-sided HV entering the IVC above the level of the occlusion. Sharp recanalization of the membranous IVC occlusion was performed with an occlusion balloon as a needle target under echocardiographic monitoring followed by balloon angioplasty with restoration of IVC patency. Clinical, laboratory, and venographic procedural success has been demonstrated to 9 months with minimal residual stenosis.

Percutaneous Transluminal Angioplasty for Complete Membranous Obstruction of Suprahepatic Inferior Vena Cava: Long-Term Results

PURPOSE

To determine the long-term results of percutaneous transluminal angioplasty (PTA) for a complete membranous obstruction of the suprahepatic inferior vena cava.

METHODS

Patients (n = 65) who were referred to the interventional unit for PTA for a complete membranous obstruction of the suprahepatic inferior vena cava between January 2006 and October 2014 were included in the study. Thirty-two patients (18 males, 14 females, mean age 35 ± 10.7, range 20-42 years) were treated. The patients presented with symptoms of ascites (88 %), pleural effusion (53 %), varicose veins (94 %), hepatomegaly (97 %), abdominal pain (84 %), and splenomegaly (40 %). Transjugular liver access set and re-entry catheter were used to puncture and traverse the obstruction from the jugular side. PTA balloon dilations were performed. The mean follow-up period was 65.6 ± 24.5 months. The objective was to evaluate technical success, complications, primary patency, and clinical improvement in the symptoms of the patients.

RESULTS

The technical success rate was 94 %. In two patients, obstruction could not be traversed. These patients underwent cavoatrial graft bypass surgery. There were no procedure-related complications. Clinical improvements were achieved in all patients within 3 months. The primary patency rate at 4 years was 90 %. There was no primary assisted patency. There was no need for metallic stent deployment in the cohort. The secondary patency rate at 4 years was 100 %.

CONCLUSIONS

Percutaneous transluminal angioplasty for a complete membranous obstruction of the suprahepatic inferior vena cava is safe and effective, and the long-term results are excellent.