Strategy and long-term outcomes of endovascular treatment for Budd-Chiari syndrome complicated by inferior vena caval thrombosis

Establishing a jugular-femoral venous route for recanalization of complicated inferior vena cava in Budd-Chiari Syndrome after transfemoral access failure

Recanalization of inferior vena cava (IVC) with complete obstruction, old thrombosis or long segmental stenosis/obstruction (complicated IVC) via transfemoral access may fail in patients with Budd-Chiari syndrome (BCS). In this study, 34 consecutive patients with BCS underwent recanalization of complicated IVC occlusion via jugular-femoral venous (JFV) route establishment. BCS with complicated IVC was detected by reviewing preoperative color Doppler ultrasonography or computed tomography (CT) venography, and confirmed by intraoperative venography. Clinical data on technical success, complications, and follow-up outcomes were analyzed. Except for one patient received surgical repair of rupture IVC after recanalization, technical success of IVC recanalization was achieved in remaining 33 (97.1%) patients. No perioperative deaths was found. Three complications were observed during recanalization, for a complication rate of 8.8%. Bleeding of the femoral vein was observed in one patient, and two patients showed bleeding of IVC. The IVC lesion diameter and blood flow of the distal IVC increased significantly after the procedure. Twenty-four patients (77.4%) were clinically cured, and four patients (12.9%) showed clinical improvement. The 1-year, 3-year, 5-year primary patency rates were 85.9%, 76.4% and 70.0%, respectively. The 5-year secondary patency rate was 96.8%. There were three deaths during follow up, and the 5-year survival rate was 90.0%. In conclusion, JFV route establishment and angioplasty for complicated IVC is safe and effective for patients with BCS after transfemoral access failure.

Long-term outcomes of individualized interventional treatment for primary Budd-Chiari syndrome complicated by inferior vena cava thrombosis

BACKGROUND

Various endovascular treatments were used for Budd-Chiari syndrome (BCS) patients complicated by inferior vena cava (IVC) thrombosis. The best treatment for this disease remains unknown. To evaluate safety and efficacy of individualized interventional treatment for primary BCS with IVC thrombosis.

METHODS

Forty-seven consecutive patients with IVC involvement BCS complicated by IVC thrombosis between June 2002 and August 2020 were analyzed retrospectively. They were treated with individualized interventional treatment based on thrombus type and size. Agitation thrombolysis, transcatheter thrombus aspiration, and catheter-directed thrombolysis were initially used for fresh and mixed thrombus (n = 20), then stent implantation for compressing thrombus and IVC recanalization were performed according to the size of the residual thrombus. Direct balloon angioplasty was used for old thrombus (n = 27).

RESULTS

Median follow-up duration was 109 (5-223) months (average 114 ± 60 months). IVC recanalization were attempted in forty patients and failed in one. The technical successful rate of IVC recanalization was 97.5%. Thrombus was completely lysed in eight patients with fresh thrombus (40%, 8/20), partially lysed in 11 patients with mixed thrombus (55%, 11/20), and no response in one patient with mixed thrombus (5%, 1/20). Thrombolytic-related complications occurred in one patient (5%, 1/20). No symptomatic pulmonary embolism occurred. Among the 11 patients with thrombus partially lysed, five patients underwent stent implantation for compressing thrombus, six patients received conservative treatment. Old thrombus was completely lysed in 15 patients (55.6%, 15/27) during follow-up. Restenosis occurred in six patients (15.4%, 6/39). Primary patency rates at 1, 5, 10 and 15 years were 92, 92, 86 and 80%, respectively. Hepatocellular carcinoma (HCC) occurred in four patients (8.5%, 4/47). One patient died of HCC. The survival rate was 97.9%.

CONCLUSIONS

The individualized interventional treatment based on thrombus type and size for primary BCS complicated by IVC thrombosis patients is safe and effective with long-term patency and survival.

Recanalization of accessory hepatic vein for hepatic vein-type Budd-Chiari syndrome

OBJECTIVE

To evaluate the clinical efficacy and long-term outcomes associated with the treatment of hepatic vein (HV)-type Budd-Chiari syndrome (BCS) via accessory HV (AHV) recanalization.

METHODS

In total, 26 HV-type BCS patients underwent AHV recanalization between July 2014 and December 2019 at our hospital, while 73 HV-type BCS patients without compensatory AHV underwent main HV (MHV) recanalization and served as controls in the present study. Short- and long-term clinical outcomes were compared.

RESULTS

AHV and MHV recanalization approaches were both associated with 100% technical success rates, with one recanalization procedure being performed per patient. Respective clinical success rates for the AHV and MHV recanalization approaches were 96.2% and 94.5% (P = 0.744). Re-obstruction rates were comparable between these two approaches at 20% and 34.8%, respectively (P = 0.17). Primary cumulative 1-, 2-, and 5-year patency rates in the AHV group were 96.0%, 91.6%, and 76.3%, respectively, whereas in the MHV group, these three respective rates were 87.0%, 78.6%, and 58.6% (P = 0.048). Secondary cumulative 1-, 2-, and 5-year patency rates in the AHV group were 96.0%, 96.0%, and 96.0%, respectively, whereas in the MHV group, they were 97.1%, 97.1%, and 81.8%, respectively (P = 0.289). Cumulative 1-, 2-, and 5-year survival rates for AHV group patients were 96.0%, 96.0%, and 96.0%, respectively, while for the MHV group, these respective rates were 98.6%, 95.2%, and 89.7% (P = 0.462).

CONCLUSION

HV-type BCS can be safely and effectively treated via AHV recanalization, which may achieve longer patency relative to MHV recanalization.

Budd-Chiari syndrome: consensus guidance of the Asian Pacific Association for the study of the liver (APASL)

Budd Chiari syndrome (BCS) is a diverse disease with regard to the site of obstruction, the predisposing thrombophilic disorders and clinical presentation across the Asia-Pacific region. The hepatic vein ostial stenosis and short segment thrombosis are common in some parts of Asia-Pacific region, while membranous obstruction of the vena cava is common in some and complete thrombosis of hepatic veins in others. Prevalence of myeloproliferative neoplasms and other thrombophilic disorders in BCS varies from region to region and with different sites of obstruction. This heterogeneity also raises several issues and dilemmas in evaluation and approach to management of a patient with BCS. The opportunity to recanalize hepatic vein in patients with hepatic vein ostial stenosis or inferior vena cava stenting or pasty among those membranous obstruction of the vena cava is a unique opportunity in the Asia-Pacific region to restore hepatic outflow closely mimicking physiology. In order to address these issues arising out of the diversity as well as the unique features in the region, the Asia Pacific Association for Study of Liver has formulated these guidelines for clinicians.

An Update on the Management of Budd-Chiari Syndrome

Budd-Chiari syndrome (BCS) is an uncommon condition, caused by obstruction to hepatic venous outflow. It is largely underdiagnosed, and a high index of suspicion is required for any patient with unexplained portal hypertension. The understanding of its etiology and pathology is improving with advances in diagnostic techniques. Recent studies reported an identifiable etiology in > 80% of cases. Myeloproliferative neoplasm (MPN) is the most common etiology, and genetic studies help in diagnosing latent MPN. Better cross-sectional imaging helps delineate the site of obstruction accurately. The majority of BCS patients are now treated by endovascular intervention and anticoagulation which have improved survival in this disease. Angioplasty of hepatic veins/inferior vena cava remains under-utilized at present. While surgical porto-systemic shunts are no longer done for BCS, liver transplantation is reserved for select indications. Some of the unresolved issues in the current management of BCS are also discussed in this review.

The outcomes of interventional treatment for Budd-Chiari Syndrome complicated by inferior vena cava thrombosis: Systematic review and meta-analysis

PURPOSE

The aim of this study was to perform a systematic review and meta-analysis to assess the safety and efficacy of interventional treatment for Budd-Chiari syndrome (BCS) complicated by Inferior Vena Cava thrombosis (IVCT) patients.

METHODS

We evaluated the published studies on interventional treatment for BCS complicated by IVCT. Meta-analysis was used to calculate the combined effect size and their 95% confidence intervals (CI) based on random effect. The publication bias was assessed by Begg's test.

RESULTS

Sixteen studies on interventional treatment for BCS complicated by IVCT patient were selected for meta-analysis, a total of 767 BCS complicated by IVCT patients were included. The combined effect size (95% CI) were 99% (98-100%) for the total successful rate of IVC recanalization, 15% (11-21%) for the rate of IVC restenosis after initial operation, 92.0% (86-97%) for the rate of clinical improvement, 76% (68-84%) for the rate of thrombus clearance and 0.00% (0-1%) for the incidence of pulmonary embolism (PE). Through subgroup meta-analysis about the rate of thrombus clearance, we got the pooled results (95% CI) of individualized treatment strategy (ITS) group and non-individualized treatment strategy (non-ITS) group, were 81% (71-92%) and 73% (63-83%), respectively.

CONCLUSIONS

The interventional treatment for BCS complicated by IVCT patients is safe and effective with low incidence of PE, high thrombus clearance rate, high technically successful rate, good patency, and high clinical improvement rate. Moreover, subgroup analysis indicated that management based on the type and extent of the thrombus is proposed.

Inferior vena cava-syndrome

Inferior vena cava syndrome (IVCS) is caused by agenesis, compression, invasion, or thrombosis of the IVC, or may be associated with Budd-Chiari syndrome. Its incidence and prevalence are unknown. Benign IVCS is separated from malignant IVCS. Both cover a wide clinical spectrum reaching from asymptomatic to highly symptomatic cases correlated to the underlying cause, the acuity, the extent of the venous obstruction, and the recruitment and development of venous collateral circuits. Imaging is necessary to determine the underlying cause of IVCS and to guide clinical decisions. Interventional therapy has changed the therapeutic approach in symptomatic patients. This article provides an overview over IVCS and focuses on interventional therapeutic methods and results.

Restenosis after recanalization for Budd-Chiari syndrome: Management and long-term results of 60 patients

BACKGROUND

Budd-Chiari syndrome is defined as hepatic venous outflow tract obstruction. For Asian Budd-Chiari syndrome patients, the major treatment modality is recanalization (percutaneous transluminal angioplasty with or without stent implantation). The cumulative 1-, 5-, and 10-year primary patency rates and survival rates are reported to be excellent or satisfactory, but the long-term outcome of patients with restenosis (the most common complication after recanalization) is unknown.

AIM

To explore the treatment strategy for restenosis in patients with Budd-Chiari syndrome after interventional therapy and to evaluate the long-term follow-up results.

METHODS

The clinical data and follow-up results of 60 patients with restenosis after interventional therapy from November 1983 to December 2013 were retrospectively analyzed.

RESULTS

Sixty patients with restenosis were retrospectively divided into a percutaneous transluminal angioplasty (PTA) group (40 patients) and a PTA + stent group (20 patients) according to the primary recanalization method. For the patients with restenosis in the PTA group, 13 refused treatment, and 27 received further treatment; among these patients, five had a second restenosis, two had a third restenosis, and one had a fourth restenosis. For the patients with restenosis in the PTA + stent group, nine refused treatment, ten received PTA alone, and the other received PTA + stent implantation. Among the patients who received further treatment, five had a second restenosis, three had a third restenosis, and one had a fourth restenosis. The 1-, 5-, 10-, 20-, and 25-year cumulative survival rates of the 38 patients who received further treatment after restenosis were 100%, 78.3%, 78.3%, 70.5%, and 70.5%, respectively; however, for the 22 patients who refused treatment, the survival rates were 72.7%, 45.9%, 30.6%, 10.2%, and unavailable, respectively (P < 0.001).

CONCLUSION

Long-term follow-up after interventional therapy is very important. Active treatment for patients with restenosis can improve prognosis, and minimally invasive treatment strategies for restenosis allows to obtain satisfactory results.

Sequential interventional therapy for Budd-Chiari syndrome associated with fresh inferior vena cava thrombosis

OBJECTIVE

Our study aimed to evaluate the safety and efficacy of sequential interventional therapy for Budd-Chiari syndrome (BCS) caused by obstruction of the inferior vena cava (IVC) with fresh thrombus in the IVC.

METHODS

Full medical records were obtained for 20 patients with BCS associated with fresh IVC thrombus who received sequential interventional therapy from 2014 to 2019 at our hospital. All patients underwent small-diameter percutaneous transluminal angioplasty (PTA) balloon catheter predilation combined with sequential catheter-directed thrombolysis and large-diameter PTA balloon dilation. Ultrasound examinations were performed at 1 week, 1 month, 3 months, and every 6 months thereafter. Therapeutic effects and perioperative and postoperative adverse effects were recorded to assess the safety of the treatment.

RESULTS

All 20 patients were treated with small PTA balloon catheters (diameter, 10-14 mm) to predilate the occlusive segment of the IVC. Urokinase 400,000 to 600,000 (465,000 ± 93,000) units was administered to patients through the catheter for 6 to 20 (9.7 ± 4.2) consecutive days postoperatively. Ultrasound re-examination showed that the IVC thrombus disappeared completely in 14 patients (70.0%), and a small amount of the old thrombus remained in 6 patients (30.0%). After thrombolysis, all 20 patients received PTA balloon dilation (diameter, 26-30 mm) in the stenosed IVC segment, and blood flow recovered subsequently. No pulmonary embolism or death occurred in the perioperative course. The perioperative survival rate was 100.0%.

CONCLUSIONS

Sequential interventional therapy for BCS associated with fresh IVC thrombus is safe and effective.

Tratamiento endovascular del síndrome de Budd-Chiari, a propósito de un caso

El síndrome de Budd-Chiari consiste en la oclusión de la circulación de salida venosa del hígado, desde las sinusoides hepáticas hasta la unión de la vena cava inferior con la aurícula derecha. Esta entidad es muy rara. Las causas son primarias, obstrucción congénita de la vena cava o trombosis espontánea, o secundarias, compresión extrínseca. Si no se trata la obstrucción esta enfermedad, lleva a cirrosis hepática. Se presenta un caso del síndrome de Budd-Chiari de causa primaria por obstrucción membranosa, tratado por vía endovascular de manera exitosa y con resolución de todos los síntomas. Es el primer reporte en Colombia de este tipo de tratamiento.

Long-term outcomes of individualized treatment strategy in treatment of type I Budd-Chiari syndrome in 456 patients

AIM

To evaluate individualized treatment strategy (ITS) and long-term outcomes of endovascular treatment of Budd-Chiari syndrome (BCS) with obstructed inferior vena cava (IVC) based on different degrees of hepatic vein (HV) involvement.

METHODS

From January 2006 to June 2017, 456 consecutive patients with BCS with obstructed IVC underwent endovascular treatment with ITS. All patients received IVC recanalization. Then, 426 patients with at least one patent HV received no additional treatment. Twenty-fivepatients with membranous or segmental occlusion of HVs underwent HV recanalization and for the remaining five patients with diffuse HVs occlusion, a transjugular intrahepatic portosystemic shunt (TIPS) was performed.

RESULTS

The endovascular treatment was technically successful in 455 of the 456 patients (99.8%). The complication rate was 5.0% (23/456), with major complications in 13 patients (2.8%) and minor complications in 10 patients (2.2%). Median follow-up time was 60.5 months (range, 4-120 months). The cumulative 1-, 2-, 5- and 10-year primary vessel patency rates were 93.6%, 89.9%, 80.5% and 74.3% respectively and the cumulative 1-, 2-, 5-, 10- year secondary patency rates were 99.8%, 99.8%, 98.2% and 97.2% respectively. The cumulative 1-, 2-, 5- and 10-year survival rates were 98.4%, 95.8%, 91.2% and 76.5% respectively. Illness duration and decreased serum albumin were independent predictors of survival.

CONCLUSION

The ITS for Asian BCS with obstructed IVC and varying degrees of HV involvement appears to be effective and with good long-term outcomes.

Interventional Treatment Strategy for Primary Budd-Chiari Syndrome with Both Inferior Vena Cava and Hepatic Vein Involvement: Patients from Two Centers in China

OBJECTIVE

This retrospective study evaluated interventional treatments (recanalization, balloon dilation, and/or stent placement) for Budd-Chiari syndrome (BCS), caused by combined obstruction of the inferior vena cava (IVC) and hepatic veins (HVs).

METHODS

Before and after interventional therapy, patients with BCS (n = 162; asymptomatic 105.2 ± 103.3 mo; follow-up 15 [6-24] mo) underwent imaging studies (color Doppler ultrasound, CT, or MRI), and inferior vena cavography and manometry. Venous lesions were characterized by occlusion features, and presence of thrombosis and peripheral collateral vessels.

RESULTS

One, 2, and 3 main HV occlusions were observed, respectively, in 25 (15.4%), 61 (37.7%), and 76 (46.9%) patients. Eighty-three (51.2%), 98 (60.5%), and 104 (64.2%) patients had, respectively, large accessory HVs, venous collaterals formed between the HVs, or venous communicating branches between the HV and the peritoneal veins. The middle, left, and right HV was patent in 32 (19.8%), 35 (21.6%), and 44 (27.2%) patients. Recanalization of both hepatic and caval occlusions was successful in 96% (51/53) of those attempted; recanalization of IVC occlusion was successful in 97% (106/109). Among 157 patients successfully treated, 146 were cured and 11 showed clinical improvement. Clinical symptoms were relieved in 82.4% after the initial intervention, and 94.2% after the second intervention.

CONCLUSION

Recanalization and balloon angioplasty was effective for the management of BCS with concurrent HV and IVC occlusions. The majority of patients required only IVC recanalization. The outcome of patients treated only by IVC intervention was similar to that of patients given combined HV and IVC intervention.

Effectiveness and Postoperative Prognosis of Using Preopening and Staged Percutaneous Transluminal Angioplasty of the Inferior Vena Cava in Treating Budd-Chiari Syndrome Accompanied with Inferior Vena Cava Thrombosis

BACKGROUND

Budd-Chiari syndrome (BCS) is a rare disorder that has relatively high prevalence in the Huang-Huai area of China. Effective treatment of BCS accompanied with inferior vena cava thrombosis is challenging.

OBJECTIVE

This study retrospectively analyzed the clinical effectiveness and safety of traditional open operations versus preopening and staged percutaneous transluminal angioplasty (PTA) of the inferior vena cava in treating BCS accompanied with inferior vena cava thrombosis.

METHODS

Data from patients hospitalized and treated for BCS accompanied with inferior vena cava thrombosis between January 1997 and December 2017 were retrospectively analyzed. Thirty-two patients received traditional open operation (open group). Fifty-six patients received preopening and staged PTA of the inferior vena cava (PTA group). Baseline and clinical data were compared between groups. The patients were followed for up to 60 months. Postoperative recurrence rates and restenosis degree were recorded.

RESULTS

Eighty-eight patients were included (47 males and 41 females), aged 41.82 ± 10.12 years (range 29-65). In the open group, no pulmonary arterial embolism was found during and after the operation, and the technique success rate was 100%. One patient died of intrathoracic bleeding. In the PTA group, 2 patients had shifting of thrombus in the inferior vena cava that blocked the blood flow restored by the preopening, one resulted in treatment failure, while the other had blood flow restored by dilation with a 12-mm balloon; the success rate was 55/56 (98.21%). The median follow-up time was 32 months (range 3-60). Two patients in the open group developed restenosis 2 years after operation (recurrence rate: 6.25%), and were successfully treated by balloon PTA. Seven patients in the PTA group had severe restenosis 18-42 months after operation (recurrence rate: 12.96%). No thrombosis was found in these 7 patients, and normal blood flow was restored in the inferior vena cava after balloon PTA.

CONCLUSIONS

Preopening and staged PTA of the inferior vena cava is a safe and simple method for the treatment of BCS accompanied with inferior vena cava thrombosis, with satisfactory treatment effectiveness that could be applied in clinical practice.

Comparison of retrievable stents and permanent stents for Budd-Chiari syndrome due to obstructive inferior vena cava

BACKGROUND AND AIM

The aim of this study is to compare long-term outcomes of retrievable stents (RSs) and permanent stents (PSs) for Budd-Chiari syndrome (BCS) due to long-segment obstructive inferior vena cava (IVC).

METHODS

Between July 2000 and August 2016, 42 patients with BCS due to long-segment obstructive IVC were treated with RSs, and 41 patients were treated with PSs. The RSs were removed eventually after thrombus disappeared. Patients were subsequently followed up by color Doppler sonography or computed tomography scanning.

RESULTS

All RS placements were successful, and 37 RSs were retrieved 8 to 29 days later. Forty-two stents were implanted in PS group. One failure retrieval of RSs occurred, and two failures of cannulations were found in PS group. Two deaths may be procedure related and died from acute pulmonary thromboembolism perioperatively. One patient developed acute cerebral infarction and recovered after treatment. In PS group, minor complications were found in three patients. The length of IVC lesion segment and length and thickness of IVC thrombus decreased significantly, and diameter of retrocaval IVC and diaphragm IVC increased significantly in both groups. During follow-up, three patients died from liver failure in RS group, and two patients died in PS group. RS group showed a significantly higher primary patency rate than PS group. Cumulative 1-, 3-, and 5-year secondary patency rates were 95.2%, 89.6%, and 89.6% in RS group and 100%, 96.6%, and 96.6% in PS group (P = 0.7109).

CONCLUSIONS

Retrievable stents are effective for BCS because of long-segment obstructive IVC, with a higher primary patency rate.

Long-Term Outcomes of Endoluminal Sharp Recanalization of Occluded Inferior Vena Cava in Budd-Chiari Syndrome

PURPOSE

To report the long-term results of endoluminal sharp recanalization of occluded inferior vena cava (IVC) in patients with the Budd-Chiari syndrome (BCS).

PATIENTS AND METHODS

Seventy-two consecutive patients with BCS and IVC occlusion underwent endoluminal recanalization of the IVC occlusion during a 6-year period. BCS with occlusive IVC was detected by reviewing patient history and color Doppler ultrasonography. Data on technical success, morbidity, mortality, complications, and color Doppler sonographic outcome were collected and analyzed.

RESULTS

Seventy-seven recanalizations were performed in 72 patients. Technical success (patent IVC with good blood flow) was achieved in 70 (97.4%) patients. No perioperative death was observed. Six complications were found during recanalization, and 10 complications were found for total interventional procedures. The complication rates were 7.8% and 7.3% for recanalization and total procedure, respectively. Bleeding of access veins was the most common complication, and 2 patients showed slight rupture of IVC. The postoperative IVC diameter and blood speed of IVC increased significantly. Fifty-seven patients (79.2%) were clinical cured, and 2 patients (2.8%) showed no improvement. The 1-year, 3-year, and 5-year primary patency rates were 92.5%, 86.8%, and 77.3%, respectively. The second patency rates were 100.0%, 97.8%, and 91.8% for 1, 3, and 5 years, respectively. There were 2 deaths during follow-up.

CONCLUSION

Endoluminal sharp recanalization of occluded IVC in patients with BCS is safe and effective with good long-term outcomes.

Role of radiological imaging and interventions in management of Budd-Chiari syndrome

Budd-Chiari syndrome (BCS) is a clinical condition resulting from impaired hepatic venous drainage, in which there is obstruction to the hepatic venous outflow at any level from the small hepatic veins to the junction of the inferior vena cava and the right atrium leading to hepatic congestion. The diagnosis of BCS is based on imaging, which can be gathered from non-invasive investigations such as ultrasonography coupled with venous Doppler, triphasic computed tomography (CT) and magnetic resonance imaging (MRI). Apart from diagnosis, various interventional radiology procedures aid in the successful management of this syndrome. In this article, we present various imaging features of BCS along with various interventional procedures that are used to treat this diverse condition.

Budd-Chiari syndrome in China: A 30-year retrospective study on survival from a single center

AIM

To investigate 30-year treatment outcomes associated with Budd-Chiari syndrome (BCS) at a tertiary hospital in China.

METHODS

A total of 256 patients diagnosed with primary BCS at our tertiary hospital between November 1983 and September 2013 were followed and retrospectively studied. Cumulative survival rates and cumulative mortality rates of major causes were calculated by Kaplan-Meier analysis, and the independent predictors of survival were identified using a Cox regression model.

RESULTS

Thirty-four patients were untreated; however, 222 patients were treated by medicine, surgery, or interventional radiology. Forty-four patients were lost to follow-up; however, 212 patients were followed, 67 of whom died. The symptom remission rates of treated and untreated patients were 81.1% (107/132) and 46.2% (6/13), respectively (P = 0.009). The cumulative 1-, 5-, 10-, 20-, and 30-year survival rates of the treated patients were 93.5%, 81.6%, 75.2%, 64.7%, and 58.2%, respectively; however, the 1-, 5-, 10-, 20-, and 30-year survival rates of the untreated patients were 70.8%, 70.8%, 53.1%, 0%, and unavailable, respectively (P = 0.007). Independent predictors of survival for treated patients were gastroesophageal variceal bleeding (HR = 3.043, 95%CI: 1.363-6.791, P = 0.007) and restenosis (HR = 4.610, 95%CI: 1.916-11.091, P = 0.001). The cumulative 1-, 5-, 10-, 20-, and 30-year mortality rates for hepatocellular carcinoma were 0%, 2.6%, 3.5%, 8%, and 17.4%, respectively.

CONCLUSION

Long-term survival is satisfactory for treated Chinese patients with BCS. Hepatocellular carcinoma is a chronic complication and should be monitored with long-term follow-up.

An Individualised Strategy and Long-Term Outcomes of Endovascular Treatment of Budd-Chiari Syndrome Complicated by Inferior Vena Cava Thrombosis

OBJECTIVES

The aim was to evaluate individualised treatment and long-term outcomes of endovascular treatment of Budd-Chiari syndrome (BCS) complicated by inferior vena cava (IVC) thrombosis.

METHODS

Between April 2005 and December 2015, 108 consecutive patients with BCS complicated by IVC thrombosis underwent endovascular treatment. According to the type, size, extent, and degree of organisation of the thrombus, agitation thrombolysis (n = 7), agitation thrombolysis combined with retrieval stent filter (n = 5), pre-dilation (n = 32), retrieval stent filter (n = 56), or direct large balloon dilation (n = 8) was performed. Peri- and post-operative follow-up data were recorded.

RESULTS

The endovascular treatment was technically successful in 107 of the 108 patients (99.1%). The incidence of thrombosis related complications was 7.4% (8/108). Major and minor complications occurred in four patients. The mean follow-up duration was 61.7 ± 39.3 months (range 3-140 months). The cumulative 1, 2, 5, and 10 year primary patency rates were 91%, 88%, 79%, and 79%, respectively, and the cumulative 1, 2, 5, and 10 year secondary patency rates were 100%, 100%, 97%, and 97%, respectively. The cumulative 1, 5, and 10 year survival rates were 95%, 86%, and 81%, respectively. Serum albumin and total bilirubin values were independent predictors of survival.

CONCLUSIONS

For patients with BCS complicated by IVC thrombosis, an individualised endovascular treatment strategy based on the type, size, extent, and degree of organisation of the thrombus is associated with long-term patency of the IVC and favourable survival and complication rates.

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.

Endovascular Treatment of an Unusual Membranous Obstruction of the Inferior Vena Cava in Budd-Chiari Syndrome Complicated by Mural Portal Vein Thrombosis

We describe the case of a patient with Budd-Chiari syndrome who presented with an unusual membranous obstruction of the inferior vena cava complicated by massive portal vein thrombosis (PVT). The patient underwent percutaneous transluminal balloon angioplasty through the right groin and was prescribed oral warfarin for 6 months. Treatment resulted in the complete disappearance of the PVT. This therapeutic strategy should be considered in the management of other cases of this rare, complex disease.

Good Clinical Outcomes in Budd-Chiari Syndrome with Hepatic Vein Occlusion

BACKGROUND

Budd-Chiari syndrome (BCS) with hepatic vein (HV) occlusion is manifested by severe liver damage in acute cases and esophageal variceal bleeding or refractory ascites in chronic cases, which is difficult to differentiate from cirrhotic portal hypertension.

AIMS

To evaluate the clinical efficacy and safety of HV angioplasty and transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of BCS with HV occlusion.

METHODS

Between May 1995 and December 2014, 60 patients with HV occlusive BCS underwent HV angioplasty or TIPS. BCS was subacute or chronic in 55 patients and acute in 5 patients. HV angioplasty was performed in 18 patients with HV occlusion, combined HV and IVC angioplasty in 9 patients with HV and IVC occlusion, TIPS in 12 patients with HV occlusion, and modified TIPS in 21 patients with extensive HV occlusion.

RESULTS

The interventional procedure was successfully performed in all 60 patients. The portal pressure decreased from 41.23 ± 10.46 cmH2O preoperatively to 26.68 ± 6.46 cmH2O postoperatively, while the portal flow velocity increased from 14.31 ± 10.43 to 52.16 ± 13.68 cm/s in patients undergoing TIPS or modified TIPS. During hospitalization, two patients died from hepatic failure, and acute shunt occlusion occurred in two other patients during subsequent treatment with repeated intervention. During 82.25 ± 46.16 months of follow-up, three patients underwent re-intervention with a stenotic shunt, and other three with repeated dilation of the stenotic HV.

CONCLUSION

HV angioplasty and TIPS yield excellent long-term outcomes in patients with HV occlusive BCS.

Percutaneous recanalization for combined-type Budd-Chiari syndrome: strategy and long-term outcome

PURPOSE

To investigate the feasibility, strategy, and long-term outcome of percutaneous recanalization for combined-type Budd-Chiari syndrome (BCS).

METHODS

From December 2007 to August 2014, consecutive symptomatic combined-type BCS patients were treated by percutaneous recanalization in our centers. Inferior vena cava (IVC) recanalization was the first-stage treatment for all patients. Recanalization of one hepatic vein (HV) was the second-stage treatment for the selected patients. If the patient had the compensatory and patent accessory HV (AHV), we observed this patient for 7 days after IVC recanalization. If the symptoms of portal hypertension improved, HV recanalization was not needed. Otherwise, HV recanalization was performed. If the patient had no patent AHV, HV recanalization was performed 3 days after IVC recanalization. Data on technical success, clinical success, and follow-up were analyzed, respectively.

RESULTS

Sixty-two symptomatic combined-type BCS patients were enrolled. Technical success of percutaneous recanalization was achieved in 60 patients. Among them, 52 patients had the patent AHV and underwent single IVC recanalization, and 8 patients had no patent AHV and underwent combined IVC and HV recanalization. Clinical success was achieved in all of the 60 patients. Three patients died during the follow-up. The cumulative 1-, 2-, and 4-year survival rates were 98.3%, 96.5%, and 92.7%, respectively.

CONCLUSION

Percutaneous recanalization is suitable for most combined-type BCS patients. Treatment strategy can be made according to the situation of AHV. If the patient has the patent AHV, single IVC recanalization is enough. Otherwise, combined IVC and HV recanalization should be performed.

Etiology and treatment of acute inferior vena cava thrombosis

Inferior vena cava thrombosis (IVCT) is a rare but severe disease that is associated with a high rate of mortality. IVCT can be categorized into primary versus secondary thrombosis dependent upon the underlying pathophysiology. The diagnosis includes both clinical probability assessment as well as the imaging evaluation. The optimal therapeutic strategy remains the target of continued research. Although anticoagulation therapy remains fundamental in treating IVCT, its inherent limitations have led to the use of minimally invasive, endovascular treatment options, including transcatheter thrombolysis, mechanical thrombectomy or a combination of these techniques. This review focuses on the etiology, diagnostic assessment, and endovascular treatment options for IVCT.

Endovascular Management of Budd-Chiari Syndrome with Inferior Vena Cava Thrombosis: A 14-Year Single-Center Retrospective Report of 55 Patients

PURPOSE

To evaluate safety and efficacy of balloon dilation and stent placement combined with thrombus aspiration and thrombolysis to treat patients with Budd-Chiari syndrome (BCS) with inferior vena cava (IVC) thrombosis.

MATERIALS AND METHODS

Charts from 55 consecutive patients with primary BCS and IVC thrombosis treated between April 2000 and August 2014 were retrospectively analyzed. Transcatheter aspiration and percutaneous recanalization were attempted in all patients, and stents were placed if balloon dilation was successful. Catheter-directed thrombolysis was performed when evident clot burden was present after recanalization.

RESULTS

Technically successful IVC recanalization was achieved in 53 of 55 patients (96.4%). Technical failures in 2 patients were due to long segment of IVC obstruction. A stent was placed in 47 of 53 patients (88.7%). Thrombus was successfully aspirated in 23 patients, and thrombolytic treatment was administered to 13 patients. Median follow-up was 58 months (range, 8-180 mo). No symptomatic pulmonary embolism occurred. Reocclusion occurred in 8 patients, and 6 of these patients (75%) underwent repeat recanalization by balloon dilation with or without stents. Cumulative 1-, 5-, and 10-year primary patency rates were 94%, 89%, and 66%. Alanine transaminase and alkaline phosphatase levels were independent risk factors for reocclusion. Cumulative 1-, 5-, and 10-year survival rates were 90%, 86%, and 86%. Child-Pugh score and reocclusion were independent predictors of survival.

CONCLUSIONS

Percutaneous vena caval balloon dilation and stent placement with thrombus aspiration and thrombolytic therapy is safe and effective for treatment of patients with BCS and IVC thrombosis.

Association of factor V Leiden, Janus kinase 2, prothrombin, and MTHFR mutations with primary Budd-Chiari syndrome in Egyptian patients

BACKGROUND AND AIM

Budd-Chiari syndrome (BCS) is defined as obstruction of hepatic venous outflow anywhere from the small hepatic veins to the suprahepatic inferior vena cava. The pathogenesis of BCS is still not fully understood. This study aimed to evaluate the association of factor V Leiden (FVL), Janus kinase 2 (JAK2), prothrombin, and methylene tetrahydrofolate reductase (MTHFR) mutations with primary BCS.

METHODS

The study was carried out on 35 patients with primary BCS and 15 age and gender matched healthy individuals as a control group. Genotyping of FVL, prothrombin, and MTHFR mutations was determined by GENEQUALITY AB-THROMBO TYPE kit based on the reverse hybridization principle. JAK2 mutation was determined by polymerase chain reaction-restriction fragment length polymorphism.

RESULTS

There was a statistically significant difference between patients and controls regarding FVL, MTHFR C677T, and MTHFR A1298C mutations with odds ratio of 1.83, 2.0, and 1.79, respectively. Hetero MTHFR C677T, hetero FVL, and hetero MTHFR A1298C were the most common etiological factors being responsible for 57.1, 42.9, and 42.9% of primary BCS cases, respectively.

CONCLUSION

It could be concluded that BCS is a multifactorial disease; in the current study, MTHFR C677T mutation was the most common cause of disease. Identification of one cause of BCS should not eliminate investigations for detection of other etiological factors.

Percutaneous recanalization for hepatic vein-type Budd-Chiari syndrome: long-term patency and survival

OBJECTIVE

To determine the long-term patency and survival of percutaneous recanalization for hepatic vein (HV)-type Budd-Chiari syndrome (BCS).

METHODS

From March 2009 to November 2014, consecutive symptomatic HV-type BCS patients were treated by percutaneous recanalization in our centers. These patients underwent main HV (MHV) or accessory HV (AHV) recanalization. Data on patient characteristics, technical success, clinical success, long-term patency, and survival were collected and analyzed.

RESULTS

During the enrolled periods, a total of 143 symptomatic HV-type BCS patients were treated by percutaneous recanalization in our centers. Technical success was achieved in 140 of 143 patients. One hundred eleven patients underwent MHV recanalization, and 29 underwent AHV recanalization. Clinical success was achieved in 136 of 140 patients. The mean MHV/AHV pressure decreased from 33.5 ± 4.1 mmHg before treatment to 12.5 ± 3.1 mmHg after treatment (p = 0.000). The 136 patients were followed for 7-75 months (mean 33.9 ± 15.3 months). Twenty-eight patients experienced re-obstruction of MHV (n = 24) or AHV (n = 4) at 3 to 36 months (mean 18.0 ± 11.5 months) after treatment. The cumulative 1-, 3-, and 6-year primary patency rates were 91.1, 77.4, and 74.0%, respectively. The cumulative 1-, 3-, and 6-year secondary patency rates were 97.0, 92.4, and 88.8%, respectively. The cumulative 1-, 3-, and 6-year survival rates were 97.7, 92.2, and 90.0%, respectively.

CONCLUSION

Percutaneous recanalization can provide good long-term patency and survival in HV-type BCS patients.

Combined thrombus aspiration and recanalization in treating Budd-Chiari syndrome with inferior vena cava thrombosis

PURPOSE

To investigate the feasibility, safety, and effectiveness of combined thrombus aspiration and inferior vena cava (IVC) recanalization for Budd-Chiari syndrome (BCS) patients with IVC thrombosis.

MATERIALS AND METHODS

From March 2011 to October 2014, 17 consecutive BCS patients with IVC thrombosis [male 13, female 4 (mean age 52.6 ± 8.4 years, range 43-72 years)] treated by combined thrombus aspiration and IVC recanalization were enrolled in this retrospective study. An 8F guiding catheter was used as the aspiration catheter. During the treatment, the aspiration catheter was placed from the right femoral vein to the IVC thrombi, and a 20-ml syringe was connected with the aspiration catheter for thrombus aspiration. IVC recanalization was performed after thrombus aspiration. Data on technical success, clinical success, and follow-up were analyzed.

RESULTS

Technical success was achieved in all patients. After thrombus aspiration, 12 patients had no visible thrombi on IVC venography, while 5 patients were shown to have the IVC mural thrombi. Afterwards, 13 patients were treated by IVC balloon dilation, and 4 patients were treated by IVC stent insertion. No patient experienced dyspnea after treatment. The average IVC pressure decreased from 29.8 ± 3.4 cmH2O to 8.6 ± 2.1 cmH2O (P < 0.001). Clinical success was achieved in all patients. The average follow-up period was 15.3 ± 11.6 months (range 2-44 months). Long-term IVC patency was achieved in 15 of 17 patients.

CONCLUSION

Combined thrombus aspiration and IVC recanalization can be a safe and effective method for BCS patients with IVC thrombosis.