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Mukhiya G, Jiao D, Han X, Zhou X, Pokhrel G. Survival and clinical success of endovascular intervention in patients with Budd-Chiari syndrome: A systematic review. J Clin Imaging Sci 2023; 13:5. [PMID: 36751561 PMCID: PMC9899460 DOI: 10.25259/jcis_130_2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/14/2023] [Indexed: 01/26/2023] Open
Abstract
Budd-Chiari syndrome is a complex clinical disorder of hepatic venous outflow obstruction, originating from the accessory hepatic vein (HV), large HV, and suprahepatic inferior vena cava (IVC). This disorder includes both HV and IVC obstructions and hepatopathy. This study aimed to conduct a systematic review of the survival rate and clinical success of different types of endovascular treatments for Budd-Chiari syndrome (BCS). All participant studies were retrieved from four databases and selected according to the eligibility criteria for systematic review of patients with BCS. The survival rate, clinical success of endovascular treatments in BCS, and survival rates at 1 and 5 years of publication year were calculated accordingly. A total of 3398 patients underwent an endovascular operation; among them, 93.6% showed clinical improvement after initial endovascular treatment. The median clinical success rates for recanalization, transjugular intrahepatic portosystemic shunt (TIPS), and combined procedures were 51%, 17.50%, and 52.50%, respectively. The median survival rates at 1 and 5 years were 51% and 51% for recanalization, 17.50% and 16% for TIPS, and 52.50% and 49.50% for combined treatment, respectively. Based on the year of publication, the median survival rates at 1 and 5 years were 23.50% and 22.50% before 2000, 41% and 41% in 2000‒2005, 35% and 35% in 2006‒2010, 51% and 48.50% in 2010‒2015, and 56% and 55.50% after 2015, respectively. Our findings indicate that the median survival rate at 1 and 5 years of recanalization treatment is higher than that of TIPS treatment, and recanalization provides better clinical improvement. The publication year findings strongly suggest progressive improvements in interventional endovascular therapy for BCS. Thus, interventional therapy restoring the physiologic hepatic venous outflow of the liver can be considered as the treatment of choice for patients with BCS which is a physiological modification procedure.
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Affiliation(s)
- Gauri Mukhiya
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dechao Jiao
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xinwei Han
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Corresponding author: Xinwei Han, Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Xueliang Zhou
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Gaurab Pokhrel
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Evaluation of outcome from endovascular therapy for Budd-Chiari syndrome: a systematic review and meta-analysis. Sci Rep 2022; 12:16166. [PMID: 36171454 PMCID: PMC9519873 DOI: 10.1038/s41598-022-20399-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 09/13/2022] [Indexed: 11/19/2022] Open
Abstract
This study was performed to evaluate the outcome of endovascular intervention therapy for Budd-Chiari syndrome (BCS) and compare recanalization, transjugular intrahepatic portosystemic shunt (TIPS)/direct intrahepatic portosystemic shunt (DIPS), and combined procedure treatment. For the meta-analysis, 71 studies were identified by searching four databases. The individual studies’ samples were used to calculate a confidence interval (CI 95%), and data were pooled using a fixed-effect model and random effect model. The pooled measure and an equal-weighted average rate were calculated in all participant studies. Heterogeneity between the studies was assessed with I2, and T2 tests, and publication bias was estimated using Egger’s regression test. A total of 4,407 BCS patients had undergone an endovascular intervention procedure. The pooled results were 98.9% (95% CI 97.8‒98.9%) for a technical success operation, and 96.9% (95% CI 94.9‒98.9%) for a clinical success operation. The re-intervention rate after the initial intervention procedure was 18.9% (95% CI 14.7‒22.9%), and the survival rates at 1 and 5 years after the initial intervention procedure were 98.9% (95% CI 96.8‒98.9%) and 94.9% (95% CI 92.9‒96.9%), respectively. Patients receiving recanalization treatment (98%) had a better prognosis than those with a combined procedure (95.6%) and TIPS/DIPS treatment (94.5%). The systematic review and meta-analysis further solidify the role of endovascular intervention treatment in BCS as safe and effective. It maintains high technical and clinical success and long-term survival rates. The recanalization treatment had a better prognosis and outcome than the combined procedures and TIPS/DIPS treatment.
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Ishikawa M, Sakamoto A. Open Cardiac Surgery in a Patient With Chronic Budd-Chiari Syndrome. J Cardiothorac Vasc Anesth 2020; 35:3042-3044. [PMID: 33358289 DOI: 10.1053/j.jvca.2020.11.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/26/2020] [Accepted: 11/27/2020] [Indexed: 11/11/2022]
Abstract
Budd-Chiari syndrome (BCS) is a rare congestive hepatopathy arising from hepatic venous outflow obstruction. The clinical presentation of BCS varies depending on the presence of collateral veins. The authors report a rare case of infective endocarditis and chronic primary BCS in a 50-year-old man who underwent open cardiac surgery. Due to the presence of dilated collateral veins flowing directly into the inferior vena cava, cardiopulmonary bypass was established by arterial cannulation of the ascending aorta, with venous cannulation of the upper portion of the superior vena cava, as well as the dilated collateral vein. Mitral valve replacement and tricuspid valvuloplasty were performed uneventfully, and the patient then was admitted to the intensive care unit. Patients with primary BCS need to be evaluated rigorously preoperatively and intraoperatively for collateral flow to establish cardiopulmonary bypass.
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Affiliation(s)
- Masashi Ishikawa
- Department of Anesthesiology, Nippon Medical School, Tokyo, Japan.
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Affiliation(s)
- O. Detry
- Department of Abdominal Surgery and Transplantation, University Hospital of Liège, University of Liège, Sart Tilman B35, B-4000 Liège, Belgium
| | - P. Honoré
- Department of Abdominal Surgery and Transplantation, University Hospital of Liège, University of Liège, Sart Tilman B35, B-4000 Liège, Belgium
| | - M. Meurisse
- Department of Abdominal Surgery and Transplantation, University Hospital of Liège, University of Liège, Sart Tilman B35, B-4000 Liège, Belgium
| | - N. Jacquet
- Department of Abdominal Surgery and Transplantation, University Hospital of Liège, University of Liège, Sart Tilman B35, B-4000 Liège, Belgium
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Venous thrombosis of the liver: current and emerging concepts in management. Transl Res 2020; 225:54-69. [PMID: 32407789 DOI: 10.1016/j.trsl.2020.04.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/11/2020] [Accepted: 04/16/2020] [Indexed: 02/08/2023]
Abstract
Venous thrombosis within the hepatic vasculature is associated with a distinct array of risk factors, characteristics, and potential complication. As such, it entails unique management considerations and strategies relative to the more common categories of venous thromboembolic disease. Although broadly divided into thrombosis of the afferent vasculature (the portal venous system) and efferent vasculature (the hepatic venous system), presentations and management strategies within these groupings are heterogeneous. Management decisions are influenced by a variety of factors including the chronicity, extent, and etiology of thrombosis. In this review we examine both portal vein thrombosis and hepatic vein thrombosis (and the associated Budd-Chiari Syndrome). We consider those factors which most impact presentation and most influence treatment. In so doing, we see how the particulars of specific cases introduce nuance into clinical decisions. At the same time we attempt to organize our understanding of such cases to help facilitate a more systematic approach. Critically, we must recognize that although increasing evidence is emerging to help guide our management strategies, the available data remain limited and largely retrospective. Indeed, current paradigms are based largely on observational experiences and expert consensus. As new and more rigorous studies emerge, treatment strategies are likely to be continually refined, and paradigm shifts are sure to occur.
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Kulkarni CB, Moorthy S, Pullara SK, Prabhu NK, Kannan RR, Nazar PK. Budd-Chiari syndrome managed with percutaneous recanalization: Long-term outcome and comparison with medical therapy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii180001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Chinmay Bhimaji Kulkarni
- Department of Radiology, Amrita Institute of Medical Sciences and Research Centre (AIMS), Amrita Vishwa Vidyapeetham, Kochi, India
| | - Srikanth Moorthy
- Department of Radiology, Amrita Institute of Medical Sciences and Research Centre (AIMS), Amrita Vishwa Vidyapeetham, Kochi, India
| | - Sreekumar Karumathil Pullara
- Department of Radiology, Amrita Institute of Medical Sciences and Research Centre (AIMS), Amrita Vishwa Vidyapeetham, Kochi, India
| | - Nirmal Kumar Prabhu
- Department of Radiology, Amrita Institute of Medical Sciences and Research Centre (AIMS), Amrita Vishwa Vidyapeetham, Kochi, India
| | - Ramiah Rajesh Kannan
- Department of Radiology, Amrita Institute of Medical Sciences and Research Centre (AIMS), Amrita Vishwa Vidyapeetham, Kochi, India
| | - Puthukudiyil Kader Nazar
- Department of Radiology, Amrita Institute of Medical Sciences and Research Centre (AIMS), Amrita Vishwa Vidyapeetham, Kochi, India
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Image-guided treatment of Budd-Chiari syndrome: a giant leap from the past, a small step towards the future. Abdom Radiol (NY) 2018; 43:1908-1919. [PMID: 28988356 DOI: 10.1007/s00261-017-1341-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Budd-Chiari syndrome (BCS) is a relatively rare vascular disease characterized by hepatic outflow tract obstruction, and image-guided endovascular treatment, namely percutaneous angioplasty, stenting, and transjugular intrahepatic portosystemic shunt (TIPS), has proven to be effective treatment modalities to alleviate symptoms and markedly improve the prognosis of the disease. Specifically, a step-wise approach is recommended, i.e., angioplasty and stenting are the prioritized choice for patients with membranous obstruction and short-length stenosis, whereas TIPS is the option for patients who fail this treatment. Currently, 5-year survival with the step-wise approach is about 75%, and the most promising way to further improve this value is to identify candidates who are at high risk of failing angioplasty, and perform pre-emptive TIPS in these patients.
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Hidaka M, Eguchi S. Budd-Chiari syndrome: Focus on surgical treatment. Hepatol Res 2017; 47:142-148. [PMID: 27249222 DOI: 10.1111/hepr.12752] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 05/11/2016] [Accepted: 05/24/2016] [Indexed: 12/28/2022]
Abstract
Budd-Chiari syndrome (BCS) is caused by an obstruction in the hepatic venous outflow tract at various levels from small hepatic veins to the inferior vena cava (IVC) due to thrombosis or fibrous sequelae. This rare disease mainly affects young adults. Risk factors have been identified and patients often have multiple risk factors. Myeloproliferative diseases of atypical presentation account for nearly 50% of patients in Europe and North America countries. Multistep management is required for such patients. Interventional revascularization and transjugular intrahepatic portosystemic shunt procedure are indicated after initial anticoagulation therapy, whereas IVC plasty using a patch graft is indicated for obstruction of the IVC. Liver transplantation (LT) is usually indicated as a treatment for liver failure despite various treatments. The outcomes of LT are good, with a 5-year survival after LT of nearly 70%.
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Affiliation(s)
- Masaaki Hidaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Parker CJ. Update on the diagnosis and management of paroxysmal nocturnal hemoglobinuria. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:208-216. [PMID: 27913482 PMCID: PMC6142517 DOI: 10.1182/asheducation-2016.1.208] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Once suspected, the diagnosis of paroxysmal nocturnal hemoglobinuria (PNH) is straightforward when flow cytometric analysis of the peripheral blood reveals a population of glycosyl phosphatidylinositol anchor protein-deficient cells. But PNH is clinically heterogeneous, with some patients having a disease process characterized by florid intravascular, complement-mediated hemolysis, whereas in others, bone marrow failure dominates the clinical picture with modest or even no evidence of hemolysis observed. The clinical heterogeneity is due to the close, though incompletely understood, relationship between PNH and immune-mediated bone marrow failure, and that PNH is an acquired, nonmalignant clonal disease of the hematopoietic stem cells. Bone marrow failure complicates management of PNH because compromised erythropoiesis contributes, to a greater or lesser degree, to the anemia; in addition, the extent to which the mutant stem cell clone expands in an individual patient determines the magnitude of the hemolytic component of the disease. An understanding of the unique pathobiology of PNH in relationship both to complement physiology and immune-mediated bone marrow failure provides the basis for a systematic approach to management.
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Affiliation(s)
- Charles J Parker
- Division of Hematology and Hematologic Malignancies, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
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Outcome of the Z-expandable metallic stent for Budd-Chiari syndrome and segmental obstruction of the inferior vena cava. Eur J Gastroenterol Hepatol 2016; 28:972-9. [PMID: 27172449 DOI: 10.1097/meg.0000000000000640] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Treatment of segmental obstruction of the inferior vena cava (SOIVC) with Z-expandable metallic stents (Z-EMS) is controversial and data on long-term follow-up are lacking. We aimed to evaluate the long-term outcomes of the use of a Z-EMS for Budd-Chiari syndrome (BCS) patients with SOIVC. MATERIALS AND METHODS Between August 2004 and December 2014, 37 consecutive BCS patients with SOIVC were referred for Z-EMS treatment and subsequently underwent follow-up in our department. Data were collected retrospectively and follow-up observations were made 1, 2, 2-5, and 5-10 years postoperatively. RESULTS Percutaneous transluminal balloon angioplasty and Z-EMS placement were technically successful in all patients. Major procedure-related complications occurred in four of 37 patients (10.81%). Follow-up for 61.89±41.45 months in 37 patients indicated portal hypertension in one patient 4 months after stent placement and symptoms were resolved by transjugular intrahepatic portosystemic stent shunting. Hepatocellular carcinoma was observed in four patients and five patients died during follow-up. Reocclusion of the inferior vena cava occurred in four patients (10.81%, 4/41) and all reocclusions were managed by percutaneous transluminal balloon angioplasty. Cumulative 1-, 2-, 2-5-, and 5-10-year primary patency rates were 94.60% (35/37), 93.33% (28/30), 88.89% (24/27), and 85.0% (17/20), respectively. Cumulative 1-, 2-, 2-5-, and 5-10-year secondary patency rates were 100% at all time-points. CONCLUSION These data suggest that Z-EMS implantation is an efficacious, safe, and curative approach for BCS with SOIVC because satisfactory long-term outcomes were achieved. Long-term follow-up is required to ascertain stent patency and hepatocellular carcinoma occurrence.
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Rikitake K, Itoh T, Natsuaki M, Katayama Y, Ohtsubo S, Kataoka H. Surgical Repair for Entire Inferior Vena Cava Occlusion in Budd-Chiari Syndrome. Asian Cardiovasc Thorac Ann 2016; 14:e88-90. [PMID: 17005873 DOI: 10.1177/021849230601400526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Successful repair of thrombotic occlusion of the entire inferior vena cava, including the iliac and hepatic veins, was performed on a 51-year-old man with Budd-Chiari syndrome associated with severe liver dysfunction.
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Affiliation(s)
- Kazuhisa Rikitake
- Department of Thoracic Surgery, Saga Medical School, Nabeshima 5-1-1, Saga city 849-0937, Saga, Japan.
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Ding PX, Zhang SJ, Li Z, Fu MT, Hua ZH, Zhang WG. Long-term safety and outcome of percutaneous transhepatic venous balloon angioplasty for Budd-Chiari syndrome. J Gastroenterol Hepatol 2016; 31:222-8. [PMID: 26102208 DOI: 10.1111/jgh.13025] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/21/2015] [Accepted: 06/15/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The restenosis following percutaneous transluminal balloon angioplasty (PTBA) is high for Budd-Chiari syndrome (BCS) patients with hepatic venous obstruction (HVO). We aim to evaluate the safety and long-term outcome of PTBA with a large balloon catheter in a large series of patients with HVO. METHODS Between January 2005 and December 2013, 93 consecutive BCS patients with HVO were referred for PTBA and subsequently underwent color Doppler ultrasonography or angiography follow-up. Data were retrospectively collected, and follow-up observations were performed at 1-, 2-, 2- to 5-, and 5- to 8-years postoperatively. RESULTS Percutaneous transluminal balloon angioplasty was technically successful in all patients. Ninety-one patients (97.85%) were treated with PTBA and two with PTBA and stent. Major procedure-related complications occurred in six of the 93 patients (6.45%). The cumulative 1-, 2-, 2- to 5-, and 5- to 8-year primary patency rates were 97.5%, 92.9%, 90%, and 86.5%, respectively. Cumulative 1-, 2-, 2- to 5-, and 5- to 8-year secondary patency rates were 100%, 100%, 98.6%, and 97.3%, respectively. Mean and median primary patency rates were 51.50 ± 3.01 months and 55.0 ± 3.63 months, respectively. Cumulative 1-, 2-, 2- to 5-, and 5- to 8-year survival rates were 98.75%, 98.6%, 100%, and 100%, respectively. Mean and median survival times were 53.10 ± 3.04 months and 55.0 ± 3.64 months, respectively. CONCLUSION Percutaneous transluminal balloon angioplasty with a large balloon is a safe and effective treatment that could provide excellent rates of long-term patency and survival for the majority of Chinese patients with BCS and HVO.
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Affiliation(s)
- Peng-Xu Ding
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Shui-Jun Zhang
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Zhen Li
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Ming-Ti Fu
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Zhao-Hui Hua
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Wen-Guang Zhang
- Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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Abstract
Budd-Chiari syndrome (BCS) is a rare and potentially life-threatening disorder characterized by obstruction of the hepatic outflow tract at any level between the junction of the inferior vena cava with the right atrium and the small hepatic veins. In the West, BCS is a rare hepatic manifestation of one or more underlying prothrombotic risk factors. The most common underlying prothrombotic risk factor is a myeloproliferative disorder, although it is now recognized that almost half of patients have multiple underlying prothrombotic risk factors. Clinical manifestations can be diverse, making BCS a possible differential diagnosis of many acute and chronic liver diseases. The index of suspicion should be very low if there is a known underlying prothrombotic risk factor and new onset of liver disease. Doppler ultrasound is sufficient for confirming the diagnosis, although tomographic imaging (computed tomography (CT) or magnetic resonance imaging (MRI)) is often necessary for further treatment and discussion with a multidisciplinary team. Anticoagulation is the cornerstone of the treatment. Despite the use of anticoagulation, the majority of patients need additional (more invasive) treatment strategies. Algorithms consisting of local angioplasty, TIPS and liver transplantation have been proposed, with treatment choice dictated by a lack of response to a less-invasive treatment regimen. The application of these treatment strategies allows for a five-year survival rate of 90%. In the long term the disease course of BCS can sometimes be complicated by recurrence, progression of the underlying myeloproliferative disorder, or development of post-transplant lymphoma in transplant patients.
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Affiliation(s)
| | - Frederik Nevens
- Department of Liver and Biliopancreatic Disorders, University Hospital Gasthuisberg KU Leuven, Leuven, Belgium
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Al-warraky M, Tharwa E, Kohla M, Aljaky M, Aziz A. Evaluation of different radiological interventional treatments of Budd–Chiari syndrome. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2015. [DOI: 10.1016/j.ejrnm.2015.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Massie A, Phillips H, Solomon J. Resolution of Budd‐Chiari syndrome secondary to needle foreign body migration in a dog: treatment with surgery and intravascular stenting. VETERINARY RECORD CASE REPORTS 2015. [DOI: 10.1136/vetreccr-2014-000128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Anna Massie
- North Houston Veterinary SpecialistsSpringTexasUSA
| | - Heidi Phillips
- Veterinary Clinical MedicineUniversity of IllinoisUrbanaIllinoisUSA
| | - Jeffrey Solomon
- Department of New Product DevelopmentInfiniti Medical LLCMenlo ParkCaliforniaUSA
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Strauss E, Valla D. Non-cirrhotic portal hypertension--concept, diagnosis and clinical management. Clin Res Hepatol Gastroenterol 2014; 38:564-9. [PMID: 24581591 DOI: 10.1016/j.clinre.2013.12.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 12/12/2013] [Accepted: 12/24/2013] [Indexed: 02/08/2023]
Abstract
Non-cirrhotic portal hypertension (NCPH) is mainly related to vascular disorders in the portal system, granuloma formation with periportal fibrosis or genetic alterations affecting the hepatobiliary system. For the diagnosis of the so-called idiopathic NCPH, it is essential to rule out chronic liver diseases associated with progression to cirrhosis as viral hepatitis B and C, alcoholic and non-alcoholic fatty liver, autoimmune disease, hereditary hemochromatosis, Wilson's disease as well as primary biliary cirrhosis and primary sclerosing cholagitis. This mini review will focus on the most common types of NCPH, excluding the idiopathic NCPH. Primary Budd-Chiari syndrome, characterized by obstruction of hepatic venous outflow, must be distinguished from sinusoidal obstruction syndrome, a cause of portal hypertension associated with exposure to toxic plants or therapeutic agents. Noninvasive imaging methods usually help the diagnosis of both Budd-Chiari syndrome and portal thrombosis, the later a relatively frequent cause NCPH. Clinical presentation and management of these vascular disorders are evaluated. Schistosomiasis, a worldwide spread endemic parasitic disease, may evolve to severe forms of the disease with huge spleen and gastroesophageal varices due to presinusoidal portal hypertension. Although management of acute upper gastrointestinal bleeding is similar to that of cirrhosis, prevention of rebleeding differs. Instead of portosystemic shunt procedures, the esophagogastric devascularization with splenectomy is the accepted surgical alternative. Its association with endoscopic therapy is suggested to be the best option for PH due to schistosomiasis. In conclusion, the prompt diagnosis of the disorder leading to non-cirrhotic portal hypertension is essential for its correct management.
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Affiliation(s)
- Edna Strauss
- School of Medicine, University of São Paulo, São Paulo, Brazil.
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Copelan A, Remer EM, Sands M, Nghiem H, Kapoor B. Diagnosis and management of Budd Chiari syndrome: an update. Cardiovasc Intervent Radiol 2014; 38:1-12. [PMID: 24923240 DOI: 10.1007/s00270-014-0919-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 04/23/2014] [Indexed: 12/16/2022]
Abstract
Imaging plays a crucial role in the early detection and assessment of the extent of disease in Budd Chiari syndrome (BCS). Early diagnosis and intervention to mitigate hepatic congestion is vital to restoring hepatic function and alleviating portal hypertension. Interventional radiology serves a key role in the management of these patients. The interventionist should be knowledgeable of the clinical presentation as well as key imaging findings, which often dictate the approach to treatment. This article concisely reviews the etiology, pathophysiology, and clinical presentation of BCS and provides a detailed description of imaging and treatment options, particularly interventional management.
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Affiliation(s)
- Alexander Copelan
- Diagnostic Radiology Department, William Beaumont Hospital, 3601 W 13 Mile Rd., Royal Oak, MI, 48073, USA,
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Tripathi D, Macnicholas R, Kothari C, Sunderraj L, Al-Hilou H, Rangarajan B, Chen F, Mangat K, Elias E, Olliff S. Good clinical outcomes following transjugular intrahepatic portosystemic stent-shunts in Budd-Chiari syndrome. Aliment Pharmacol Ther 2014; 39:864-72. [PMID: 24611957 DOI: 10.1111/apt.12668] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 12/24/2013] [Accepted: 01/30/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND There have been encouraging reports on transjugular intrahepatic portosystemic stent-shunt (TIPSS) for Budd-Chiari syndrome (BCS). Long-term data are lacking. AIM To assess long-term outcomes and validate prognostic scores following TIPSS for BCS. METHODS A single centre retrospective study. Patients underwent TIPSS using bare or polytertrafluoroethane (PTFE)-covered stents. RESULTS Sixty-seven patients received successful TIPSS between 1996 and 2012 using covered (n = 40) or bare (n = 27) stents. Patients included had a Male: Female ratio of 21:46, and were characterised (mean ± s.d.) by age 39.9 ± 14.3 years, Model of end stage liver disease (MELD) 16.1 ± 7.0 and Child's score 8.8 ± 2.0. Seventy-eight percent had haematological risk factors. Presenting symptoms were ascites (n = 61) and variceal bleeding (n = 6). Nine patients underwent hepatic vein dilatation or stenting prior to TIPSS. Mean follow-up was 82 months (range 0.5-184 months). Fifteen percent had post-TIPSS encephalopathy. Two have been transplanted. Primary patency rates (76% vs. 27%, P < 0.001) and shunt re-interventions (22% vs. 100%, P < 0.001) significantly favoured covered stents. Secondary patency was 99%. Six-, 12-, 24-, 60- and 120-month survival was 97%, 92%, 87%, 80% and 72% respectively. Six patients had liver related deaths. Two patients developed hepatocellular carcinoma. The BCS TIPS PI independently predicted mortality in the whole cohort, but no prognostic score was a significant predictor of mortality after subgroup validation. CONCLUSIONS Long-term outcomes following TIPSS for Budd-Chiari syndrome are very good. PTFE-covered stents have significantly better primary patency. The value of prognostic scores is controversial. TIPSS should be considered as first line therapy in symptomatic patients in whom hepatic vein patency cannot be restored.
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Affiliation(s)
- D Tripathi
- Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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Zhang B, Jiang ZB, Huang MS, Zhu KS, Qian JS, Shan H. Effects of percutaneous transhepatic interventional treatment for symptomatic Budd-Chiari syndrome secondary to hepatic venous obstruction. J Vasc Surg Venous Lymphat Disord 2013; 1:392-9. [DOI: 10.1016/j.jvsv.2013.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 05/17/2013] [Accepted: 05/28/2013] [Indexed: 01/28/2023]
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Han G, Qi X, Zhang W, He C, Yin Z, Wang J, Xia J, Xu K, Guo W, Niu J, Wu K, Fan D. Percutaneous recanalization for Budd-Chiari syndrome: an 11-year retrospective study on patency and survival in 177 Chinese patients from a single center. Radiology 2013; 266:657-67. [PMID: 23143028 DOI: 10.1148/radiol.12120856] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To evaluate the long-term outcomes of percutaneous recanalization and determine the predictors of patency and survival in a large case series of Chinese patients with Budd-Chiari syndrome (BCS). MATERIALS AND METHODS This retrospective study was approved by the institutional ethics committee. Informed consent for the procedure was obtained from all patients. Between July 1999 and August 2010, 177 consecutive Chinese patients with primary BCS were treated with percutaneous recanalization and followed up until death or their last clinical evaluation. Recanalization therapeutic strategy and complications were recorded. Cumulative patency and survival rates were assessed with Kaplan-Meier curves. Independent predictors of patency and survival were calculated with the Cox regression model. RESULTS Percutaneous recanalization was technically successful in 168 of the 177 patients (95%). Fifty-one of the 168 patients (30%) were treated with percutaneous transluminal angioplasty (PTA) alone and 117 (70%) were treated with a combination of PTA and stent placement. Procedure-related complications occurred in seven of the 168 patients (4%). The cumulative 1-, 5-, and 10-year primary patency rates were 95%, 77%, and 58%, respectively. Independent predictors of reocclusion included increased white blood cell count and use of PTA alone. The cumulative 1-, 5-, and 10-year secondary patency rates were 97%, 90%, and 86%, respectively. Twenty-two patients died during a median follow-up of 30 months (range, 0.25-137 months). The cumulative 1-, 5-, and 10-year survival rates were 96%, 83%, and 73%, respectively. Independent predictors of survival included variceal bleeding, increased alkaline phosphatase and blood urea nitrogen levels, and reocclusion. CONCLUSION Percutaneous recanalization could achieve excellent long-term patency and survival in most Chinese patients with BCS. PTA combined with stent placement should be recommended to decrease the frequency of reocclusion and its associated mortality.
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Affiliation(s)
- Guohong Han
- Department of Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 15 West Changle Rd, Xi'an 710032, China.
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Wang YL, Ding PX, Li YD, Han XW, Wu G. Comparative study of predilation with stent filter for Budd-Chiari syndrome with old IVC thrombosis: A nonrandomized prospective trial. Eur J Radiol 2012; 81:1158-64. [DOI: 10.1016/j.ejrad.2011.03.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 03/04/2011] [Indexed: 11/26/2022]
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Chen H, Cheng Y, Ning S, Chen Y. Budd--Chiari syndrome caused by multiple membranous obstruction of the inferior vena cava in a young man. Ann Vasc Surg 2011; 25:1139.e5-7. [PMID: 21835582 DOI: 10.1016/j.avsg.2011.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 06/01/2011] [Accepted: 06/14/2011] [Indexed: 11/18/2022]
Abstract
Membranous obstruction of the inferior vena cava is a frequent cause of Budd--Chiari syndrome in Eastern countries. The study reports the case of a young male patient with Budd--Chiari syndrome caused by extremely rare multiple membranous obstruction of inferior vena cava. A percutaneous transluminal angioplasty with stent placement was performed successfully, accompanied with satisfactory resolution of clinical symptoms and signs. The graft was reported to be patent 2 years postoperatively.
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Affiliation(s)
- Hongqiang Chen
- Department of Hepato-Biliary, Qilu Hospital, Shandong University, Ji'nan, China
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Anticoagulation With Warfarin for Budd–Chiari Syndrome with Chronic Inferior Vena Cava Thrombosis: An Initial Clinical Experience. Ann Vasc Surg 2011; 25:359-65. [DOI: 10.1016/j.avsg.2010.07.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Revised: 06/07/2010] [Accepted: 07/19/2010] [Indexed: 11/17/2022]
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Hasija RP, Nagral A, Marar S, Bavdekar AR. Transjugular intrahepatic portosystemic shunt (TIPSS) for Budd Chiari syndrome. Indian Pediatr 2010; 47:527-8. [DOI: 10.1007/s13312-010-0081-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Warfarin anticoagulation before angioplasty relieves thrombus burden in Budd-Chiari syndrome caused by inferior vena cava anatomic obstruction. J Vasc Surg 2010; 52:1242-5. [PMID: 20674242 DOI: 10.1016/j.jvs.2010.05.098] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Revised: 05/20/2010] [Accepted: 05/24/2010] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Pulmonary embolism (PE) is one of the major complications after percutaneous balloon angioplasty (PTBA) for Budd-Chiari's syndrome (BCS). The purpose of this study was to investigate the role of warfarin pre-treatment in the prevention of PE after PTBA in patients with large inferior vena cava (IVC) thrombus. PATIENTS AND METHODS From October 2002 to December 2009, 16 patients with symptomatic membranous or segmental IVC occlusion and large thrombus were treated with warfarin before PTBA. Eleven patients were men and 5 were women. The median age was 36 years, ranging from 21 to 52 years. The median duration of warfarin treatment before PTBA was 7 months, ranging from 3 to 12 months. Fourteen patients had membranous IVC occlusion and 2 had segmental occlusion. All 16 patients had significant thrombi underneath the obstructive lesions. PE diagnosis was based on clinical presentation and pulmonary computerized tomographic angiogram, if indicated. RESULTS In 14 of 16 patients, IVC thrombus was completely or near-completely resolved based on follow-up cavogram and PTBA was performed. In the other 2 patients, residual thrombus was demonstrated by cavogram at 12 months. PTBA and stent placement were carried out. IVC patency in the 16 patients was confirmed by completion cavogram. No major bleeding complication during warfarin pre-treatment aimed to keep international normalized ratio (INR) 2 to 3. There was no clinically significant PE or death in this group during follow-up, ranging from 6 to 40 months (median 21 months). CONCLUSION Spontaneous fibrinolysis of IVC thrombus occurs within 1 year in the majority of the patients treated with warfarin. Pre-treatment with warfarin prevents PE after PTBA in the patients with BCS with IVC membranous or segmental occlusion and large thrombus.
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Outcome of a retrieval stent filter and 30mm balloon dilator for patients with Budd-Chiari syndrome and chronic inferior vena cava thrombosis: a prospective pilot study. Clin Radiol 2010; 65:629-35. [PMID: 20599065 DOI: 10.1016/j.crad.2010.01.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Revised: 01/20/2010] [Accepted: 01/27/2010] [Indexed: 11/22/2022]
Abstract
AIM To evaluate the mid-term safety and efficacy of a retrieval stent filter and 30mm balloon dilator in the treatment of Budd-Chiari syndrome (BCS) patients with chronic inferior vena cava (IVC) thrombosis. MATERIALS AND METHODS Twenty-three consecutive patients with BCS and chronic IVC thrombosis were treated with a retrieval stent filter and a 30mm balloon dilator, and subsequently underwent color Doppler ultrasound follow-up at our hospital. Data relating to the technical success, angiographic and ultrasound results, mortality, morbidity, and final clinical outcome were collected retrospectively and follow-ups were performed 1, 3, 6, and 12 months after placement of the stent, and annually thereafter. RESULTS Stent filter placement and balloon dilation were technically successful in all patients, with no procedure-related complications. Removal of the stent filter was technically successful in 22 of 23 attempts, yielding a technical successful rate of 95.7% (95% confidence intervals (CI): 87%, 105%). Inferior vena cavagrams performed immediately before stent removal demonstrated that the IVC thrombus had completely resolved in all patients without pulmonary embolism. The mean primary patency rate 3, 6, 12, and 24 months after venoplasty was 0.91 (95% CI: 0.79-1.04), 0.87 (95% CI: 0.72-1.02), 0.87 (95% CI: 0.72-1.02), and 0.87 (95% CI: 0.72-1.02), respectively. The secondary patency rates were 1.00 throughout the follow-up period. All patients are alive with resolution of the symptoms at the time of this report. CONCLUSIONS The preliminary results indicate that the retrieval stent filter and 30mm balloon dilator are a safe and effective treatment for BCS patients with chronic IVC thrombosis.
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Abstract
OBJECTIVES Budd-Chiari syndrome (BCS) in children is not uncommon. Published literature on therapy for this condition is scarce. We therefore attempted radiological interventions in these patients to determine their efficacy and safety. PATIENTS AND METHODS Fourteen of 16 children with a median age of 22 months diagnosed as having BCS were subjected to an inferior vena cava/hepatic venogram with the aim to establish a normal antegrade flow in at least 1 hepatic vein (HV). RESULTS A normal antegrade flow in at least 1 of the HVs could be established in 11 children. Three patients had angioplasty of the HV (vein size <or=4 mm), 2 underwent HV stent placements (vein size >or=5 mm), and 6 had transjugular intrahepatic porta systemic shunt ([TIPSS] total occlusion of all 3 HVs or veno-occlusive disease). The youngest child undergoing a successful stenting was 7 months of age and the child undergoing TIPSS was 3 years of age. One patient had reversal of fulminant liver failure following a successful TIPSS. Postprocedure, 2 patients developed reversible encephalopathy and 1 had a neck hematoma. There was no procedure-related mortality. The procedure was successful in both patients with stenting (100%), 5 of the 6 patients with TIPSS (80%), and only 1 of the 4 patients (25%) with angioplasty. The median follow-up was 31 months. CONCLUSIONS Radiological therapeutic intervention is feasible and safe in children with BCS. The overall results of stenting/TIPSS are better than with angioplasty; however, long-term results of these interventions need to be evaluated.
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Kikuchi Y, Yoshida H, Mamada Y, Taniai N, Mineta S, Yoshioka M, Hirakata A, Kawano Y, Ueda J, Uchida E. Huge Caudate Lobe of the Liver due to Budd-Chiari Syndrome. J NIPPON MED SCH 2010; 77:328-32. [DOI: 10.1272/jnms.77.328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Yuta Kikuchi
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Hiroshi Yoshida
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
- Department of Surgery, Nippon Medical School Tama Nagayama Hospital
| | - Yasuhiro Mamada
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Nobuhiko Taniai
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Sho Mineta
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Masato Yoshioka
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Atsushi Hirakata
- Department of Surgery, Nippon Medical School Tama Nagayama Hospital
| | - Yoichi Kawano
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Junji Ueda
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Eiji Uchida
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
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Abstract
This guideline has been approved by the American Association for the Study of Liver Diseases (AASLD) and represents the position of the association.
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Affiliation(s)
- Laurie D DeLeve
- Division of Gastrointestinal and Liver Diseases and the Research Center for Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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Abstract
Primary Budd-Chiari syndrome is characterized by a blocked hepatic venous outflow tract at various levels from small hepatic veins to inferior vena cava, resulting from thrombosis or its fibrous sequellae. This rare disease affects mainly young adults. Multiple risk factors have been identified and are often combined in the same patient. Myeloproliferative diseases of atypical presentation account for nearly 50% of patients; their diagnosis can be made by showing the V617F mutation in Janus tyrosine kinase-2 gene of peripheral blood granulocytes and, should this mutation be absent, by showing clusters of dystrophic megacaryocytes at bone marrow biopsy. Presentation and manifestations are extremely varied, so that the diagnosis must be considered in any patient with acute or chronic liver disease. Doppler-ultrasound, computed tomography or magnetic resonance imaging of hepatic veins and inferior vena cava are usually successful in demonstrating non-invasively the obstacle or its consequences, the collaterals to hepatic veins or inferior vena cava. The disease is considered to be spontaneously lethal within 3 years of first symptoms. A therapeutic strategy has been proposed where anticoagulation, correction of risk factors, diuretics and prophylaxis for portal hypertension are used first; then angioplasty for short-length venous stenoses; then TIPS; and ultimately liver transplantation. Treatment progression is dictated by the response to previous therapy. This strategy has achieved 5-year survival rates approaching 90%. Medium-term prognosis depends on the severity of liver disease. Long-term outcome might be jeopardized by transformation of underlying conditions and hepatocellular carcinoma.
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Affiliation(s)
- Dominique-Charles Valla
- Centre de Référence des Maladies Vasculaires du Foie, AP-HP, Hôpital Beaujon, Service d'Hépatologie, Clichy 92118, France.
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Treatment of Budd-Chiari syndrome with transjugular intrahepatic portosystemic shunt (TIPS). Radiol Med 2008; 113:727-38. [PMID: 18618075 DOI: 10.1007/s11547-008-0288-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Accepted: 07/04/2007] [Indexed: 12/13/2022]
Abstract
PURPOSE This study was performed to evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of patients affected by Budd-Chiari syndrome (BCS). MATERIALS AND METHODS From January 1999 to December 2006, 15 patients (seven male and eight female subjects, age range 7-52 years) with BCS uncontrolled by medical therapy were treated with TIPS placement. In seven cases BCS was idiopathic, in four it was caused by myeloproliferative disorders and in four by other disorders. One patient also had portal vein thrombosis. In 5/15 cases TIPS was created through a transcaval approach. Eight patients (53.4%) received a bare stent, and seven (46.6%) received a stent graft. The follow-up lasted a median of 29.4 (range 3.2-68) months. RESULTS Technical success was achieved in all patients without major complications. TIPS was very effective in decreasing the portosystemic pressure gradient from 26.2+/-5.8 to 10+/-6.2 mmHg. All patients but two were alive at the time of writing. Acute leukaemia was the cause of the single early death and was unrelated to the procedure. The patient with portal vein thrombosis underwent thrombolysis before TIPS, but the vein occluded again after 3 weeks, and the patient died 6 months later. The other patients showed significant improvements in liver function, ascites and symptoms related to portal hypertension. Primary patency was 53.3%, and primary assisted patency was 93.3%. No patient required or was scheduled for liver transplantation. CONCLUSIONS TIPS is an effective and safe treatment for BCS and may be considered a valuable alternative to traditional surgical portosystemic shunting or liver transplantation.
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Interventional radiology in the management of Budd Chiari syndrome. Cardiovasc Intervent Radiol 2008; 31:839-47. [PMID: 18214592 DOI: 10.1007/s00270-007-9285-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2007] [Accepted: 12/06/2007] [Indexed: 12/12/2022]
Abstract
Budd Chiari syndrome is an uncommon condition in the Western world but interventional radiology can contribute significantly to the management of the majority of patients. This review examines the role and technique of interventions including hepatic vein dilatation and stent insertion as well as thrombolysis and TIPS. Liver transplantation and surgical shunt surgery are discussed in relation to radiological interventions. With appropriate selection and technique, surgery is only required in a minority of patients.
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Grams J, Teh SH, Torres VE, Andrews JC, Nagorney DM. Inferior vena cava stenting: a safe and effective treatment for intractable ascites in patients with polycystic liver disease. J Gastrointest Surg 2007; 11:985-90. [PMID: 17508255 DOI: 10.1007/s11605-007-0182-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We performed a retrospective study of seven patients with polycystic liver disease who underwent stenting of the inferior vena cava for intractable ascites. All patients had symptomatic ascites and inferior vena cava stenosis demonstrable by venography. The mean pressure gradient across the inferior vena cava stenosis before stenting was 14.5 mm Hg (range 6-25 mm Hg) and significantly decreased to a mean pressure gradient of 2.8 mm Hg (range 0-6 mm Hg, p = 0.008) after stenting. Two patients also had stenting of hepatic venous stenoses after unsuccessful inferior vena cava stenting. After a mean follow-up of 12.2 months (range 0.5-39.1 months), five of the seven patients have had maintained clinical improvement, defined as decreased symptoms, diuretic requirements, and frequency of paracentesis. Four patients have required no further intervention. The other patient was lost in follow-up. Patients with clinical improvement had an overall larger mean pressure gradient before stenting (19.2 vs. 9.8 mm Hg) and a larger Delta pressure gradient (15.8 vs. 7.8 mm Hg) compared to those in whom stenting was unsuccessful. These results suggest inferior vena cava stenting is safe and effective and should be considered as a first-line intervention in the treatment of medically intractable ascites in select patients with polycystic liver disease.
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Affiliation(s)
- Jayleen Grams
- Department of Surgery, Mayo Clinic College of Medicine, 200 1st Street SW, Rochester, MN 55905, USA
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Abstract
Budd Chiari syndrome presents with a wide range of severity and duration of symptoms. Transjugular intrahepatic portosystemic shunt has been used to treat selected Budd Chiari syndrome patients for several years. The technique of transjugular intrahepatic portosystemic shunt may be more challenging than in cirrhosis because of hepatic vein occlusion. Covered transjugular intrahepatic portosystemic shunt stents have reduced the requirement for follow-up interventions. Transjugular intrahepatic portosystemic shunt has been a successful bridge to liver transplant for Budd Chiari syndrome but is the definitive treatment in many cases. Patient selection is important to determine who will benefit from transjugular intrahepatic portosystemic shunt or other treatments such as hepatic vein recanalization or liver transplant.
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Affiliation(s)
- Simon P Olliff
- Clinical Radiology Department, Queen Elizabeth Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK.
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Parker C, Omine M, Richards S, Nishimura JI, Bessler M, Ware R, Hillmen P, Luzzatto L, Young N, Kinoshita T, Rosse W, Socié G. Diagnosis and management of paroxysmal nocturnal hemoglobinuria. Blood 2005; 106:3699-709. [PMID: 16051736 PMCID: PMC1895106 DOI: 10.1182/blood-2005-04-1717] [Citation(s) in RCA: 489] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Charles Parker
- Division of Hematology, University of Utah School of Medicine and Hematology/Oncology Section (111H), George E. Whalen VA Medical Center, Salt Lake City, UT 84148, USA.
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Barrault C, Plessier A, Valla D, Condat B. [Non surgical treatment of Budd-Chiari syndrome: a review]. ACTA ACUST UNITED AC 2004; 28:40-9. [PMID: 15041809 DOI: 10.1016/s0399-8320(04)94839-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Shirai Y, Yoshiji H, Fujimoto M, Kojima H, Yanase K, Namisaki T, Kitade M, Yamamoto K, Sakaguchi H, Kichikawa K, Fukui H. Successful treatment of acute Budd-Chiari syndrome with percutaneous transluminal angioplasty. ACTA ACUST UNITED AC 2004; 29:685-7. [PMID: 15185028 DOI: 10.1007/s00261-004-0183-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2003] [Accepted: 01/28/2004] [Indexed: 10/26/2022]
Abstract
A 26-year-old man developed progressive, massive ascites and hematemesis due to rupture of esophageal varices. Combination diagnostic modalities of color doppler ultrasonography, enhanced computed tomography, and magnetic resonance imaging led to the case being diagnosed as acute Budd-Chiari syndrome with severe stricture of the intrahepatic inferior vena cava. Percutaneous transluminal angioplasty this resulted in great improvement of the clinical manifestations.
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Affiliation(s)
- Y Shirai
- Third Department of Internal Medicine, Nara Medical University, 840 Shijo-cho Kashihara, Nara 634-8522, Japan
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Sharma S, Texeira A, Texeira P, Elias E, Wilde J, Olliff SP. Pharmacological thrombolysis in Budd Chiari syndrome: a single centre experience and review of the literature. J Hepatol 2004; 40:172-80. [PMID: 14672630 DOI: 10.1016/j.jhep.2003.09.028] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND/AIMS To review our experience of thrombolytic therapy in patients with acute Budd Chiari syndrome (BCS). METHODS Records of 10 patients with BCS, treated by thrombolysis over a 12-year period were retrospectively analysed for demographics, clinical presentation/duration, primary disease, thrombolytic regimen, and follow-up. The same characteristics were also studied in previously reported patients. The agent used was recombinant tissue plasminogen activator (tPA) in all patients. RESULTS Thrombolysis was used 12 times in 10 patients. Infusion was made systemically in three patients, into the hepatic artery in one patient, locally into a hepatic vein and/or IVC in four patients and locally within TIPS/portal vein in two patients. Only one infusion made systemically was partially successful. Adjunctive balloon angioplasty and/or stent insertion was undertaken for all eight procedures (in six patients) where local infusion was into the hepatic vein or TIPS. Six of these were ultimately successful (in five patients) and two were unsuccessful. Thrombolysis was more likely to be successful in the presence of a short history of thrombosis, when the thrombolytic agent was locally infused and when it was combined with a successful radiological procedure. Mean follow-up was 4.5 years (range 1-10 years). No serious bleeding complication occurred. CONCLUSIONS We observed no benefit from thrombolysis when delivered systemically or arterially except in one case. Thrombolysis was useful in adjunctive management of BCS when the drug was infused locally into recently thrombosed veins that had appreciable flow following partial recanalisation. Thrombolysis was clearly of benefit in the repermeation of occluded/partially occluded hepatic veins/TIPS when early detection of new thrombus followed interventional procedures such as balloon angioplasty or stenting of hepatic veins.
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Affiliation(s)
- S Sharma
- Department of Radiology, Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, The Liver Unit, Birmingham B15 2TH, UK
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Affiliation(s)
- Terry S Desser
- Department of Radiology, Stanford University School of Medicine, Mail Code 5621, 300 Pasteur Dr., CA 94305, USA
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Janssen HLA, Garcia-Pagan JC, Elias E, Mentha G, Hadengue A, Valla DC. Budd-Chiari syndrome: a review by an expert panel. J Hepatol 2003; 38:364-71. [PMID: 12586305 DOI: 10.1016/s0168-8278(02)00434-8] [Citation(s) in RCA: 298] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Harry L A Janssen
- Department of Gastroenterology and Hepatology, University Hospital Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
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Randi ML, Sartori MT, Luzzatto G, Ruzzon E, Boccagni P, Ragazzi R, Girolami A. Thrombocytosis and recurrent hepatic outflow obstruction (Budd-Chiari syndrome) after successful thrombolysis: case report and literature review. Clin Appl Thromb Hemost 2002; 8:369-74. [PMID: 12516687 DOI: 10.1177/107602960200800409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Approximately two thirds of cases of hepatic flow obstruction are due to myeloproliferative disorders. Restoration of hepatic blood flow is the essential goal of treatment. Thrombolytic therapy seems to achieve good results at least in selected cases. A 32-year-old woman is presented, with an intermittent increase in platelet count (526-725 x 10(9)/L), two previous spontaneous abortions and acute symptomatic occlusion of hepatic veins, and in whom a diagnosis of essential thrombocythemia was initially carried out in agreement with the polycythemia vera study group criteria. She received recombinant tissue plasminogen activator followed by heparin with restoration of normal hepatic outflow. Asymptomatic re-occlusion of the hepatic veins was observed 1 year later, despite adequate continuous warfarin treatment. Angiography showed marked narrowing of the intrahepatic cava vein due to extrinsic compression by an enlarged liver, not due to a new thrombosis so that no specific intervention could be performed. In the presence of a dearly documented hepatic vein thrombosis, thrombolytic therapy should be considered. The patient was given low-molecular-weight heparin with a dramatic reduction in previously elevated fibrinogen level and a good control of the hepatic function.
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Affiliation(s)
- Maria Luigia Randi
- Department of Medical and Surgical Sciences, University of Padua Medical School, Padua, Italy.
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Te HS, Jeevanandam V, Millis JM, Cronin DC, Baker AL. Open cardiotomy for removal of migrating transjugular intrahepatic portosystemic shunt stent combined with liver transplantation. Transplantation 2001; 71:1000-3. [PMID: 11349708 DOI: 10.1097/00007890-200104150-00030] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transjugular intrahepatic shunts are widely used for the management of variceal bleeding. Complications such as stent misplacement or migration may occur. METHODS We describe the management of a transjugular intrahepatic shunts stent that migrated across the tricuspid valve in a patient with Child-Pugh category C cirrhosis. RESULTS An attempt at percutaneous retrieval of the stent was unsuccessful. Due to the unacceptably high risk for mortality from open heart surgery with cardiopulmonary bypass in the setting of cirrhosis, stent removal was deferred until the time of orthotopic liver transplantation. The procedures were performed successfully, and the patient made a good recovery. CONCLUSION Surgical stent extraction and valve repair can be performed safely along with orthotopic liver transplantation in carefully selected patients with end-stage liver disease.
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Affiliation(s)
- H S Te
- Department of Medicine, University of Chicago Hospitals, IL 60637, USA
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Mourad FH, Khalifeh M, Al-Kutoubi A, Khalil I. Inferior vena cava obstruction in Budd-Chiari syndrome: successful treatment by radiological stenting followed by a portosystemic shunt. Eur J Gastroenterol Hepatol 2001; 13:275-7. [PMID: 11293448 DOI: 10.1097/00042737-200103000-00010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Surgical decompression by a portosystemic shunt in Budd-Chiari syndrome depends on the caval state. Obstruction of the inferior vena cava (IVC) precludes such an operation due to the risk of reduced blood flow across the shunt and subsequent thrombosis. Similar risks are encountered in more complicated operations such as mesoatrial shunt. We report a patient with Budd-Chiari syndrome in whom obstruction of the intrahepatic IVC by a hypertrophied caudate lobe of the liver precluded the construction of a standard portocaval shunt. A two-step procedure with preoperative radiological stenting of the narrowed IVC followed by a portocaval shunt was successfully performed. This is the fifth case reported in the literature of such an approach.
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Affiliation(s)
- F H Mourad
- Department of Internal Medicine, American University of Beirut Medical Center, Lebanon.
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Pfammatter T, Benoit C, Cathomas G, Blum U. Budd-Chiari syndrome with spleno-mesenteric-portal thrombosis: treatment with extended TIPS. J Vasc Interv Radiol 2000; 11:781-4. [PMID: 10877427 DOI: 10.1016/s1051-0443(07)61641-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- T Pfammatter
- Institute of Diagnostic Radiology, University Hospital, Zurich, Switzerland.
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Murray D, Platts AD, Watkinson AF. Imaging and intervention of vascular retroperitoneal pathology. IMAGING 2000. [DOI: 10.1259/img.12.1.120061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Abstract
Budd-Chiari syndrome represents a spectrum of disorders characterized by obstruction to hepatic venous drainage. Originally described as an "obliterating endophlebitis of the hepatic veins," this condition has come to refer to the manifestations of hepatic venous outflow obstruction anywhere above the level of the hepatic venulae regardless of the etiology, position, or severity of the obstruction or of the clinical course. Depending on the nature and anatomy of the obstruction, the disease presents acutely, with a rapidly progressive course, or insidiously, with gradual development of symptoms. The optimal management strategy for a given patient with Budd-Chiari syndrome depends on the anatomy of the obstruction, its physiologic consequences, and the natural history of the specific lesion. The specific treatments available and their use in the treatment of Budd-Chiari syndrome are reviewed.
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Affiliation(s)
- A T Olzinski
- Department of Surgery, Virginia Commonwealth University, Medical College of Virginia, Richmond, USA
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Holt D, Saunders HM, Aronson L, Peikes H, Goldschmidt M, Haskal ZJ. Caudal vena cava obstruction and ascites in a cat treated by balloon dilation and endovascular stent placement. Vet Surg 1999; 28:489-95. [PMID: 10582747 DOI: 10.1111/j.1532-950x.1999.00489.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To present details of an unusual case of caudal vena caval obstruction and its management in a cat. STUDY DESIGN Clinical case report. STUDY POPULATION A 15 month old male castrated domestic shorthaired cat. RESULTS The diagnostic evaluation included the use of digital subtraction angiography and ultrasonography to locate the caudal vena caval obstruction. Treatment initially involved puncture and balloon dilation of the obstructed area of the cava. After reobstruction, the stenotic area was redilated and stented. The cat was euthanatized 4 weeks later because of vomiting, anorexia, and abnormal behavior, presumed to be associated with liver disease. CONCLUSION AND CLINICAL RELEVANCE Interventional radiography provided a minimally invasive way to manage this unusual vascular anomaly.
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Affiliation(s)
- D Holt
- Department of Clinical Studies, University of Pennsylvania School of Veterinary Medicine, Philadelphia 19104-6010, USA
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Chunqing Z, Lina F, Guoquan Z, Lin X, Zhaohai W, Tao J, Chengyong Q, Juzhen Z. Ultrasonically guided percutaneous transhepatic hepatic vein stent placement for Budd-Chiari syndrome. J Vasc Interv Radiol 1999; 10:933-40. [PMID: 10435714 DOI: 10.1016/s1051-0443(99)70141-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To evaluate the utility of ultrasonically guided hepatic vein stent placement in the treatment of Budd-Chiari syndrome (BCS) in patients with short hepatic vein obstruction. MATERIALS AND METHODS Twenty-five patients with BCS, each with three obstructed hepatic veins diagnosed with ultrasound (US), color Doppler, probing with guide wire, and echo contrast, underwent hepatic vein stent placement under US guidance. Nine patients had hepatic vein obstruction alone, and 16 had hepatic vein obstruction along with primary inferior vena cava (IVC) obstruction. In each patient, only one of the hepatic veins was selected for recanalization and stent placement. In patients with primary IVC lesions, a stent was placed in the IVC first. Clinical and US examinations were performed at 3-6-month intervals on every patient during follow-up. RESULTS Hepatic vein stents were successfully placed in 23 of the 25 patients, a success rate of 92%. The mean +/- SD hepatic vein pressure decreased from 25.57 mm Hg +/- 9.46 to 9.67 mm Hg +/- 2.31 (P < .01), and the flow direction in the hepatic vein became centripetal and its spectral analysis showed a normal phasic flow. Twenty-two patients experienced a significant improvement in hepatic outflow, as evidenced by disappearance of ascites, remission of hepatosplenomegaly, improvement in liver function, and alleviation of esophageal varices. Severe intraperitoneal hemorrhage occurred in one patient. No other serious procedure-related complications were observed. During follow-up of 1-43 months (mean, 23 months), stent reocclusion occurred in one patient. The other stents remained patent, and clinical features of BCS did not recur. CONCLUSION Percutaneous transhepatic hepatic vein stent placement is a reasonable treatment for BCS in patients with hepatic vein obstruction, and the procedures can be performed safely and accurately with US.
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Affiliation(s)
- Z Chunqing
- Department of Gastroenterology, Shandong Provincial Hospital, Jinan, China
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Suhocki PV, Trotter JF. Percutaneous hepatic vein reconstruction for Budd-Chiari syndrome. AJR Am J Roentgenol 1998; 171:189-91. [PMID: 9648786 DOI: 10.2214/ajr.171.1.9648786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- P V Suhocki
- Department of Radiology, Duke University Medical Center, Durham, NC 27710-3808, USA
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Hatrick AG, Burnand KG, Irvine AT. Relief of Budd-Chiari syndrome by primary placement of a metallic stent in the inferior vena cava: Case report. MINIM INVASIV THER 1997. [DOI: 10.3109/13645709709153360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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