Percutaneous balloon angioplasty of inferior vena cava in Budd-Chiari syndrome-R1

Interventional Treatment of Budd-Chiari Syndrome

Medical treatment is regarded as the primary course of action in patients with Budd-Chiari syndrome (BCS). Its efficacy, however, is limited, and most patients require interventional treatment during follow-up. Short-segment stenosis or the occlusion (the so-called web) of hepatic veins or the inferior vena cava are frequent in Asian countries. An angioplasty with or without stent implantation is the treatment of choice to restore hepatic and splanchnic blood flow. The long-segment thrombotic occlusion of hepatic veins, common in Western countries, is more severe and may require a portocaval shunting procedure to relieve hepatic and splanchnic congestion. Since it was first proposed in a publication in 1993, the transjugular intrahepatic portosystemic shunt (TIPS) has gained more and more attention, and in fact it has been so successful that previously utilized surgical shunts are only used for few patients for whom it does not work. Both interventional treatment options can be performed successfully in about 95% of patients even after the complete obliteration of the hepatic veins. The long-term patency of the TIPS, a considerable problem in its early years, has been improved with PTFE-covered stents. The complication rates of these interventions are low and the survival rate is excellent with five- and ten-year survival rates of 90% and 80%, respectively. Present treatment guidelines recommend a step-up approach indicating interventional treatment after the failure of medical treatment. However, this widely accepted algorithm has several points of contention, and early interventional treatment is proposed instead.

Survival and clinical success of endovascular intervention in patients with Budd-Chiari syndrome: A systematic review

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.

Evaluation of outcome from endovascular therapy for Budd-Chiari syndrome: a systematic review and meta-analysis

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.

Hepatocellular carcinoma with Budd-Chiari syndrome due to membranous obstruction of the inferior vena cava with long-term follow-up: a case report

Membranous obstruction of the inferior vena cava (MOVC) is a rare subset of Budd-Chiari syndrome (BCS) with a subacute onset that is often complicated by cirrhosis and hepatocellular carcinoma (HCC). Here we report a case of recurrent HCC in a patient with cirrhosis and BCS that was treated with several episodes of transarterial chemoembolization followed by surgical tumorectomy, whereas the MOVC was successfully treated with balloon angioplasty followed by endovascular stenting. The patient was followed up for 9.9 years without anticoagulation and experienced no stent thrombosis. After the tumorectomy, the patient was HCC-free for 4.4 years of follow-up.

Budd-Chiari Syndrome: An Uncommon Cause of Chronic Liver Disease that Cannot Be Missed

Budd-Chiari syndrome (BCS), or hepatic venous outflow obstruction, is a rare cause of liver disease that should not be missed. Variable clinical presentation among patients with BCS necessitates a high index of suspicion to avoid missing this life-threatening diagnosis. BCS is characterized as primary or secondary, depending on etiology of venous obstruction. Most patients with primary BCS have several contributing risk factors leading to a prothrombotic state. A multidisciplinary stepwise approach is integral in treating BCS. Lifelong anticoagulation is recommended. Long-term monitoring of patients for development of cirrhosis, complications of portal hypertension, hepatocellular carcinoma, and progression of underlying diseases is important.

Is There Still a Role for Surgical Shunts in the Treatment of Budd-Chiari Syndrome? A 25-Year Experience

PURPOSE

To investigate the long-term results of shunt surgery in the treatment of Budd-Chiari Syndrome.

METHODS

Medical records of patients treated with Budd-Chiari Syndrome between 1993 and 2006 were reviewed.

RESULTS

Thirty-seven patients (26 female, 11 male) were identified, with a median age of 30 years (range 14-51). Median duration of symptoms was 3 months (range 1 month to 10 years). Twenty-five patients, all in acute or subacute stages of disease, were treated surgically. Constructed shunts were mesoatrial in 17, portocaval in five (one was converted from a failed portorenal shunt) and mesocaval in three. Median portal pressure decreased from 44 cm H₂O (range 31-55) to 20 cm H₂O (range 5-27). Seven patients (28%) died in the perioperative period. Eighteen patients (72%) were followed up for a median of 186 months (24-241 months). Seven patients died during follow-up, five due to reasons related to the underlying cause and treatment. Remaining 11 patients (61%) were alive at a median of 18 years (13-25 years) with patent shunts. One-, 5-, and 10-year survival rates in patients undergoing shunt surgery were 78%, 72%, and 66%, respectively.

CONCLUSION

Portosystemic shunts may still be considered when expertise for transjugular intrahepatic portosystemic shunt or liver transplantation is not available.

Inferior Vena Cava Rupture Caused by Balloon Angioplasty During the Treatment of Budd-Chiari Syndrome

OBJECTIVE

Percutaneous transluminal balloon angioplasty (PTA) is the main treatment option for Budd-Chiari syndrome (BCS) with inferior vena cava (IVC) obstruction. However, IVC rupture caused by PTA has never been reported.

MATERIALS AND METHODS

Between August 2004 and December 2016, a consecutive cohort of 617 BCS patients with obstructed IVC who underwent PTA with or without stent placement were reviewed retrospectively to identify IVC rupture. Pre- and post-procedural imaging data, clinical and procedural technical data were analyzed.

RESULTS

Of the 617 BCS patients, five patients had IVC rupture caused by PTA (0.81%). Four of these patients had retroperitoneal, intra-hepatic IVC rupture without extravasation into abdominal cavity which was successfully managed conservatively. One patient had supra-hepatic IVC rupture into the pericardial cavity which was surgically treated.

CONCLUSION

IVC rupture is a rare complication of PTA treatment of BCS and most commonly located at the intra-hepatic IVC caused by oversized balloons which does not require additional treatment.

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.

Review article: a multidisciplinary approach to the diagnosis and management of Budd-Chiari syndrome

BACKGROUND

Budd-Chiari syndrome (BCS) is a rare but fatal disease caused by obstruction in the hepatic venous outflow tract.

AIM

To provide an update of the pathophysiology, aetiology, diagnosis, management and follow-up of BCS.

METHODS

Analysis of recent literature by using Medline, PubMed and EMBASE databases.

RESULTS

Primary BCS is usually caused by thrombosis and is further classified into "classical BCS" type where obstruction occurs within the hepatic vein and "hepatic vena cava BCS" which involves thrombosis of the intra/suprahepatic portion of the inferior vena cava (IVC). BCS patients often have a combination of prothrombotic risk factors. Aetiology and presentation differ between Western and certain Asian countries. Myeloproliferative neoplasms are present in 35%-50% of European patients and are usually associated with the JAK2-V617F mutation. Clinical presentation is diverse and BCS should be excluded in any patient with acute or chronic liver disease. Non-invasive imaging (Doppler ultrasound, computed tomography, or magnetic resonance imaging) usually provides the diagnosis. Liver biopsy should be obtained if small vessel BCS is suspected. Stepwise management strategy includes anticoagulation, treatment of identified prothrombotic risk factors, percutaneous revascularisation and transjugular intrahepatic portosystemic stent shunt to re-establish hepatic venous drainage, and liver transplantation in unresponsive patients. This strategy provides a 5-year survival rate of nearly 90%. Long-term outcome is influenced by any underlying haematological condition and development of hepatocellular carcinoma.

CONCLUSIONS

With the advent of newer treatment strategies and improved understanding of BCS, outcomes in this rare disease have improved over the last three decades. An underlying haematological disorder can be the major determinant of outcome.

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.

Direct Intrahepatic Portosystemic Shunt in Budd-Chiari Syndrome: A Case Report and Review of the Literature

Transjugular intrahepatic portosystemic shunt (TIPS) is an alternative interventional procedure used to manage refractory Budd-Chiari syndrome (BCS) when conservative medical therapy has failed. However, TIPS is not always technically successful because of hepatic vein thrombosis and inability to catheterize the hepatic veins. In these situations, direct intrahepatic portosystemic shunt (DIPS) with access to the portal vein from the IVC has been shown to be a viable alternative that may ameliorate portal hypertension in these patients. Typically, DIPS involves the use of transabdominal ultrasound to target the portal vein. Herein a case in which a 39-year-old female underwent DIPS without the use of ultrasound guidance is presented. Instead, a hepatic venogram generated using collateral circulation was used to opacify and guide access to the portal vein.

Timing of Transjugular Intrahepatic Portosystemic Stent-shunt in Budd-Chiari Syndrome: A UK Hepatologist's Perspective

Budd-Chiari syndrome (BCS) is a rare but fatal disease caused by the obstruction in hepatic venous outflow tract (usually by thrombosis) and is further classified into two subtypes depending on the level of obstruction. Patients with BCS often have a combination of prothrombotic risk factors. Clinical presentation is diverse. Stepwise management strategy has been suggested with excellent 5-year survival rate. It includes anticoagulation, treatment of identified prothrombotic risk factor, percutaneous recanalization, and transjugular intrahepatic portosystemic shunt (TIPS) to reestablish hepatic venous outflow and liver transplantation in unresponsive patients. Owing to the rarity of BCS, there are no randomized controlled trials (RCTs) precisely identifying the timing for TIPS. TIPS should be considered in patients with refractory ascites, variceal bleed, and fulminant liver failure. Liver replacement is indicated in patients with progressive liver failure and in those in whom TIPS is not technically possible. The long-term outcome is usually influenced by the underlying hematologic condition and the development of hepatocellular carcinoma. This review focuses on the timing and the long-term efficacy of TIPS in patients with BCS.

Angioplasty for Budd-Chiari Syndrome in a Child with 26-Year Follow-up

Budd-Chiari syndrome (BCS) is a rare but life-threatening disease. If not treated promptly, it is almost always lethal with progressive liver failure, severe nutritional depletion, and renal failure at the late stage. We report the successful treatment of a 5-year-old boy with BCS due to a stenosis of the inferior vena cava (IVC) with a 26-year follow-up. We performed a percutaneous transluminal angioplasty, which resulted in a great improvement of BCS and the disappearance of ascites. Restenosis occurred at 25 years after the initial angioplasty, for which balloon angioplasty was repeatedly performed. The IVC was patent at 1-year follow-up after the second angioplasty.

Long-term Outcome of Recoverable stents for Budd-Chiari syndrome Complicated with Inferior Vena Cava Thrombosis

This study aimed to present long-term results of a 12-year patient follow-up of recoverable stents for BCS complicated by inferior vena cava (IVC) thrombosis. Forty consecutive patients with BCS complicated by IVC thrombosis were treated with recoverable stents. The median duration of symptoms was 24 months. Recoverable stents was placed after predilation of the obstructed IVC, and then agitation thrombolysis or catheter-directed thrombolysis of IVC was performed. The recoverable stents was removed eventually after thrombus disappeared. Clinical patency was defined as absence or improvement of symptoms. Patients were subsequently followed-up by color Doppler ultrasound. Recoverable stents placement, balloon angioplasty and thrombolysis were technically successful in all patients. Stents were successfully removed in 92.1% of patients. A few serious related complications including one acute pulmonary thromboembolism, one stent migration, and one failure retrieval stents occurred. The median follow-up was 43.7 months. The long-term results were satisfactory except 2 patients who presented with a restenosis or re-obstruction and underwent additional therapy. There were 5 deaths owing to pulmonary embolism or underlying malignant disease 0.4–101.8 months after the procedures, including one procedure-related death. In conclusion, Recoverable stents treatment is safe and effective for BCS complicated by IVC thrombosis, with a good long-term outcome.

Budd-Chiari syndrome with upper gastrointestinal hemorrhage: Characteristic and long-term outcomes of endovascular treatment

Purpose To identify the characteristics and evaluate the long-term outcomes of endovascular treatment of Budd-Chiari syndrome with upper gastrointestinal hemorrhage. Methods Forty-seven consecutive Budd-Chiari syndrome patients with upper gastrointestinal hemorrhage were referred for the treatment with percutaneous transluminal balloon angioplasty, and subsequently underwent follow-up. Data were retrospectively collected and follow-up observations were performed at 1, 2, 2-5, and 5-8 years postoperatively. Results Cirrhosis was presented in 16 patients, and splenoportography reviewed obvious varices in 18 patients. Percutaneous transluminal balloon angioplasty was technically successful in all patients. Major procedure-related complications occurred in 3 of the 47 patients (6.38%). The cumulative 1, 2, 2-5, and 5-8 year primary patency rates were 100% (46/46), 93.2% (41/44), 90.9% (40/44), and 86.4% (19/22), respectively. The cumulative 1, 2, 2-5, and 5-8 year secondary patency rates were 100% (47/47), 100% (44/44), 100% (44/44), and 95.5% (21/22), respectively. Mean and median duration of primary patency was 65.17 ± 3.78 and 69.0 ± 5.69 months, respectively. No upper gastrointestinal hemorrhage recurred during follow-ups. The mean survival time was 66.97 ± 3.61 months and the median survival time was 69.0 ± 4.10 months. Conclusion PTBA was an effective treatment that can prevent recurrence of the life-threatening complications and ensured long-term satisfactory clinical outcomes for Budd-Chiari syndrome patients with upper gastrointestinal hemorrhage. Percutaneous transhepatic variceal embolization was not recommended for all Budd-Chiari syndrome patients with upper gastrointestinal hemorrhage.

Number and function of circulating endothelial progenitor cells in patients with primary Budd-Chiari syndrome

BACKGROUND AND AIM

Primary Budd-Chiari syndrome (BCS) is associated with vascular endothelial injury. Circulating endothelial progenitor cells (EPCs) provide an endogenous mechanism to repair endothelial injury. This study investigated the levels and functionality of EPCs in patients with primary BCS.

METHODS

EPCs (CD34⁺/CD133⁺/KDR⁺) were quantified in 82 patients with primary BCS (inferior vena cava type: n=19; hepatic vein type: n=22; and mixed type: n=41), 10 cirrhosis controls (CC group) and 10 age-matched healthy controls (HC group), using flow cytometry. EPCs proliferation was detected by MTT assay, adhesion by adhesion activity assay, and migration capacity by Transwell assay.

RESULTS

EPCs levels were significantly lower in the BCS group (0.020±0.005%) than in the CC and HC groups (0.260±0.201%, 0.038±0.007%; P<0.001 for each). EPCs cultured in vitro from BCS and CC groups had, respectively, lower proliferation activity (0.20±0.04, 0.23±0.06 vs 0.58±0.07, each P<0.001), adhesion activity (15.8±1.7, 18.2±4.3 vs 35.0±2.5 cells/random microscopic field (RMF), each P<0.001) and migration activity (16.1±1.5, 16.7±3.0 vs 23.9±2.0 cells/RMF, each P<0.001) than in the HC group. EPCs functionality did not significantly differ between the BCS and CC groups. The numbers and functions of EPCs did not significantly differ among patients with inferior vena cava type, hepatic vein type and mixed type of BCS.

CONCLUSION

Patients with primary BCS had lower EPCs levels, with less proliferation, adhesion and migration activities. These findings suggest that lower levels of less functional EPCs may be associated with venous occlusion in primary BCS patients.

Liver Transplantation for Budd-Chiari Syndrome With Large Solitary Focal Nodular Hyperplasia of the Liver in a Patient With Essential Thrombocythemia: Case Report. [Corrected]

Budd-Chiari syndrome is a rare condition caused by interrupted hepatic venous outflow in the hepatic veins, inferior vena cava, or right atrium. Reports from the literature have delineated on focal nodular hyperplasia (FNH)-like lesions in association with Budd-Chiari Syndrome. To our knowledge, there are no reports about true FNH lesions in patients with Budd-Chiari Syndrome. Focal nodular hyperplasia develops in disorders with aberrant circulation and vasculature. We report a case of Budd-Chiari syndrome in association with large solitary FNH in a 22-year-old man who was referred to our institution with sudden intermittent right upper quadrant abdominal pain, vomiting, diarrhea with pale stool, decreased appetite, dark urine, and abdominal distention for 15 days. Laboratory investigations revealed anemia, thrombocytosis, and abnormal liver function tests and coagulation profile. Imaging revealed hepatic vein thrombosis, confirming Budd-Chiari syndrome, and a 6.2 × 6.1 × 6.8 cm lesion in segment 8 of the liver. Primary cause of Budd-Chiari syndrome was essential thrombocythemia according to bone marrow biopsy and molecular testing results. The patient was treated medically and underwent transjugular intrahepatic portosystemic shunt insertion. The lesion in segment 8 continued to enlarge. Cadaveric liver transplantation was carried out. On gross and histologic examination of the explanted liver, the lesion was found to be a true FNH.

Long-term safety and outcome of percutaneous transhepatic venous balloon angioplasty for Budd-Chiari syndrome

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.

The outcomes of interventional treatment for Budd-Chiari syndrome: systematic review and meta-analysis

The purpose of this study was to conduct a systematic review with meta-analysis quantitatively assesses the outcomes of interventional treatment for Budd-Chiari syndrome (BCS). We evaluated the published studies on interventional treatment for BCS and reviewed reference lists from retrieved articles. Meta-analysis was applied to calculate the combined rates and their 95% confidence intervals. The risk of bias was assessed by the Egger test. As many as 29 articles on interventional treatment with BCS were selected according to the eligibility criteria and included in the meta-analysis, for a total of 2,255 BCS patients. The pooled results (95 % CI) were 93.7 % (92.6-4.8 %) for successful rate of interventional operation, 6.5 % (5.3-7.7 %) for restenosis rate of interventional treatment, and 92.0 % (89.8-94.3 %) and 76.4 % (72.5-80.4 %) for the survival rate at 1 and 5 years, respectively. The interventional therapy of major BCS patients is safe with successful operation, good patency, and long-term survival. Moreover, a step-wise management of BCS is proposed to manage and cure all BCS patients with personalized treatment.

Transjugular intrahepatic portosystemic shunt for Budd-Chiari syndrome: techniques, indications and results on 51 Chinese patients from a single centre

BACKGROUND & AIMS

In Western countries, transjugular intrahepatic portosytemic shunt (TIPS) is widely applied for the treatment of Budd-Chiari syndrome (BCS). However, the outcome of Chinese BCS patients treated with TIPS is extremely limited. Furthermore, the timing of conversion from percutaneous recanalization to TIPS remains uncertain.

METHODS

All consecutive BCS patients treated with TIPS between December 2004 and June 2012 were included. Patients were classified as the early and converted TIPS groups. Indications, TIPS-related complications, post-TIPS hepatic encephalopathy, shunt dysfunction and death were reported.

RESULTS

Of 51 patients included, 39 underwent percutaneous recanalization for 1024 days (0-4574) before TIPS. Early TIPS group (n = 19) has a shorter history of BCS and a lower proportion of prior percutaneous recanalization than converted TIPS group (n = 32). Main indications were diffuse obstruction of three HVs (n = 12), liver failure (n = 2), liver function deterioration (n = 8), refractory ascites (n = 10) and variceal bleeding (n = 19). Procedure-related intraperitoneal bleeding was reversible in three patients. The cumulative 1-year rate of being free of first episode of post-TIPS hepatic encephalopathy and shunt dysfunction was 78.38 and 61.69% respectively. The cumulative 1-, 2-, and 3-year survival rates were 83.82, 81.20 and 76.93% respectively. BCS-TIPS score, but not Child-Pugh, MELD, Clichy or Rotterdam score, could predict the survival. Age, total bilirubin and inferior vena cava thrombosis were also significantly associated with overall survival. Survival was similar between early and converted TIPS groups.

CONCLUSIONS

TIPS can achieve an excellent survival in Chinese patients in whom percutaneous recanalization is ineffective or inappropriate. BCS-TIPS score could effectively predict these patients' survival.

Combining angioplasty with percutaneous microwave ablation for treating primary Budd-Chiari syndrome associated with hepatocellular carcinoma in two patients: A case report

Percutaneous transluminal angioplasty using balloon catheters for Budd-Chiari syndrome (BCS) and transcatheter arterial chemoembolization (TACE) for unresectable hepatocellular carcinoma (HCC) have become increasingly accepted as alternative therapeutic modalities. However, few studies have investigated the clinical efficacy of combining percutaneous microwave ablation with angioplasty for patients with BCS complicated by HCC. In the present study, a safe and effective method for treating BCS associated with HCC is presented. Color Doppler ultrasonography, magnetic resonance imaging (MRI), computed tomography (CT), inferior venacavography, hepatic arteriogram and cytological examinations were used for the diagnosis. A KY2000 microwave system with an emission of 915 MHz was also employed for the treatment. Two patients with BCS associated with HCC that were administered different adjuvant drug treatments underwent percutaneous transluminal angioplasty and percutaneous microwave ablation successfully, with no treatment-related complications. Combining angioplasty with percutaneous microwave ablation may represent an alternative method for the treatment of BCS associated with HCC.

Outcomes of Thrombolysis With and Without Predilation of the Inferior Vena Cava (IVC) in Patients With Budd–Chiari Syndrome With Old IVC Thrombosis

Purpose:

To compare the efficacy of thrombolysis with and without predilation of the inferior vena cava (IVC) for Budd–Chiari syndrome (BCS) with old IVC thrombosis.

Methods:

We divided 40 patients with BCS with old IVC thrombosis into 2 groups, group A (n = 21), thrombolysis after dilation of the obstructed IVC and group B (n = 19), thrombolysis without predilation of the obstructed IVC. Thrombolysis was performed via urokinase administration through the dorsal vein of the foot.

Results:

Color Doppler ultrasonography at 30 days showed complete resolution of the thrombus in 21 (100%) group A patients and 6 group B patients (31.6%; P < .001). Thrombolysis was achieved using a lower dose of urokinase and within a shorter time frame in group A than in group B ( P < .001).

Conclusions:

Thrombolysis after dilation was superior to thrombolysis alone and was safe and efficacious in patients with BCS with old IVC thrombosis.

Percutaneous recanalization for Budd-Chiari syndrome: an 11-year retrospective study on patency and survival in 177 Chinese patients from a single center

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.

Budd-Chiari syndrome complicating the surgical closure of patent foramen ovale in right minithoracotomy

We present the case of a 45-year old female operated on for minimally invasive closure of patent foramen ovale, who suffered in the postoperative course of the Budd-Chiari syndrome caused by the thrombotic occlusion of the inferior vena cava. Medical treatment with oral anticoagulants and heparin was promptly established, avoiding a further increase of the thrombus that completely disappeared 3 months later.

Prevalence of the JAK2V617F mutation in Chinese patients with Budd-Chiari syndrome and portal vein thrombosis: a prospective study

BACKGROUND AND AIM

Whether routine screening for the JAK2V617F mutation should be performed in Chinese patients with Budd-Chiari syndrome (BCS) and portal vein thrombosis (PVT) is unclear. Therefore, we aimed to evaluate the prevalence of the JAK2V617F mutation in such patients and to explore the risk factors associated with the mutation.

METHODS

All consecutive patients with BCS and PVT diagnosed between September 2009 and May 2011 were prospectively enrolled in the observational study and underwent the JAK2V617F mutation detection.

RESULTS

Prevalence of the JAK2V617F mutation was 4.3% (4/92) in patients with primary BCS, 26.6% (17/64) in non-malignant and non-cirrhotic patients with PVT, and 1.4% (1/71) in cirrhotic patients with PVT. All BCS patients with the JAK2V617F mutation had both platelet count (PLT) of above 100 × 10(9) /L (range, 107-188 × 10(9) /L) and splenomegaly. In non-malignant and non-cirrhotic patients with PVT, higher PLT and older ages were the independent predictors of the JAK2V617F mutation. Further, the difference in PLT between the patients with and without the mutation displayed greater significance in the subgroup of patients with splenomegaly (P < 0.0001), but the statistical significance disappeared in the subgroup of patients with splenectomy (P = 0.1312).

CONCLUSIONS

The low prevalence of the JAK2V617F mutation in patients with BCS suggests that myeloproliferative neoplasm should be an uncommon etiological factor of BCS in China. Routine screening for the JAK2V617F mutation might be recommended in non-malignant and non-cirrhotic patients with PVT, but not in cirrhotic patients with PVT. The coexistence of higher PLT and splenomegaly might be closely associated with the JAK2V617F mutation.

Budd--Chiari syndrome caused by multiple membranous obstruction of the inferior vena cava in a young man

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.

Warfarin anticoagulation before angioplasty relieves thrombus burden in Budd-Chiari syndrome caused by inferior vena cava anatomic obstruction

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.

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

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.

Agitation thrombolysis for fresh iatrogenic IVC thrombosis in patients with Budd-Chiari syndrome

Three patients with Budd-Chiari syndrome (BCS) and fresh inferior vena cava (IVC) thrombosis were treated by agitation thrombolysis as a mechanical thrombectomy procedure and followed up by duplex ultrasonography. Agitation thrombolysis was technically and clinically successful in all patients. Inferior vena cavagrams after the procedure showed complete resolution of the iatrogenic, fresh IVC thrombi without occurrence of pulmonary embolism. Duplex ultrasonography follow-ups after 12, 24, and 28 months, respectively, confirmed complete patency of the IVC without rethrombosis and reobstruction. The results indicate that agitation thrombolysis may be a safe and feasible approach for BCS patients with iatrogenic, fresh IVC thrombosis.

Vascular disorders of the liver

This guideline has been approved by the American Association for the Study of Liver Diseases (AASLD) and represents the position of the association.

Interventional radiology in the management of Budd Chiari syndrome

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.

Primary Budd-Chiari syndrome: outcome of endovascular management for suprahepatic venous obstruction

OBJECTIVE

Primary Budd-Chiari syndrome (BCS) is a rare form of hepatic venous outflow obstruction at the suprahepatic inferior vena cava (IVC), the hepatic veins, or both. We assessed our 4-year experience in the management of BCS to evaluate the results of our methods of care.

METHODS

We conducted a retrospective review of a nonrandomized clinical trial conducted in three teaching hospitals. Among 28 primary BCS patients, 9 remained in medical treatment only, and 19 who failed to respond to medical treatment received additional endovascular (n = 17) or surgical therapy (n = 2). Nine underwent IVC balloon angioplasty alone, 6 had angioplasty plus stents, and 2 had transjugular intrahepatic portosystemic shunts (TIPS) for hepatic vein lesions. One patient had a mesoatrial bypass; another had liver transplantation. Immediate response to the therapy was assessed with angiography and ultrasonography based on anatomic and/or hemodynamic correction or reduction of the lesion. Subsequent assessment of portal hypertension status was made with periodic clinical and laboratory evaluation (eg, ultrasonography, liver biopsy).

RESULTS

Twenty-six patients had had IVC stenosis or occlusion by focal or segmental lesion. Two patients had hepatic vein outlet obstruction. There was no evidence of coagulopathy as the pathogenesis; all were related to membranous obstruction of the vena cava. Excellent immediate response to the endovascular therapy and subsequent relief of portal hypertension were achieved in 14 patients. Four patients had restenosis or progression of the residual lesion within 2 years; three responded to repeated stenting. Primary patency was 76.5%, and primary assisted patency was 94.1%. Two patients with TIPS and two with surgical therapy maintained excellent results. The medical treatment remained effective only in a limited group of 6 (21.4%) of the 28 patients.

CONCLUSIONS

In BCS, both endovascular and surgical interventions provide excellent results and potentially halt liver parenchymal deterioration caused by portal hypertension. Liver transplantation remains the ultimate solution for advanced liver failure.

Membranous obstruction of the inferior vena cava and its causal relation to hepatocellular carcinoma

Although rare in most countries, membranous obstruction of the inferior vena cava (MOIVC) occurs more frequently in Nepal, South Africa, Japan, India, China, and Korea. The occlusive lesion always occurs at approximately the level of the diaphragm. It commonly takes the form of a membrane, but may be a fibrotic occlusion of variable length. Controversy exists as to whether MOIVC is a developmental abnormality or a result of organization of a thrombus in the hepatic portion of the inferior vena cava. The outstanding physical sign associated with MOIVC are large truncal collateral vessels with a cephalad flow. A dilated vena azygous is seen on chest radiography. Definitive diagnosis is made by contrast inferior vena cavography. The long-standing obstruction to hepatic venous flow causes severe centrolobular fibrosis and predisposes to the development of hepatocellular carcinoma (HCC). Percutaneous balloon angioplasty, transatrial membranotomy, or more complex vena caval and portal decompression surgery should be performed to prevent these complications. HCC occurs in more than 40% of South African Black and Japanese patients with MOIVC, but less often in other populations. It is thought to result from the tumour-promoting effect of continuous hepatocyte necrosis, although the associated environmental risk factors have not been identified.

Successful treatment with stent angioplasty for Budd-Chiari syndrome in Behçet's disease

Budd-Chiari syndrome (BCS) is a very rare vascular complication of Behçet's disease (BD) which often leads to death as a result of portal hypertension and liver failure. We report a 45-year-old BD patient who presented with BCS. Diagnosis was confirmed with CT scan and contrast-enhanced MR angiography which showed ascites, short-segment stenosis of the inferior vena cava (IVC), and middle and left hepatic venous thrombosis. Percutaneous transluminal angioplasty (PTA) of the obstructed segment in the IVC was performed and resulted in dramatic reduction of portal venous pressure. Our experience indicates that PTA may be a safe and effective therapeutic modality for BCS in BD which is caused by short segmental obstruction of the IVC.

Surgical treatment of Budd-Chiari syndrome

Shunting and transplantation are satisfactory methods of treating Budd-Chiari syndrome (BCS). Selection of treatment is based on the degree of hepatic injury (clinical settings), liver biopsy results, potential for parenchymal recovery, and pressure measurements. Shunting is recommended in cases of preserved hepatic function and architecture. In the presence of fulminant forms of BCS, in cases of established cirrhosis or frank fibrosis, or for patients with defined hepatic metabolic defects (e.g., protein C or protein S deficiency), liver transplantation is the treatment of choice. Nonsurgical alternatives, although encouraging, have limited long-term outcome results at the present time. In most cases of BCS, a thrombophilic disorder can be identified. However, it is important to note that postoperative vascular thrombosis has been identified in patients with BCS who do not have a definable hypercoagulable predisposition. It therefore is our practice to recommend early (<24 hours postoperatively) initiation of intravenous heparin therapy in all patients with BCS, who then undergo life-long anticoagulation with coumadin.