Interventional management of benign obstruction of the hepatic inferior vena cava

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Inferior vena cava obstruction: long-term results of endovascular management

BACKGROUND

Hepatic venous outflow obstruction (HVOO) can have acute or chronic presentation. In the chronic variety of inferior vena cava (IVC) obstruction, endovascular management with balloon angioplasty and stent implantation has emerged as a feasible, safe alternative to surgery which has high incidence of mortality and morbidity.

AIMS AND OBJECTIVES

To study the feasibility and long-term follow-up of endovascular management of chronic IVC obstruction.

METHODS

We studied 12 cases of HVOO who underwent endovascular management (balloon dilatation ± stenting). In most of the cases, the cause of obstruction was not obvious, but one case had metastatic hepatic nodules compressing on IVC. Diagnosis was established by clinical examination, venous Doppler and was confirmed by venography and/or computed tomography (CT) angiography. Cases underwent balloon dilatation and/or stenting.

RESULTS

Out of 12 cases, six had membranous obstruction (four complete and two incomplete), five cases had segmental stenosis and one case had tumour compression. The lesion was crossed with either guide wire or Brockenbrough needle with Mullins sheath assembly and balloon dilatation was done with Inoue or Mansfield balloon. Seven cases underwent balloon dilatation alone while five cases underwent stenting. There was procedural success in all cases with reduction of gradient by 84%, disappearance of collaterals and clinical improvement. During the follow-up of 13 years, one case had restenosis, which was managed by stenting.

CONCLUSION

Endovascular management of IVC obstruction is safe with good long-term patency rates.

Endovascular treatment of obliterative hepatocavopathy with inferior vena cava occlusion and renal vein thrombosis

We describe the endovascular treatment of an occlusion of the inferior vena cava (IVC) due to obliterative hepatocavopathy with renal and iliac vein thrombosis. A 34-year-old man with nephrotic syndrome and hepatic dysfunction presented to the hospital after a 3-month history of lower extremity swelling with an acute deterioration in his condition. Magnetic resonance venography diagnosed a massive IVC occlusion with thrombosis of the entire IVC, iliac veins, and renal vein. He was treated with thrombolysis, and a chronic occlusion of the infrahepatic IVC was discovered. After venous stenting of the IVC and iliac veins, he dramatically improved. After 24 months, he remains symptom-free with a patent IVC and iliac veins.

Endovascular Recanalization of Chronic Long-Segment Occlusions of the Inferior Vena Cava:Midterm Results

PURPOSE

To report the midterm results of endovascular recanalization of chronic long-segment (> 5 cm) occlusions of the inferior vena cava (IVC) with stent placement.

METHODS

Nine patients (5 men; median age 30 years, range 14-58) with disabling complaints for more than 6 months caused by IVC occlusions were treated by endovascular recanalization. Mean occlusion length was 11 cm (range 6-22); some occlusions extended to the iliac (n = 3) or common femoral (n = 2) veins. All procedures were performed under local anesthesia via a bilateral femoral (n = 7) or popliteal (n = 2) approach. In 3 patients, combined access to the brachial or internal jugular vein was necessary. Patients with acute-on-chronic thrombosis were pretreated with urokinase. After guidewire recanalization, the chronic occlusions were predilated and self-expanding Wallstents were implanted.

RESULTS

The initial technical and clinical success was 100%. The venous clinical severity score (pain, venous edema, inflammation, and active ulceration) decreased from a mean 8 +/- 2 to 5 +/- 1 after the procedure. Over a median follow-up of 9 months (mean 21, range 4- 110), 3 patients died. One rethrombosis occurred, and an asymptomatic restenosis was discovered on routine imaging. The primary patency rate was 78%, and the 9-month occlusion-free survival rate was 56%.

CONCLUSION

Endovascular recanalization of chronic long-segment occlusions of the IVC is a safe and worthwhile technique to offer patients with debilitating symptoms.

Primary Gianturco stent placement for inferior vena cava abnormalities following liver transplantation

PURPOSE

To determine the efficacy of primary Gianturco stent placement for patients with inferior vena caval (IVC) abnormalities following liver transplantation.

MATERIALS AND METHODS

From August 1996 through March 1999, nine adult patients developed significant IVC abnormalities following liver transplantation. Patients were referred for vena cavography on the basis of abnormal clinical findings, laboratory values, liver biopsy results, Doppler findings, or a combination. Those patients demonstrating a significant caval or hepatic venous gradient were treated with primary Gianturco stent placement. Patients were followed clinically (nine patients), with duplex ultrasound (nine patients), vena cavography (four patients), and biopsy (seven patients).

RESULTS

Original pressure gradients ranged from 3 to 14 mm Hg, with a mean of 9 mm Hg. Gradients were reduced to 3 mm Hg or less in all nine patients; presenting signs and symptoms either resolved or improved in eight of nine patients. The ninth patient required repeated transplantation 2 days later. A second patient died 433 days after stent placement of recurrent hepatitis C. Another initially improved following caval stent placement, but underwent repeated transplantation 7 days later due to hepatic necrosis from hepatic arterial thrombosis. Follow-up for the remaining six patients has averaged 491 days, with no clinical, venographic, or ultrasound evidence for recurrent caval stenosis.

CONCLUSIONS

Intermediate term results suggest that primary Gianturco stent placement for IVC stenosis, compression, or torsion resulting after liver transplantation is safe and effective.

Chronically occluded inferior venae cavae: endovascular treatment

PURPOSE

To report the results of endoluminal recanalization and stent placement in patients with chronic occlusions of the inferior vena cava (IVC).

MATERIALS AND METHODS

Seventeen consecutive patients (12 male, five female patients; mean age, 40.6 years; age range, 15-77 years) with chronic IVC occlusions were treated during a 6-year period. The mean duration of symptoms was 32 months. Underlying active malignancy was the cause of occlusion in four patients. Five patients with superimposed acute thrombus underwent catheter-directed thrombolysis prior to IVC recanalization. Clinical patency was defined as absence or improvement of symptoms. Clinical follow-up was supplemented with ultrasonography, vena cavography, or both in 10 patients.

RESULTS

Technical success was achieved in 15 (88%) patients. Additional thrombolytic therapy and stent placement was needed in two patients to maintain patency at 4 and 6 months after the procedure. Twelve patients had IVCs that remained patent after a mean follow-up of 19 months for a primary patency rate of 80%. The primary assisted patency rate was 87% (13 of 15). There were four deaths owing to underlying disease 6-21 months after the procedures. There were no procedure-related complications.

CONCLUSION

Endoluminal recanalization and stent placement in chronically occluded IVCs has a good intermediate-term outcome and should be considered in patients who have symptoms and who often do not have adequate alternative therapy.

Ultrasonically guided percutaneous transhepatic hepatic vein stent placement for Budd-Chiari syndrome

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.

Ultrasonically guided inferior vena cava stent placement: experience in 83 cases

PURPOSE

Traditionally, inferior vena cava (IVC) stent placement is performed with fluoroscopic guidance. The object of this study was to evaluate use of ultrasound (US) as guidance for IVC stent placement for the management of Budd-Chiari syndrome.

MATERIALS AND METHODS

Eighty-three patients with IVC membranous stenosis (n = 30), membranous occlusion (n = 19), segmental stenosis (n = 21), or segmental occlusion (n = 13) underwent IVC recanalization, balloon dilation, and stent placement under US guidance. Among the 83 patients, 67 had at least one patent hepatic vein, while 16 patients had three occluded hepatic veins.

RESULTS

IVC stents were successfully placed in 79 of 83 patients, with a success rate of 95%. After the procedure, the symptoms and signs of IVC obstruction disappeared or markedly improved in all patients, and the blockage of hepatic outflow was alleviated in 67 patients. Pericardial effusion, complete atrial ventricular block, and stent migration into the right atrium occurred, respectively, in one patient. During 1-46-month follow-up, stent restenosis occurred in one patient; the other stents remained open and functioned effectively.

CONCLUSION

Because of the absence of nonionizing radiation and iodinated contrast material, and its low cost, US is well suited and often preferred for guidance of IVC stent placement.

Interventional therapeutic techniques in Budd-Chiari syndrome

PURPOSE

To analyze the results obtained with percutaneous therapeutic procedures in patients with Budd-Chiari syndrome (BCHS).

METHODS

Between August 1991 and April 1993, seven patients with BCHS were treated in our hospital. Three presented with a congenital web; in another three cases the hepatic veins and/or the inferior vena cava (IVC) were compromised after major hepatic surgery; one patient presented with a severe stenosis of the intrahepatic IVC due to hepatomegaly.

RESULTS

One of the patients with congenital web has required several new dilatations due to restenosis; one patient required a transjugular intrahepatic portosystemic shunt procedure while awaiting a liver transplantation. The two postsurgical patients with stenosed hepatic veins did not require any new procedure after the placement of metallic endoprostheses. However, the patient with liver transplantation presented IVC restenosis after balloon angioplasty that required the deployment of metallic endoprostheses. In the patient with hepatomegaly a self-expandable prosthesis was placed in the intrahepatic portion of the IVC before (4 months) a liver transplantation.

CONCLUSION

Interventional therapeutic techniques offer a wide variety of possibilities for the treatment of patients with BCHS. For IVC stenoses, the results obtained with balloon angioplasty are at least as good as those obtained with surgery.

Management of idiopathic obstruction of the hepatic and suprahepatic inferior vena cava with a self-expanding metallic stent

Ten patients (median age 36 yr, 5 male) with idiopathic IVC obstruction underwent balloon angioplasty followed by placement of a self-expanding stent due to unfavourable lesion characteristics. Six had total occlusion, 5 had restenosis (including 2 with total occlusion), and 1 had a suboptimal result after initial dilatation. Median minimum IVC diameter increased from 0 to 14.5 mm, and the median gradient across the lesion decreased from 16.5 to 1 mmHg. Follow-up venography (median interval 69 d) in six patients revealed no restenosis with further enlargement at the lesion site (median 4.5 mm) and abolition of gradients. Follow-up ultrasound in nine patients revealed no restenosis in the IVC. One patient died 6 mo after the procedure with acute Budd-Chiari syndrome due to hepatic vein occlusion. Autopsy revealed a widely patent stent with hepatic vein thrombus. Stent implantation is useful in the management of IVC obstruction with prior restenosis, total occlusion, or suboptimal result of balloon angioplasty.

Stent Placement for Idiopathic Obstruction of the Inferior Vena Cava

Ten patients (mean age 36.6 ± 8 years; 5 male) with idiopathic inferior vena cava obstruction underwent balloon angioplasty, followed by placement of a self-expanding stent. Six had total occlusion, 5 had restenosis (including 2 with total occlusion), and I had a suboptimal result after initial dilatation. The mean diameter of the inferior vena cava increased from 1.5 ± 2.1 mm to 14.4 ± 2.7 mm, and the pressure gradient between the vena cava and the right atrium decreased from 15.2 ± 5.0 mm Hg to 1.1 ± 1.5 mm Hg. Follow-up venography after 74 ± 35 days in 6 patients, revealed ho restenosis, with further enlargement of the mean diameter by 5.2 ± 3.1 mm (44 ± 35%) and abolition of pressure gradients. One patient died 6 months after the procedure from acute Budd-Chiari syndrome. Autopsy revealed a widely patent stent with hepatic vein thrombus. Stent implantation is useful in the management of inferior vena cava obstruction with prior restenosis, total occlusion, or suboptimal results of balloon angioplasty.

Management of idiopathic Budd-Chiari syndrome with primary stent placement: early results

PURPOSE

To evaluate the utility of primary stent placement in the management of Budd-Chiari syndrome (BCS) secondary to idiopathic inferior vena caval (IVC) obstruction.

PATIENTS AND METHODS

The case records of nine patients (four women, five men), ranging in age from 22 to 58 years (median, 26 years), with idiopathic IVC obstruction were reviewed. Hepatosplenomegaly, esophageal varices, and prominent collateral veins were found in all patients, while four also had ascites. Hepatic functional reserve was graded as Child class A in three patients and class B in the remaining six. All had at least one patent hepatic vein opening into the IVC below the site of occlusion. Percutaneous angioplasty of the IVC was performed, followed by the placement of double-skirt Gianturco-Rösch or hybrid Gianturco stents. Clinical follow-up was supplemented with duplex ultrasound (n = 8), endoscopy (n = 4), and cavography (n = 2).

RESULTS

Caval lesions were segmental. Revascularization was technically successful in all patients. The median pressure gradient across the lesion dropped from 38 mm Hg (range, 27-61 mm Hg) to 15 mm Hg (range, 10-20 mm Hg) (P = .008). Residual stenosis after stent placement ranged from 9% to 40% (median, 20%). One patient died of presumed pulmonary embolism; another patient experienced an episode of epistaxis. The procedure was followed by regression of signs and symptoms in the eight survivors. During the follow-up period (range, 3-31 months; median, 7 months) the IVC remained patent in all patients, and clinical features of BCS did not recur.

CONCLUSION

Primary stent placement could serve as the first line of treatment in patients with idiopathic BCS when the underlying lesion is not amenable to angioplasty.

Venous recanalization by metallic stents after failure of balloon angioplasty or surgery: four-year experience

PURPOSE

This retrospective study describes our updated experience in treating venous stenoses and occlusions with metallic endovascular stents.

METHODS

Gianturco, Palmaz, and Wallstent stents were placed in 55 patients over a 4-year period. Stent sites included the subclavian veins (9), innominate veins (3), superior vena cava (4), inferior vena cava (3), iliac veins (29), femoral veins (5), and portal veins (6). The most common indications for stent placement were malignant stenoses and chronic pelvic venous occlusions. Venoplasty and/or urokinase were used as ancillary therapy. Patients were anticoagulated for 3-6 months. Follow-up included clinical assessment and duplex ultrasound.

RESULTS

Lifetable analysis shows 59%, 63%, and 72% primary, primary assisted, and secondary 1-year patency rates, respectively. The 4-year primary patency rates were the same. Duration of patency depended on the venous site. Death was a complication of stent placement in 2 patients and 12 patients died within 6 months after stent placement from primary disease progression. Although early failures were more common in stents placed across occlusions than stenoses, 1-year secondary patency rates were comparable. Primary patency rates were only slightly lower in patients with malignant obstruction than in patients with benign disease.

CONCLUSION

Endovascular stent placement provides a nonsurgical alternative for reestablishment of venous flow and symptomatic relief in patients with benign as well as malignant venous obstruction.

Posttraumatic Budd-Chiari syndrome treated with thrombolytic therapy and angioplasty

Injury of the hepatic veins or suprahepatic inferior vena cava is a rare cause of Budd-Chiari syndrome. Treatment of this syndrome has primarily involved hepatic venous decompression with a variety of portosystemic shunts. We report a case of thrombosis of the inferior vena cava after blunt injury managed with interventional radiologic techniques.