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Dongelmans E, Erler N, Adam R, Nadalin S, Karam V, Yilmaz S, Kelly C, Pirenne J, Acarli K, Allison M, Hakeem A, Dhakshinamoorthy V, Fedaruk D, Rummo O, Kilic M, Nordin A, Fischer L, Parente A, Mirza D, Bennet W, Tokat Y, Faitot F, Antonelli BB, Berlakovich G, Patch D, Berrevoet F, Ribnikar M, Gerster T, Savier E, Gruttadauria S, Ericzon BG, Valdivieso A, Cuervas-Mons V, Perez Saborido B, Croner RS, De Carlis L, Magini G, Rossi R, Popescu I, Razvan L, Schneeberger S, Blokzijl H, Llado L, Gomez Bravo MA, Duvoux C, Mezjlík V, Oniscu GC, Pearson K, Dayangac M, Lucidi V, Detry O, Rotellar F, den Hoed C, Polak WG, Darwish Murad S. Recent outcomes of liver transplantation for Budd-Chiari syndrome: A study of the European Liver Transplant Registry (ELTR) and affiliated centers. Hepatology 2024:01515467-990000000-00750. [PMID: 38358658 DOI: 10.1097/hep.0000000000000778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/06/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND AND AIMS Management of Budd-Chiari syndrome (BCS) has improved over the last decades. The main aim was to evaluate the contemporary post-liver transplantant (post-LT) outcomes in Europe. APPROACH AND RESULTS Data from all patients who underwent transplantation from 1976 to 2020 was obtained from the European Liver Transplant Registry (ELTR). Patients < 16 years with secondary BCS or HCC were excluded. Patient survival (PS) and graft survival (GS) before and after 2000 were compared. Multivariate Cox regression analysis identified predictors of PS and GS after 2000. Supplemental data was requested from all ELTR-affiliated centers and received from 44. In all, 808 patients underwent transplantation between 2000 and 2020. One-, 5- and 10-year PS was 84%, 77%, and 68%, and GS was 79%, 70%, and 62%, respectively. Both significantly improved compared to outcomes before 2000 ( p < 0.001). Median follow-up was 50 months and retransplantation rate was 12%. Recipient age (aHR:1.04,95%CI:1.02-1.06) and MELD score (aHR:1.04,95%CI:1.01-1.06), especially above 30, were associated with worse PS, while male sex had better outcomes (aHR:0.63,95%CI:0.41-0.96). Donor age was associated with worse PS (aHR:1.01,95%CI:1.00-1.03) and GS (aHR:1.02,95%CI:1.01-1.03). In 353 patients (44%) with supplemental data, 33% had myeloproliferative neoplasm, 20% underwent TIPS pre-LT, and 85% used anticoagulation post-LT. Post-LT anticoagulation was associated with improved PS (aHR:0.29,95%CI:0.16-0.54) and GS (aHR:0.48,95%CI:0.29-0.81). Hepatic artery thrombosis and portal vein thrombosis (PVT) occurred in 9% and 7%, while recurrent BCS was rare (3%). CONCLUSIONS LT for BCS results in excellent patient- and graft-survival. Older recipient or donor age and higher MELD are associated with poorer outcomes, while long-term anticoagulation improves both patient and graft outcomes.
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Affiliation(s)
- Edo Dongelmans
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Nicole Erler
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rene Adam
- Department of Hepato-Biliary Surgery, Cancer and Transplantation Unit, Hospital Paul Brousse, Villejuif, France
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, Universitätsklinik Tübingen, Tubingen, Germany
| | - Vincent Karam
- Department of Hepato-Biliary Surgery, Cancer and Transplantation Unit, Hospital Paul Brousse, Villejuif, France
| | - Sezai Yilmaz
- Department of Surgery, Liver Transplant Institute, Turgut Özal Medical Center, Malatya, Turkey
| | - Claire Kelly
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Jacques Pirenne
- Department of Abdominal Transplant Surgery, Universitaire Ziekenhuizen Leuven, Belgium
| | - Koray Acarli
- Department of Liver and Biliary Tract Surgery, Memorial Hospital, Istanbul, Turkey
| | - Michael Allison
- Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge NIHR Biomedical Research Center, Cambridge, UK
| | - Abdul Hakeem
- Department of HPB Surgery and Liver Transplantation, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Dzmitry Fedaruk
- Department of Transplantation, Minsk Scientific and Practical Center for Surgery, Transplantology and Hepatology, Minsk, Belarus
| | - Oleg Rummo
- Department of Transplantation, Minsk Scientific and Practical Center for Surgery, Transplantology and Hepatology, Minsk, Belarus
| | - Murat Kilic
- Department of Surgery, Kent Hospital, Izmir, Turkey
| | - Arno Nordin
- Transplantation and Liver Surgery Unit, Helsinki University Hospital, Helsinki, Finland
| | - Lutz Fischer
- Department of Surgery, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Darius Mirza
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - William Bennet
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Yaman Tokat
- Department of General Surgery, International Liver Center and Acibadem Health Care Hospitals, Istanbul, Turkey
| | - Francois Faitot
- Department of HPB Surgery and Transplantation, C.H.R.U. de Strasbourg, Strasbourg, France
| | - Barbara B Antonelli
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gabriela Berlakovich
- Department of Transplantation Surgery, Medical University of Vienna, Wien, Austria
| | - David Patch
- Department of Hepatology and Liver Transplantation, Royal Free Hospital, London, UK
| | - Frederik Berrevoet
- Department of General and HPB Surgery and Liver Transplantation, University Hospital Gent, Ghent, Belgium
| | - Marija Ribnikar
- Department of Gastroenterology, University Medical Center Lubljana, Ljubljana, Slovenia
| | - Theophile Gerster
- Department of Gastroenterology and Hepatology, C.H.U. de Grenoble, Grenoble, France
| | - Eric Savier
- Department of Digestive Surgery and Liver Transplantation, Pitie Salpetriere university hospital, Sorbonne University, Paris, France
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), Palermo, Italy
- Department of Surgery and Medical and Surgical Specialties, University of Catania, Catania, Italy
| | - Bo-Göran Ericzon
- Department of Transplantation Surgery, Karolinska University Hospital, Huddinge, Sweden
| | - Andrés Valdivieso
- Department of HBP Surgery and Liver Transplantation, Cruces University hospital, Bilbao, Spain
| | | | - Baltasar Perez Saborido
- Department of General and Digestive Surgery, Hospital Universitario "Rio Hortega", Valladolid, Spain
| | - Roland S Croner
- Department of General-, Visceral-, Vascular- and Transplant Surgery, University Hospital Magdeburg, Germany
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, University of Milano-Bicocca, Milan, Italy
| | - Giulia Magini
- Department of Surgery, Hôpital Universitaire de Genève, Geneve, Switzerland
| | - Roberta Rossi
- Department of Gastroenterology and Transplantation, Università Politecnica delle Marche, Ancona, Italy
| | - Irinel Popescu
- Department of Surgery, University of Medicine "Carol Davila", Bucharest, Romania
| | - Laze Razvan
- Department of Surgery, University of Medicine "Carol Davila", Bucharest, Romania
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, University Hospital, Innsbruck, Austria
| | - Hans Blokzijl
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Laura Llado
- Department of Surgery, Hospital Universitari de Bellvitge, Barcelona, Spain
| | | | - Christophe Duvoux
- Department of Medical Liver Transplant Unit and Liver, Hôpital Henri Mondor, Creteil, France
| | - Vladimír Mezjlík
- Department of Transplantation, Center of cardiovascular surgery and transplantations, Brno, Czech Republic
| | - Gabriel C Oniscu
- Edinburgh Transplant Center, Royal Infirmary of Edinburgh, Edinburg, UK
| | - Kelsey Pearson
- Edinburgh Transplant Center, Royal Infirmary of Edinburgh, Edinburg, UK
| | - Murat Dayangac
- Center for Organ Transplantation, Medipol University Hospital, Istanbul, Turkey
| | - Valerio Lucidi
- Department of abdominal surgery, Unit of Hepato-biliary surgery and Liver Transplantation, Hôpital Erasme, Cliniques Universitaires de Bruxelles, Brussels, Belgium
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, CHU Liege, Liege, Belgium
| | - Fernando Rotellar
- Department of General and Digestive Surgery, Clinica Universitaria de Navarra, Pamplona, Spain
| | - Caroline den Hoed
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Wojciech G Polak
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC Transplant Institute, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Erden A, Kuru Öz D, Adıgüzel M, Özalp Ateş FS. Quantitative liver magnetic resonance imaging: correlation between conventional magnetic resonance imaging, laboratory values, and prognostic indices in Budd-Chiari syndrome. Diagn Interv Radiol 2023; 29:428-436. [PMID: 36960638 PMCID: PMC10679617 DOI: 10.4274/dir.2022.221462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 09/29/2022] [Indexed: 01/15/2023]
Abstract
PURPOSE In Budd-Chiari syndrome (BCS), unevenly distributed parenchymal changes and perfusion abnormalities occur due to hepatic venous outflow obstruction. This study aimed to evaluate the changes in the liver parenchyma in BCS using the quantitative magnetic resonance (MR) techniques of MR elastography, T1 and T2 mapping, and diffusion imaging and correlate the quantitative MR parameters through biochemical results and prognostic indices. METHODS Fourteen patients with BCS (seven men and seven women) were examined retrospectively. Liver stiffness (kPa), T1 relaxation times (ms) were achieved using the modified Look-Locker inversion recovery (MOLLI) 3(2)3(2)5 sequence and B1-corrected variable flip angle methods, T2 relaxation times (ms), and apparent diffusion coefficient (ADC) values (mm2/s) were measured using regions of interest placed in the same region in all quantitative methods. Measurements were repeated at the precontrast and postcontrast hepatobiliary phases. The reduction rate (RR; %) and adjusted postcontrast T1 (%) were calculated. The values obtained from different liver parenchyma areas (whole liver, caudate lobe, pathological T2 hyperintense tissue, and relatively preserved normal-appearing tissue) were compared using the Wilcoxon signed-rank test. Spearman's correlation coefficient was used to investigate the correlation between quantitative MR parameters and biochemical parameters/ prognostic scores (Child-Pugh score, Clichy score, and Rotterdam index). RESULTS The parenchymal stiffness and precontrast T1 values of the caudate lobe were significantly lower than those of the remainder of the parenchyma, whereas the adjusted postcontrast T1 percentages (MOLLI) were significantly higher (P ≤ 0.027). The parenchymal stiffness value, T1 and T2 values, percentages of RR (MOLLI), and adjusted postcontrast T1 values for the pathological tissue and relatively normal tissue were significantly different (P < 0.028). No significant difference was found in terms of ADC values between any of the distinct regions of the liver. A strong correlation was detected between the Child-Pugh score, Clichy score, and precontrast T1 values obtained through the MOLLI sequence (r = 0.867, P = 0.012, r = 0.821, P = 0.023, respectively). No correlation was found between the whole liver stiffness values and the laboratory parameters, fibrosis markers, prognostic indices, or MR parameters. A significant correlation was identified between creatinine levels and several T1 parameters and the T2 relaxation time (r ≥ 0.661, P ≤ 0.052). CONCLUSION Tissue stiffness and T1 relaxation values are high in the areas identified as fibrosis compared with those in the relatively preserved parenchyma. The T1 relaxation time can offer quantitative information for assessing segmental functional changes and prognosis in BCS.ion for assessing segmental functional changes and prognosis in BCS.
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Affiliation(s)
- Ayşe Erden
- Department of Radiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Diğdem Kuru Öz
- Department of Radiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Adıgüzel
- Department of Radiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Funda Seher Özalp Ateş
- Department of Biostatistics and Medical Informatics, Manisa Celal Bayar University, Faculty of Medicine, Manisa, Turkey
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Sastry UMK, Doddaiah MS, Arunakumar P, Marimuthu V, Kasturi S, Srinivas BC, Jayranganath M, Manjunath CN. Percutaneous hepatic vein recanalization in pediatric Budd-Chiari syndrome - 10 years' experience from a tertiary center. Ann Pediatr Cardiol 2023; 16:168-174. [PMID: 37876952 PMCID: PMC10593285 DOI: 10.4103/apc.apc_160_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/03/2023] [Accepted: 04/10/2023] [Indexed: 10/26/2023] Open
Abstract
Background Budd - Chiari syndrome (BCS) due to hepatic venous outflow obstruction is a rare cause of liver disease with dismal outcome, often amenable to catheter intervention. Materials and Methods This retrospective single-center study analyzed the clinical profile and medium-term outcome of interventional treatment with balloon angioplasty ± stenting in all pediatric BCS over a 10-year period. Clinical, laboratory, imaging, and interventional data were retrieved. Transhepatic (TH) access was utilized in the recent 3 years. Results We included a total of 27 patients. Acute and subacute BCS comprised 93% of subjects. Ascites was the most common symptom. COVID-19 infection and Takayasu arteritis were two novel etiologies in our study. There was isolated hepatic vein (HV) narrowing in 11 (41%), isolated inferior vena cava obstruction in 4, and combined occlusion in 12 (44%). Intervention was successful in 22 (82%) patients. Stenting was required in 14 (64%) patients and the rest underwent balloon angioplasty. The immediate outcome was better with stenting than balloon (91% vs. 64%). Transhepatic access in 6 patients allowed HV cannulation in all and achieved patency in five patients. Two patients from the balloon group (25%) and 9 from the stent group (64%) are alive with patent veins at a median follow-up of 60 months, indicating a high attrition rate. Conclusion Catheter interventions restored physiological blood flow in pediatric BCS. TH route improved cannulation of occluded HV compared to other accesses. Immediate and medium-term outcomes were better after stenting with lower rates of reinterventions than balloon angioplasty. Life-long surveillance is required as mortality is high on follow-up.
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Affiliation(s)
| | | | - Priyadarshini Arunakumar
- Department of Pediatric Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Varun Marimuthu
- Department of Pediatric Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Sowmya Kasturi
- Department of Pediatric Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Budnur C Srinivas
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Mahimarangaiah Jayranganath
- Department of Pediatric Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
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Rössle M. Interventional Treatment of Budd-Chiari Syndrome. Diagnostics (Basel) 2023; 13:diagnostics13081458. [PMID: 37189559 DOI: 10.3390/diagnostics13081458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/13/2023] [Accepted: 04/15/2023] [Indexed: 05/17/2023] Open
Abstract
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.
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Affiliation(s)
- Martin Rössle
- Department of Gastroenterology, University Hospital, 79106 Freiburg, Germany
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Garcia-Pagán JC, Valla DC. Primary Budd-Chiari Syndrome. N Engl J Med 2023; 388:1307-1316. [PMID: 37018494 DOI: 10.1056/nejmra2207738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Affiliation(s)
- Juan Carlos Garcia-Pagán
- From the Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic (a provider of the European Reference Network on Rare Liver Disorders [ERN-Liver]), Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, and Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid - both in Spain (J.C.G.-P.); and Université Paris Cité, Unite Mixte de Recherche 1149, INSERM, Paris, and Centre de Référence des Maladies Vasculaires du Foie, Service d'Hépatologie, Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon (a provider of the ERN-Liver), Clichy - both in France (D.-C.V.)
| | - Dominique-Charles Valla
- From the Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic (a provider of the European Reference Network on Rare Liver Disorders [ERN-Liver]), Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, and Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid - both in Spain (J.C.G.-P.); and Université Paris Cité, Unite Mixte de Recherche 1149, INSERM, Paris, and Centre de Référence des Maladies Vasculaires du Foie, Service d'Hépatologie, Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon (a provider of the ERN-Liver), Clichy - both in France (D.-C.V.)
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Elkrief L, Payancé A, Plessier A, d’Alteroche L, Ronot M, Paradis V, Valla D, Rautou PE. Management of splanchnic vein thrombosis. JHEP Rep 2023; 5:100667. [PMID: 36941824 PMCID: PMC10023986 DOI: 10.1016/j.jhepr.2022.100667] [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: 06/15/2022] [Revised: 12/11/2022] [Accepted: 12/23/2022] [Indexed: 01/04/2023] Open
Abstract
The expression splanchnic vein thrombosis encompasses Budd-Chiari syndrome and portal vein thrombosis. These disorders have common characteristics: they are both rare diseases which can cause portal hypertension and its complications. Budd-Chiari syndrome and portal vein thrombosis in the absence of underlying liver disease share many risk factors, among which myeloproliferative neoplasms represent the most common; a rapid comprehensive work-up for risk factors of thrombosis is needed in these patients. Long-term anticoagulation is indicated in most patients. Portal vein thrombosis can also develop in patients with cirrhosis and in those with porto-sinusoidal vascular liver disease. The presence and nature of underlying liver disease impacts the management of portal vein thrombosis. Indications for anticoagulation in patients with cirrhosis are growing, while transjugular intrahepatic portosystemic shunt is now a second-line option. Due to the rarity of these diseases, studies yielding high-grade evidence are scarce. However, collaborative studies have provided new insight into the management of these patients. This article focuses on the causes, diagnosis, and management of patients with Budd-Chiari syndrome, portal vein thrombosis without underlying liver disease, or cirrhosis with non-malignant portal vein thrombosis.
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Key Words
- BCS, Budd-Chiari syndrome
- CALR, calreticulin
- Cavernoma
- DOACs, direct-acting oral anticoagulants
- Direct oral anticoagulants
- EHPVO, extrahepatic portal vein obstruction
- GFR, glomerular filtration rate
- JAK2, Janus kinase 2
- LMWH, low-molecular-weight heparin
- MPN, myeloproliferative neoplasm
- MTHFR, methylene-tetrahydrofolate reductase
- PNH, paroxysmal nocturnal hemoglobinuria
- PVT, portal vein thrombosis
- Portal biliopathy
- Portal vein recanalisation
- SVT, splanchnic vein thrombosis
- TIPS, transjugular intrahepatic portosystemic shunt
- VKAs, vitamin K antagonists
- Vascular liver diseases
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Affiliation(s)
- Laure Elkrief
- Service d’Hépato-Gastroentérologie CHU de Tours, France
| | - Audrey Payancé
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Aurélie Plessier
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | | | - Maxime Ronot
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service de radiologie, Hôpital Beaujon APHP.Nord, Clichy, France
| | - Valérie Paradis
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service d’anatomie et cytologie pathologique, Hôpital Beaujon APHP.Nord, Clichy, France
| | - Dominique Valla
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Pierre-Emmanuel Rautou
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
- Corresponding author. Address: Service d’Hépatologie, Hôpital Beaujon, 100 boulevard du Général Leclerc, 92110, Clichy, France; Tel.: +331 40 87 50 91, fax +331 40 87 44 35
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Åberg F, Rajani R, Wester A, Widman L, Hagström H. Three-fold Increased Risk of Death in Budd-Chiari Syndrome Compared to Matched Controls: A Population-based Cohort Study. Clin Gastroenterol Hepatol 2023; 21:995-1004.e9. [PMID: 35569740 DOI: 10.1016/j.cgh.2022.04.032] [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: 01/03/2022] [Revised: 04/20/2022] [Accepted: 04/26/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with Budd-Chiari syndrome (BCS) have an elevated risk of overall and liver-specific mortality, but this has not been quantified on a population level nor compared against a matched general population cohort. METHODS We identified all patients in Sweden with a recorded diagnosis of BCS in the Swedish National Patient Register between 1987 and 2016. Patients with BCS were matched for age, sex, and municipality at baseline with up to 10 reference individuals from the general population. Data on cause-specific mortality were obtained from the Causes of Death Register. A Cox regression model was performed to investigate rates of all-cause and cause-specific mortality. RESULTS A total of 478 patients with BCS were matched with 4603 reference individuals. Of the patients with BCS, 43% were men, the median age was 58 years, 39% had a recorded diagnosis of a precipitating risk factor, and 13% had underlying liver disease. During a follow-up of up to 29 years, 243 (51%) of the patients with BCS died compared with 1346 (29%) of the reference individuals. Overall mortality was 70 per 1000 person-years in patients with BCS compared with 28 per 1000 person-years in reference individuals, translating into an adjusted hazard ratio (aHR) of 3.1 (95% confidence interval [CI], 2.6-3.6). Although liver-related mortality was particularly high (aHR, 47.6; 95% CI, 16.5-137.4), liver disease accounted for only 10% of deaths in BCS. The most common cause of death was cardiovascular disease (aHR, 2.2; 95% CI, 1.7-2.9). CONCLUSIONS Patients with BCS in Sweden had a 3-fold higher risk of death compared with general population reference individuals. Although mortality from liver diseases was high in relative terms, most patients died from cardiovascular causes.
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Affiliation(s)
- Fredrik Åberg
- Transplantation and Liver Surgery, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Rupesh Rajani
- Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Axel Wester
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Linnea Widman
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Hannes Hagström
- Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden; Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.
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Semmler G, Lindorfer A, Schäfer B, Bartl S, Hametner-Schreil S, Gensluckner S, Balcar L, Pomej K, Lampichler K, Trauner M, Aigner E, Datz C, Zoller H, Hofer H, Schöfl R, Mandorfer M, Reiberger T, Scheiner B. Outcome of Budd-Chiari Syndrome Patients Treated With Direct Oral Anticoagulants: An Austrian Multicenter Study. Clin Gastroenterol Hepatol 2023; 21:978-987.e2. [PMID: 35533994 DOI: 10.1016/j.cgh.2022.04.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Direct oral anticoagulants (DOACs) may simplify management of Budd-Chiari syndrome (BCS). Here, we report our experience with off-label use of DOACs for anticoagulation in BCS. METHODS The safety of DOAC vs vitamin K antagonist treatment as well as associated clinical outcomes were retrospectively assessed in 47 BCS patients treated at 6 Austrian centers. RESULTS Mean age at study inclusion was 37.9 ± 14.0 years and mean Model for End-Stage Liver Disease was 13.1 ± 5.1. Overall, 63.8% (n = 30) of patients had decompensated liver disease, and 87.2% (n = 41) showed clinical signs of portal hypertension. During a median follow-up of 82.5 (interquartile range, 43.1-121.8) months, 43 (91.5%) patients received anticoagulation alone or following interventional treatment, including 22 (46.8%) patients treated with DOACs (edoxaban: 10, apixaban: 4, rivaroxaban: 3, dabigatran: 3, more than one DOAC sequentially: 2) for a median of 24.4 (interquartile range, 5.7-35.1) months. While 72.7% (n = 16 of 22) of patients were switched from low-molecular-weight heparin (n = 12) or vitamin K antagonist (n = 4) to DOAC after disease stabilization or improvement, 27.3% (n = 6 of 22) of BCS patients were initially treated with DOAC. Complete response (European Association for the Study of the Liver criteria) was achieved or maintained in 14 (63.6%) of 22 patients, with ongoing response in 2 patients, while disease progressed in 6 patients (including 2 patients with hepatocellular carcinoma). Four major spontaneous bleedings (18.2%; incidence rate 8.8 per 100 patient-years; n = 2 upper gastrointestinal bleeding, n = 1 lower gastrointestinal bleeding, n = 1 hepatocellular carcinoma rupture), 7 minor bleedings, and 1 major procedure-related bleeding (4.5%; 2.2 per 100 patient-years) occurred during DOAC therapy. Overall transplant-free survival was 91.6% at 5 years. CONCLUSIONS DOACs seem to be effective and safe for long-term anticoagulation in patients with BCS, but confirmation by larger prospective studies is needed.
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Affiliation(s)
- Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alexander Lindorfer
- Department of Internal Medicine IV, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - Benedikt Schäfer
- Department of Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Bartl
- Department of Internal Medicine I, Klinikum Wels-Grieskirchen, Wels, Austria
| | | | - Sophie Gensluckner
- Department of Medicine I, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Katharina Pomej
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Katharina Lampichler
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Elmar Aigner
- Department of Medicine I, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Christian Datz
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Heinz Zoller
- Department of Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Harald Hofer
- Department of Internal Medicine I, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Rainer Schöfl
- Department of Internal Medicine IV, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria.
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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9
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Găman MA, Cozma MA, Manan MR, Srichawla BS, Dhali A, Ali S, Nahian A, Elton AC, Simhachalam Kutikuppala LV, Suteja RC, Diebel S, Găman AM, Diaconu CC. Budd-Chiari syndrome in myeloproliferative neoplasms: A review of literature. World J Clin Oncol 2023; 14:99-116. [PMID: 37009527 PMCID: PMC10052333 DOI: 10.5306/wjco.v14.i3.99] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 02/10/2023] [Accepted: 03/01/2023] [Indexed: 03/19/2023] Open
Abstract
Myeloproliferative neoplasms (MPNs) are defined as clonal disorders of the hematopoietic stem cell in which an exaggerated production of terminally differentiated myeloid cells occurs. Classical, Philadelphia-negative MPNs, i.e., polycythemia vera, essential thrombocythemia and primary myelofibrosis, exhibit a propensity towards the development of thrombotic complications that can occur in unusual sites, e.g., portal, splanchnic or hepatic veins, the placenta or cerebral sinuses. The pathogenesis of thrombotic events in MPNs is complex and requires an intricate mechanism involving endothelial injury, stasis, elevated leukocyte adhesion, integrins, neutrophil extracellular traps, somatic mutations (e.g., the V617F point mutation in the JAK2 gene), microparticles, circulating endothelial cells, and other factors, to name a few. Herein, we review the available data on Budd-Chiari syndrome in Philadelphia-negative MPNs, with a particular focus on its epidemiology, pathogenesis, histopathology, risk factors, classification, clinical presentation, diagnosis, and management.
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Affiliation(s)
- Mihnea-Alexandru Găman
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Bucharest 050474, Romania
- Department of Hematology, Center of Hematology and Bone Marrow Transplantation, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Matei-Alexandru Cozma
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Bucharest 050474, Romania
| | | | - Bahadar S Srichawla
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, Massachusetts 01655, United States
| | - Arkadeep Dhali
- Department of Internal Medicine, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, United Kingdom
| | - Sajjad Ali
- Department of Medicine, Ziauddin University, Karachi 75600, Pakistan
| | - Ahmed Nahian
- California Baptist University-Lake Erie College of Osteopathic Medicine, Riverside, CA 92504, United States
| | - Andrew C Elton
- University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - L V Simhachalam Kutikuppala
- Department of General Surgery, Dr NTR University of Health Sciences, Andhra Pradesh, Vijayawada 520008, India
| | - Richard Christian Suteja
- Department of Undergraduate Medicine, Faculty of Medicine, Udayana University Denpasar, Bali 80232, Indonesia
| | - Sebastian Diebel
- Department of Family Medicine, Northern Ontario School of Medicine Timmins, Ontario 91762, Canada
| | - Amelia Maria Găman
- Department of Pathophysiology, University of Medicine and Pharmacy of Craiova, Romania & Clinic of Hematology, Filantropia City Hospital, Craiova 200143, Romania
| | - Camelia Cristina Diaconu
- Department of Internal Medicine, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Romania & Internal Medicine Clinic, Clinical Emergency Hospital of Bucharest, Bucharest 105402, Romania
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Wang Z, Wang Z, Zhang Z, Li J, Pan Z, Liu A, Lu J, Guo J, Zu M, Xu H. Establishment and validation of a prediction model for the first recurrence of Budd-Chiari syndrome after endovascular treatment: a large sample size, single-center retrospective study. Hepatol Int 2022; 17:159-169. [PMID: 36567373 PMCID: PMC9895038 DOI: 10.1007/s12072-022-10464-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 11/24/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To investigate the independent risk factors for the first recurrence after endovascular management in patients with Budd-Chiari syndrome (BCS), and to establish a prediction model for predicting recurrence in target patients. METHODS BCS patients who underwent endovascular treatment in the Affiliated Hospital of Xuzhou Medical University from January 2010 to December 2015 were retrospectively examined, with their clinical, laboratory test, and imaging data collected and analyzed. Independent risk factors for recurrence were identified, and a prediction model was established and validated. RESULTS A total of 450 patients met the filtering criteria, and 102 recurred during the follow-up. The median follow-up time was 87 months, ranging from 1 to 137 months. The 1-, 3-, 5- and 10-year cumulative recurrence rate was 9.11% (6.41-11.73%), 17.35% (13.77-20.78%), 20.10% (16.30-23.72%), and 23.06% (18.86-27.04%), respectively. Liver cirrhosis, ascites, thrombosis, and all the main intrahepatic drainage veins obstructed (obstructed HV + AHV) are independent risk factors, while age is an independent protective factor. The prediction model was named MRBET. Based on the model, the risk score of each patient equals (-0.385981 * Age/10) + (0.0404184 * PT) + (0.0943423 * CRE/10) + (0.0157053 * LDH/10) + (0.592179 * LC) + (0.896034 * Ascites) + (0.691346 * Thrombosis) + (0.886741 * obstructed HV + AHV), and those in the high-risk group (risk score ≥ 1.57) were more likely to recur than those in the low-risk group (HR = 6.911, p < 0.001). The MRBET model is also available as a web tool at https://mrbet.shinyapps.io/dynnomapp . CONCLUSION Liver cirrhosis, ascites, thrombosis, and obstructed HV + AHV are independent risk factors for the first recurrence; age is an independent protective factor. The prediction model can effectively and conveniently predict the risk of recurrence and screen out patients at a high recurrence risk.
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Affiliation(s)
- Zhongkai Wang
- Department of Interventional Radiology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Road, Xuzhou, 221006 Jiangsu China ,Center of Interventional Radiology and Vascular Surgery, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nanjing, 210009 Jiangsu China
| | - Ziwei Wang
- Department of Urology, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433 China
| | - Zhiyuan Zhang
- Department of Interventional Oncology, The Second Affiliated Hospital of Xuzhou Medical University, 32 Meijian Road, Xuzhou, 221006 Jiangsu China
| | - Jiandong Li
- Department of Interventional Radiology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Road, Xuzhou, 221006 Jiangsu China
| | - Zhiyang Pan
- Department of Interventional Radiology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Road, Xuzhou, 221006 Jiangsu China
| | - Ang Liu
- Department of Interventional Radiology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Road, Xuzhou, 221006 Jiangsu China ,Department of Structural Heart Disease, Cardiovascular Institute and Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Beijing, 100037 China
| | - Jian Lu
- Center of Interventional Radiology and Vascular Surgery, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nanjing, 210009 Jiangsu China
| | - Jinhe Guo
- Center of Interventional Radiology and Vascular Surgery, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nanjing, 210009 Jiangsu China
| | - Maoheng Zu
- Department of Interventional Radiology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Road, Xuzhou, 221006 Jiangsu China
| | - Hao Xu
- Department of Interventional Radiology, The Affiliated Hospital of Xuzhou Medical University, 99 West Huaihai Road, Xuzhou, 221006 Jiangsu China
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11
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Liver Transplantation for Budd-Chiari Syndrome in the MELD Era. Transplant Direct 2022; 8:e1407. [PMID: 36398192 PMCID: PMC9666155 DOI: 10.1097/txd.0000000000001407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/09/2022] [Accepted: 09/26/2022] [Indexed: 01/24/2023] Open
Abstract
UNLABELLED To evaluate clinical characteristics and factors associated with survival among liver transplantation (LT) recipients with Budd-Chiari syndrome (BCS), with or without transjugular intrahepatic portosystemic shunt (TIPS), in the post-Model for End-stage Liver Disease era. METHODS We extracted data from the United Network for Organ Sharing database on all adult (≥18 y old) waitlisted candidates and recipients of LT with BCS in the United States between 2002 and 2019. Multivariable Cox regression was used to determine predictors of mortality and hazard ratios (HRs). RESULTS A total of 647 BCS patients were waitlisted between 2002 and 2019. BCS was an indication for LT in 378 (0.2%) of all adult LT recipients during the study period. Of BCS patients who received LT, approximately three-fourths (72.3%) were alive for up to 10 y. We found no significant difference in LT outcomes in BCS patients with or without TIPS. Longer length of hospital stay following LT (HR, 1.32; 95% confidence interval [CI], 1.19-1.47), Black/African American race (HR, 2.24; 95% CI, 1.38-3.64), diabetes (HR, 3.17; 95% CI, 1.62-6.21), donor risk index (HR, 1.44; 95% CI, 1.05-1.99), and lower albumin levels at the time of transplantation (HR, 0.66; 95% CI, 0.50-0.88) were negatively associated with survival after LT. Interestingly, neither the Model for End-stage Liver Disease nor prior TIPS showed a significant association with survival after LT. CONCLUSIONS These findings demonstrate good comparable survival among TIPS versus no TIPS in LT recipients with BCS. The decision for TIPS versus LT should be individualized on a case-by-case basis.
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Elkilany A, Alwarraky M, Denecke T, Geisel D. Percutaneous transluminal angioplasty for symptomatic hepatic vein-type Budd-Chiari syndrome: feasibility and long-term outcomes. Sci Rep 2022; 12:14095. [PMID: 35982064 PMCID: PMC9388522 DOI: 10.1038/s41598-022-16818-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/15/2022] [Indexed: 11/09/2022] Open
Abstract
For management of Budd-Chiari syndrome (BCS), a step-wise therapeutic approach starting with medical treatment, followed by endovascular recanalization, transjugular intrahepatic portosystemic shunt, and finally liver transplantation has been adopted. We retrospectively analyzed 51 patients with symptomatic short segment (≤ 30 mm) hepatic vein (HV)-type BCS who underwent percutaneous transluminal balloon angioplasty (PTBA) with/without stenting to determine the feasibility, clinical effectiveness, and long-term outcomes. The intervention was technically successful in 94.1% of cases (48/51)—32 patients underwent PTBA and 16 patients underwent HV stenting. Procedure-related complications occurred in 14 patients (29.1%). The clinical success rate at 4 weeks was 91.7% (44/48). Nine patients underwent reintervention, six patients due to restenosis/occlusion and three patients with clinical failure. The mean primary patency duration was 64.6 ± 19.9 months (CI, 58.5–70.8; range, 1.2–81.7 months). The cumulative 1-, 2-, and 5-year primary patency rates were 85.4, 74.5, and 58.3%, respectively. The cumulative 1-, 2-, and 5-year secondary patency rates were 93.8, 87.2, and 75%, respectively. The cumulative 1-, 2-, and 5-year survival rates were 97.9, 91.5, and 50%, respectively. Percutaneous transluminal angioplasty with and without stenting is effective and achieves excellent long-term patency and survival rates in patients with symptomatic HV-type BCS. With its lower incidence of re-occlusion and higher clinical success rate, HV angioplasty combined with stenting should be the preferred option especially in patients with segmental HV-type BCS.
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Affiliation(s)
- Aboelyazid Elkilany
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany. .,Department of Diagnostic Medical Imaging and Interventional Radiology, National Liver Institute, Menoufia University, Menoufia, Egypt.
| | - Mohamed Alwarraky
- Department of Diagnostic Medical Imaging and Interventional Radiology, National Liver Institute, Menoufia University, Menoufia, Egypt
| | - Timm Denecke
- Department of Diagnostic and Interventional Radiology, Leipzig University Hospital, Leipzig, Germany
| | - Dominik Geisel
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
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13
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Establishing a jugular-femoral venous route for recanalization of complicated inferior vena cava in Budd-Chiari Syndrome after transfemoral access failure. Sci Rep 2022; 12:3903. [PMID: 35273255 PMCID: PMC8913740 DOI: 10.1038/s41598-022-07935-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 02/21/2022] [Indexed: 11/17/2022] Open
Abstract
Recanalization of inferior vena cava (IVC) with complete obstruction, old thrombosis or long segmental stenosis/obstruction (complicated IVC) via transfemoral access may fail in patients with Budd-Chiari syndrome (BCS). In this study, 34 consecutive patients with BCS underwent recanalization of complicated IVC occlusion via jugular-femoral venous (JFV) route establishment. BCS with complicated IVC was detected by reviewing preoperative color Doppler ultrasonography or computed tomography (CT) venography, and confirmed by intraoperative venography. Clinical data on technical success, complications, and follow-up outcomes were analyzed. Except for one patient received surgical repair of rupture IVC after recanalization, technical success of IVC recanalization was achieved in remaining 33 (97.1%) patients. No perioperative deaths was found. Three complications were observed during recanalization, for a complication rate of 8.8%. Bleeding of the femoral vein was observed in one patient, and two patients showed bleeding of IVC. The IVC lesion diameter and blood flow of the distal IVC increased significantly after the procedure. Twenty-four patients (77.4%) were clinically cured, and four patients (12.9%) showed clinical improvement. The 1-year, 3-year, 5-year primary patency rates were 85.9%, 76.4% and 70.0%, respectively. The 5-year secondary patency rate was 96.8%. There were three deaths during follow up, and the 5-year survival rate was 90.0%. In conclusion, JFV route establishment and angioplasty for complicated IVC is safe and effective for patients with BCS after transfemoral access failure.
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14
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Agrawal D, Gupta D, Nathani R, Dhore P, Meshram M, Bhatia SJ, Shukla A. Presence of Ascites at Presentation is Associated With Absence of Long-Term Response Amongst Patients With Budd-Chiari Syndrome When Treated With Medical Therapy Alone: A Single Centre Real-Life Experience. J Clin Exp Hepatol 2022; 12:861-870. [PMID: 35677520 PMCID: PMC9168723 DOI: 10.1016/j.jceh.2021.10.148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/27/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND There is lack of data on long-term outcomes of patients with Budd-Chairi Syndrome (BCS) treated with medical therapy including anticoagulation alone. METHODS Consecutive patients (N = 138, mean [standard deviation, SD] age 29.3 [12.9] years; 66 men) with BCS, treated with medical therapy alone including anticoagulation, with minimum follow-up of 12 months were included. Initial response was classified as complete (CR), partial (PR) or nonresponse (NR) and on follow-up as loss of response (LoR) or maintenance of response (MoR). The association of baseline, clinical and biochemical parameters with different responses was evaluated. RESULTS Seventy-six patients (55.1%) had CR, 26 (18.8%) had PR and 36 (26.1%) had NR. None with PR or NR had CR later. At a median follow-up of 40 (range 12-174) months, LoR was more common in PR group than in CR group (12 [46.2%] vs 18 [23.7%], P = 0.03). LoR was associated with presence of ascites (odds ratio [OR] 1.5; 95% confidence interval [CI] 0.06-0.71), gastrointestinal bleed (OR 1.33; 95% CI 0.09-0.82) or jaundice (OR 1.01; 95% CI 0.11-0.97) at baseline and duration of follow-up (OR 0.018; 95% CI 1.006-1.030). Mortality was higher in NR (28 [77.8%]) compared with CR (15 [19.7%], P = 0.001) and PR (8 [30.8%], P = 0.001). On binary logistic regression analysis, presence of ascites at baseline was associated with LoR (OR 0.303 [0.098-0.931]). CONCLUSION Patients with initial CR have better survival than nonresponders. One-third had LoR on follow-up. The presence of ascites at baseline is associated with LoR.
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Key Words
- AC-BCS, Acute on chronic BCS
- BCS, Budd-Chairi Syndrome
- CR, Complete response
- CTP, Child-Pugh score
- EVL, Endoscopic variceal band ligation
- GAVE, Gastric antral vascular ectasia
- GI, gastrointestinal
- GOV1/2, Gastroesophageal varices 1 and 2
- HVOTO, Hepatic venous outflow tract obstruction
- INR, International Normalised Ratio
- IVC, inferior vena cava thrombosis
- LMWH, low-molecular-weight heparin
- LoR, Loss of response
- MELD, Model for end stage liver disease
- MoR, Maintenance of response
- NR, Nonresponse
- PHG, portal hypertensive gastropathy
- PR, Partial response
- SBP, Spontaneous bacterial peritonitis
- Warfarin
- budd-chiari syndrome
- cirrhosis
- portal hypertension
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Affiliation(s)
| | | | | | | | | | | | - Akash Shukla
- Address for correspondence: Akash Shukla, Department of Gastroenterology, New building 11th floor, Seth GS Medical College and KEM Hospital, Mumbai 400012, India.
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Lichoska-Josifovikj F, Grivcheva-Stardelova K, Todorovska B, Genadieva Dimitrovа M, Petkovska L, Trajkovska M. Predictive potential of the MELD and Child-Turcotte-Pugh II scores for SBP in patients with cirrhosis and ascites. Arch Public Health 2021. [DOI: 10.3889/aph.2021.6022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
It is very important for patients with spontaneous bacterial peritonitis (SBP) to assess the length of survival and the risk of death, primarily because of the wide range of potential complications that can lead to multisystem organ failure and fatal outcome. The aim of this study was to determine the predictive potential of MELD and Child-Turcotte-Pugh II score for SBP in patients with cirrhosis and ascites. Material and methods: The study was designed as a prospective-analytical-observational and was conducted at the University Clinic for Gastroenterohepatology in Skopje for a period of one year. The study population included 70 hospitalized patients with established liver cirrhosis, regardless of etiology, divided into two groups, 35 patients with SBP and 35 non-SBP. Prognostic scores in patients with liver cirrhosis and ascites: MELD score, according to the formula: MELD = [(0.957 x Ln Creatinin) + (0.378 x Ln Bilirubin) + (1.12 x Ln INR) + (0.643) x 10]. The Child-Turcotte-Pugh II score includes 6 parameters: serum albumin and bilirubin, amount of ascites, degree of encephalopathy ( HE), prothrombin time (PT) and serum creatinine, and assessment of the degree of hepatic encephalopathy according to the West Haven criteria. Results: The average value of the MELD score in patients with SBP was 22.6 ± 8.27 and in non-SBP the average value was lower - 17.83±5.87. According to the Mann-Whitney U test, the difference between the mean values was statistically significant for p <0.05 (z = 2.41; p = 0.015). A score of 30 to 39 was registered in 25.7% of patients with SBP, and only in 2.9% in non-SBP; the percentage difference was statistically significant for p <0.05 (Difference test, p = 0.0064 ). Patients with SBP had an average Child-Pugh score of 13.09 ± 2.48 or 100.0% C-class points. In patients with non-SBP, an average child-Pugh score of 9.63 ± 1.62 was recorded, or class B in 65.7% and class C in 34.3%. The percentage difference was statistically significant for p <0.05 (Difference test, p = 0.000000). According to the Mann-Whitney U test, the difference between the mean values was statistically significant for p <0.05 (z = -5.44; p = 0.00001). ROC analysis indicated that the Child-Turcotte-Pugh II score contributed to the diagnosis of SBP - 90.7% (p = 0.000) (excellent predictor), closer to the ideal value of 1.0 and above the worst value of 0.5. ROC analysis indicated that the MELD score did not contribute to the diagnosis of SBP - 66.7% (p = 0.017) (weak predictor), closer to the worst value of 0.5. Conclusion:Our research confirmed that SBP occurs in patients with severe hepatic dysfunction calculated according to the CTP II score and MELD score. Mean value of the MELD score in patients with SBP was higher then in patients with non-SBP. On the other hand all patients with SBP had an average CTP II score, C-class points, while the largest percentage of patients with non-SBP were class B-class points. MELD score is a weak predictor of SBP. The best predictor for predicting SBP is the CTP II score (rank C).
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Lupasco I, Dumbrava VT. Diagnosis and therapy of Budd Chiari syndrome. Med Pharm Rep 2021; 94:S68-S71. [PMID: 34527916 DOI: 10.15386/mpr-2235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Budd-Chiari syndrome is described as a disorder characterized by the obstruction of hepatic venous outflow. The first description of the syndrome was done by George Budd in 1846. The etiology of the disease is multifactorial and requires differential diagnosing. The prognostic evaluation of patients with liver outflow obstruction differentiates special groups for further treatment procedures. The stepwise approach of Budd-Chiari syndrome allows the finding of the right technique on an individual basis for every patient.
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Affiliation(s)
- Iulianna Lupasco
- Research Laboratory of Gastroenetrology, "Nicolae Testemitanu" State University of Medicine and Pharmacy, Chisinau, Republic of Moldova
| | - Vlada-Tatiana Dumbrava
- Research Laboratory of Gastroenetrology, "Nicolae Testemitanu" State University of Medicine and Pharmacy, Chisinau, Republic of Moldova
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A Scoring Model to Predict In-Hospital Mortality in Patients With Budd-Chiari Syndrome. Am J Gastroenterol 2021; 116:1905-1912. [PMID: 33900212 DOI: 10.14309/ajg.0000000000001273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 03/18/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION A model that can predict short-term mortality in patients with the Budd-Chiari syndrome (BCS) with a high degree of accuracy is currently lacking. The primary objective of our study was to develop an easy-to-use in-hospital mortality prediction model in patients with BCS using easily available clinical variables. METHODS Data were extracted from the National Inpatient Sample to identify all adult patients with a listed diagnosis of BCS from 2008 to 2017 using ICD-9 or ICD-10 codes. After identifying independent risk factors of in-hospital mortality, we developed a prediction model using logistic regression analysis. The model was built and validated in a training and a validation data set, respectively. Using the model, we risk stratified patients into low-, intermediate-, and high-risk groups. RESULTS Between 2008 and 2017, we identified a total of 5,306 (weighted sample size 26,110) discharge diagnosis of patients with BCS, with an overall in-hospital mortality of 7.14%. The independent risk factors that predicted mortality were age of 50 years or older, ascites, sepsis, acute respiratory failure, acute liver failure, hepatorenal syndrome, and cancers. The mortality prediction model that incorporated these risk factors had an area under the receiver operating characteristic curve of 0.87 (95% CI 0.85-0.95) for the training data and 0.89 (95% CI 0.86-0.92) for the validation data. Patients with low-, intermediate-, and high-risk scores had a predicted in-patient mortality of 4%, 30%, and 66%, respectively. DISCUSSION Using a national administrative database, we developed a reliable in-patient mortality prediction model with an excellent accuracy. The model was able to risk stratify patients into low-, intermediate-, and high-risk groups.
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Alukal JJ, Zhang T, Thuluvath PJ. Mortality and health care burden of Budd Chiari syndrome in the United States: A nationwide analysis (1998-2017). World J Hepatol 2021; 13:686-698. [PMID: 34239703 PMCID: PMC8239494 DOI: 10.4254/wjh.v13.i6.686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/27/2021] [Accepted: 05/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The Budd Chiari syndrome (BCS) is a rare and potentially fatal disease, but there is a paucity of data on the in- hospital mortality as well its economic burden on the health care system.
AIM To evaluate trends in mortality, length of hospital stays and resource utilization among inpatients with BCS.
METHODS Data on all adult patients with a diagnosis of BCS were extracted from the National Inpatient Sample (NIS) from 1998 to 2017. To make inferences regarding the national estimates for the total number of BCS discharges across the study period, sample weights were applied to each admission per recommendations from the NIS.
RESULTS During the study period, there were 3591 (8.73%) in-patient deaths. The overall in-hospital mortality rates among BCS patients decreased from 18% in 1998 to 8% in 2017; the mortality decreased by 4.41% (P < 0.0001) every year. On multivariate analysis, older age, higher comorbidity score, acute liver failure, acute kidney injury, acute respiratory failure, hepatic encephalopathy, hepatorenal syndrome, inferior vena cava thrombosis, intestinal infarct, sepsis/septic shock and cancer were associated increased risk of mortality. The average of length of stay was 8.8 d and it consistently decreased by 2.04% (95%CI: -2.67%, -1.41%, P < 0.001) from 12.7 d in 1998 to 7.6 d in 2017.The average total charges after adjusted for Medical Care Consumers Price Index to 2017 dollars during the time period was $94440 and the annual percentage change increased by 1.15% (95%CI: 0.35%, 1.96%, P = 0.005) from $95515 in 1998 to $103850 in 2017.
CONCLUSION The in-hospital mortality rate for patients admitted with BCS in the United States has reduced between 1998 and 2017 and this may a reflection of better management of these patients.
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Affiliation(s)
- Joseph J Alukal
- Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, MD 21202, United States
| | - Talan Zhang
- Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, MD 21202, United States
| | - Paul Joseph Thuluvath
- Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, MD 21202, United States
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21202, United States
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Shukla A, Shreshtha A, Mukund A, Bihari C, Eapen CE, Han G, Deshmukh H, Cua IHY, Lesmana CRA, Al Meshtab M, Kage M, Chaiteeraki R, Treeprasertsuk S, Giri S, Punamiya S, Paradis V, Qi X, Sugawara Y, Abbas Z, Sarin SK. Budd-Chiari syndrome: consensus guidance of the Asian Pacific Association for the study of the liver (APASL). Hepatol Int 2021; 15:531-567. [PMID: 34240318 DOI: 10.1007/s12072-021-10189-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/11/2021] [Indexed: 02/07/2023]
Abstract
Budd Chiari syndrome (BCS) is a diverse disease with regard to the site of obstruction, the predisposing thrombophilic disorders and clinical presentation across the Asia-Pacific region. The hepatic vein ostial stenosis and short segment thrombosis are common in some parts of Asia-Pacific region, while membranous obstruction of the vena cava is common in some and complete thrombosis of hepatic veins in others. Prevalence of myeloproliferative neoplasms and other thrombophilic disorders in BCS varies from region to region and with different sites of obstruction. This heterogeneity also raises several issues and dilemmas in evaluation and approach to management of a patient with BCS. The opportunity to recanalize hepatic vein in patients with hepatic vein ostial stenosis or inferior vena cava stenting or pasty among those membranous obstruction of the vena cava is a unique opportunity in the Asia-Pacific region to restore hepatic outflow closely mimicking physiology. In order to address these issues arising out of the diversity as well as the unique features in the region, the Asia Pacific Association for Study of Liver has formulated these guidelines for clinicians.
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Affiliation(s)
- Akash Shukla
- Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India.
| | | | - Amar Mukund
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chhagan Bihari
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - C E Eapen
- Christian Medical College, Vellore, India
| | - Guohong Han
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China
| | - Hemant Deshmukh
- Dean and Head of Radiology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| | - Ian Homer Y Cua
- Institute of Digestive and Liver Diseases, St Lukes Medical Center, Global City, Philippines
| | - Cosmas Rinaldi Adithya Lesmana
- Dr. Cipto Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta, Indonesia
- Digestive Disease & GI Oncology Center, Medistra Hospital, Jakarta, Indonesia
| | - Mamun Al Meshtab
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
- Center for Innovative Cancer Therapy, Kurume University Research, 67 Asahi-machi, Kurume, 830-0011, Japan
| | - Masayoshi Kage
- Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| | - Roongruedee Chaiteeraki
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sombat Treeprasertsuk
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Suprabhat Giri
- Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| | - Sundeep Punamiya
- Vascular and Interventional Radiology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Valerie Paradis
- Dpt dAnatomie Pathologique, Hôpital Beaujon, 100 bd du Gal Leclerc, Clichy, 92110, France
| | - Xingshun Qi
- General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, China
| | - Yasuhiko Sugawara
- Department of Transplantation and Pediatric Surgery, Kumamoto University, Kumamoto, Japan
| | - Zaigham Abbas
- Department of Hepatogastroenterology, Dr. Ziauddin University Hospital Clifton, Karachi, Pakistan
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20
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Sharma A, Keshava SN, Eapen A, Elias E, Eapen CE. An Update on the Management of Budd-Chiari Syndrome. Dig Dis Sci 2021; 66:1780-1790. [PMID: 32691382 DOI: 10.1007/s10620-020-06485-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/04/2020] [Indexed: 12/17/2022]
Abstract
Budd-Chiari syndrome (BCS) is an uncommon condition, caused by obstruction to hepatic venous outflow. It is largely underdiagnosed, and a high index of suspicion is required for any patient with unexplained portal hypertension. The understanding of its etiology and pathology is improving with advances in diagnostic techniques. Recent studies reported an identifiable etiology in > 80% of cases. Myeloproliferative neoplasm (MPN) is the most common etiology, and genetic studies help in diagnosing latent MPN. Better cross-sectional imaging helps delineate the site of obstruction accurately. The majority of BCS patients are now treated by endovascular intervention and anticoagulation which have improved survival in this disease. Angioplasty of hepatic veins/inferior vena cava remains under-utilized at present. While surgical porto-systemic shunts are no longer done for BCS, liver transplantation is reserved for select indications. Some of the unresolved issues in the current management of BCS are also discussed in this review.
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Affiliation(s)
- A Sharma
- Hepatology Department, Christian Medical College, Vellore, Tamil Nadu, India
| | - S N Keshava
- Department of Interventional Radiology, Christian Medical College, Vellore, India
| | - A Eapen
- Department of Radiodiagnosis, Christian Medical College, Vellore, India
| | - E Elias
- Hepatology Department, Christian Medical College, Vellore, Tamil Nadu, India.,Liver Unit, University Hospitals Birmingham, Birmingham, UK
| | - C E Eapen
- Hepatology Department, Christian Medical College, Vellore, Tamil Nadu, India.
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21
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Thuluvath PJ, Alukal JJ, Zhang T. Acute liver failure in Budd-Chiari syndrome and a model to predict mortality. Hepatol Int 2021; 15:146-154. [PMID: 33387301 DOI: 10.1007/s12072-020-10115-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/19/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVE Acute liver failure (ALF) occurs in approximately 1-2% of patients with Budd-Chiari syndrome (BCS). The primary objective of our study was to study the outcome of patients with BCS-ALF using the National Inpatient Sample (NIS) database and develop a mortality prediction model. DESIGN We identified all adult patients with BCS, with and without ALF, using ICD-9 or ICD-10. Using clinical variables, we identified risk factors for in-hospital mortality and developed a prediction model using logistic regression analysis. The model was built and validated in a training and validation datasets. RESULTS Between 2008 and 2017, of the estimated total of 5,306 (weighted sample size 26,110) BCS discharges, 325 (6.1%) patients (weighted sample size 1,598) presented with ALF. Of 325 BCS-ALF patients, 114 (34.7%, weighted n = 554) died and in contrast only 267 of 4,981 (5%, weighted n = 1310) without ALF died during the hospitalization. The independent risk factors that predicted mortality were age 50 years or older, acute respiratory failure, spontaneous bacterial peritonitis, sepsis and cancers. The prediction model that incorporated these risk factors had an area under the receiver operating characteristic curve (AUROC) of 0.85 (95% CI 0.80-0.90) for training data and 0.80 (95% CI 0.71-0.89) for validation data. The predicted mortality risk with low (score < 6), intermediate (score 6-16), and high risk (score ≥ 17) scores were 8%, 37% and 71%, respectively. CONCLUSION ALF due to BCS is associated with a very high in-hospital mortality that could be predicted with reasonable accuracy.
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Affiliation(s)
- Paul J Thuluvath
- Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, MD, USA. .,Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Joseph J Alukal
- Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, MD, USA
| | - Talan Zhang
- Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, MD, USA
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22
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Inchingolo R, Posa A, Mariappan M, Tibana TK, Nunes TF, Spiliopoulos S, Brountzos E. Transjugular intrahepatic portosystemic shunt for Budd-Chiari syndrome: A comprehensive review. World J Gastroenterol 2020; 26:5060-5073. [PMID: 32982109 PMCID: PMC7495032 DOI: 10.3748/wjg.v26.i34.5060] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/06/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023] Open
Abstract
Budd-Chiari syndrome (BCS) is a relatively rare clinical condition with a wide range of symptomatology, caused by the obstruction of the hepatic venous outflow. If left untreated, it has got an high mortality rate. Its management is based on a step-wise approach, depending on the clinical presentation, and includes different treatment from anticoagulation therapy up to Interventional Radiology techniques, such as transjugular intrahepatic portosystemic shunt (TIPS). TIPS is today considered a safe and highly effective treatment and should be recommended for BCS patients, including those awaiting orthotopic liver transplantation. In this review the pathophysiology, diagnosis and treatment options of BCS are presented, with a special focus on published data regarding the techniques and outcomes of TIPS for the treatment of BCS. Moreover, unresolved issues and future research will be discussed.
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Affiliation(s)
- Riccardo Inchingolo
- Interventional Radiology Unit, "F. Miulli" Regional Hospital, Acquaviva delle Fonti 70021, Italy
- Department of Radiology, King´s College Hospital, London SE5 9RS, United Kingdom
| | - Alessandro Posa
- Department of Radiology, Gemelli Hospital, Roma 00135, Italy
| | - Martin Mariappan
- Interventional Radiology Department, Aberdeen Royal Infirmary Hospital, Aberdeen AB25 2ZN, United Kingdom
| | - Tiago Kojun Tibana
- Interventional Radiology Department, Universidade Federal de Mato Grosso do Sul, Campo Grande 79070-900, Brazil
| | - Thiago Franchi Nunes
- Interventional Radiology Department, Universidade Federal de Mato Grosso do Sul, Campo Grande 79070-900, Brazil
| | - Stavros Spiliopoulos
- 2nd Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Chaidari Athens GR 12461, Greece
| | - Elias Brountzos
- 2nd Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Chaidari Athens GR 12461, Greece
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23
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Coilly A, Potier P, Broué P, Kounis I, Valla D, Hillaire S, Lambert V, Dutheil D, Hernández-Gea V, Plessier A, Vilgrain V, Bureau C. Budd-Chiari syndrome. Clin Res Hepatol Gastroenterol 2020; 44:420-425. [PMID: 32249150 DOI: 10.1016/j.clinre.2020.03.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/03/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Audrey Coilly
- Hepatobiliary Center, Paul Brousse Hospital APHP, 12, avenue Paul-Vaillant Couturier, 94800 Villejuif, France; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, APHP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France.
| | - Pascal Potier
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, APHP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Department of Gastroenterology and Hepatology, De La Source Hospital, Regional Hospital of Orleans, 14, avenue de l'hôpital, 45100 Orléans La Source, France
| | - Pierre Broué
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, APHP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Pediatric hepatology Unit, University Hospital of Toulouse, 9, place Lange, 31300 Toulouse, France
| | - Ilias Kounis
- Hepatobiliary Center, Paul Brousse Hospital APHP, 12, avenue Paul-Vaillant Couturier, 94800 Villejuif, France; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, APHP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - Dominique Valla
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, APHP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Department of Hepatology, Beaujon Hospital AP-HP, 100, boulevard du Général-Leclerc, 92118 Clichy, France; Reference center of vascular liver diseases, European Reference Network (ERN) 'Rare-Liver'
| | - Sophie Hillaire
- Department of Internal Medicine, Foch Hospital, 40, rue Worth, 92150 Suresnes, France
| | - Vincent Lambert
- General medicine, 46, avenue Yolande-d'Aragon, 49100 Angers, France
| | - Danielle Dutheil
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, APHP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Association of patients with vascular liver diseases (AMVF), Beaujon Hospital, Department of Hepatology, 100, boulevard du Général Leclerc, 92118 Clichy, France
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona. Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd). Health Care Provider of the European Reference Network onRare Liver Disorders (ERN-Liver), Spain
| | - Aurélie Plessier
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, APHP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Department of Hepatology, Beaujon Hospital AP-HP, 100, boulevard du Général-Leclerc, 92118 Clichy, France; Reference center of vascular liver diseases, European Reference Network (ERN) 'Rare-Liver'
| | - Valérie Vilgrain
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, APHP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Department of Hepatology, Beaujon Hospital AP-HP, 100, boulevard du Général-Leclerc, 92118 Clichy, France; Department of radiology, Beaujon Hospital, AP-HP, 100, boulevard du Général Leclerc, 92118 Clichy, France
| | - Christophe Bureau
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, APHP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Department of Gastroenterology and Hepatology, Rangueil Hospital, University Hospital of Toulouse, 1, avenue du Professeur Jean-Poulhès, 31400 Toulouse, France
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Sharma A, Goel A, Moses V, Keshava SN, Zachariah UG, Elias E, Eapen CE. Anticoagulating Budd-Chiari syndrome patients presenting with variceal bleed: A retrospective study. J Gastroenterol Hepatol 2020; 35:1397-1403. [PMID: 31900982 DOI: 10.1111/jgh.14971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/21/2019] [Accepted: 01/02/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM This aims to study incidence of re-bleeding on anticoagulation and survival of Budd-Chiari syndrome (BCS) patients presenting with variceal bleeding. METHODS Budd-Chiari syndrome patients presenting with variceal bleed between 01/01/2007 and 01/05/2019 were retrospectively studied. Patients underwent endoscopic treatment ± endovascular therapy, followed by anticoagulation. Variceal re-bleed (on anticoagulation) and survival were studied. RESULTS Of 376 BCS patients diagnosed during the study period, 40 (10.7%) patients, presenting with variceal bleed (age 33 [25-40] years; male patients 70%; Rotterdam score 1.13 [0.63-1.22]), Group 1 were compared with 40 randomly selected age-matched BCS patients presenting with ascites, no bleeds (40 [23-42] years; male patients 42.5%; Rotterdam score 1.11 [1.09-1.16]), Group 2. The commonest site of obstruction was hepatic vein (65%) in Group 1 and combined hepatic veins and inferior vena cava (57.5%) in Group 2 (P < 0.01). Thirty-six Group 1 patients underwent endoscopic intervention (variceal ligation, 33; sclerotherapy, 2; glue injection, 1). Endovascular intervention was performed in 30 Group 1 patients (angioplasty ± stent, 22; endovascular shunt, 8) and in 34 Group 2 patients (angioplasty ± stent, 26; endovascular shunt, 8). All 80 patients were started on anticoagulation. Variceal bleed on anticoagulation occurred in five patients in Group 1 and three patients in Group 2. One-year and 5-year survival were 94.2% and 87.5%, respectively, in Group 1 and 100% and 80%, respectively, in Group 2. CONCLUSIONS About one-tenth of BCS patients present with variceal bleed. On management with endoscopic ± endovascular therapy, followed by anticoagulation, variceal re-bleed in these patients were comparable with those in BCS patients presenting with ascites and survival was excellent at 1 and 5 years.
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Affiliation(s)
- Anand Sharma
- Department of Hepatology, Christian Medical College, Vellore, India
| | - Ashish Goel
- Department of Hepatology, Christian Medical College, Vellore, India
| | - Vinu Moses
- Department of Radiology, Christian Medical College, Vellore, India
| | | | | | - Elwyn Elias
- Department of Hepatology, Christian Medical College, Vellore, India.,Liver Unit, University Hospital Birmingham, Birmingham, UK
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Abstract
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.
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26
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Abstract
Disorders of the mesenteric, portal, and hepatic veins and mesenteric and hepatic arteries have important clinical consequences and may lead to acute liver failure, chronic liver disease, noncirrhotic portal hypertension, cirrhosis, and hepatocellular carcinoma. Although literature in the field of vascular liver disorders is scant, these disorders are common in clinical practice, and general practitioners, gastroenterologists, and hepatologists may benefit from expert guidance and recommendations for management of these conditions. These guidelines represent the official practice recommendations of the American College of Gastroenterology. Key concept statements based on author expert opinion and review of literature and specific recommendations based on PICO/GRADE analysis have been developed to aid in the management of vascular liver disorders. These recommendations and guidelines should be tailored to individual patients and circumstances in routine clinical practice.
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27
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Hernández-Gea V, De Gottardi A, Leebeek FWG, Rautou PE, Salem R, Garcia-Pagan JC. Current knowledge in pathophysiology and management of Budd-Chiari syndrome and non-cirrhotic non-tumoral splanchnic vein thrombosis. J Hepatol 2019; 71:175-199. [PMID: 30822449 DOI: 10.1016/j.jhep.2019.02.015] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/15/2019] [Accepted: 02/19/2019] [Indexed: 12/11/2022]
Abstract
Budd-Chiari syndrome and non-cirrhotic non-tumoral portal vein thrombosis are 2 rare disorders, with several similarities that are categorized under the term splanchnic vein thrombosis. Both disorders are frequently associated with an underlying prothrombotic disorder. They can cause severe portal hypertension and usually affect young patients, negatively influencing life expectancy when the diagnosis and treatment are not performed at an early stage. Yet, they have specific features that require individual consideration. The current review will focus on the available knowledge on pathophysiology, diagnosis and management of both entities.
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Affiliation(s)
- Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, European Reference Network for Rare Vascular Liver Diseases, Universitat de Barcelona, Spain
| | - Andrea De Gottardi
- Hepatology, University Clinic of Visceral Medicine and Surgery, Inselspital, and Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Pierre-Emmanuel Rautou
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France; Inserm, UMR-970, Paris Cardiovascular Research Center, PARCC, Paris, France
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, European Reference Network for Rare Vascular Liver Diseases, Universitat de Barcelona, Spain.
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28
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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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29
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Khan F, Armstrong MJ, Mehrzad H, Chen F, Neil D, Brown R, Cain O, Tripathi D. Review article: a multidisciplinary approach to the diagnosis and management of Budd-Chiari syndrome. Aliment Pharmacol Ther 2019; 49:840-863. [PMID: 30828850 DOI: 10.1111/apt.15149] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 11/06/2019] [Accepted: 12/29/2018] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Faisal Khan
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Matthew J Armstrong
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Homoyon Mehrzad
- Imaging and Interventional Radiology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Frederick Chen
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK.,Department of Clinical Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Desley Neil
- Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Rachel Brown
- Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Owen Cain
- Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Shatzel JJ, O'Donnell M, Olson SR, Kearney MR, Daughety MM, Hum J, Nguyen KP, DeLoughery TG. Venous thrombosis in unusual sites: A practical review for the hematologist. Eur J Haematol 2018; 102:53-62. [PMID: 30267448 DOI: 10.1111/ejh.13177] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/20/2018] [Accepted: 09/21/2018] [Indexed: 12/13/2022]
Abstract
Thrombosis of unusual venous sites encompasses a large part of consultative hematology and is encountered routinely by practicing hematologists. Contrary to the more commonly encountered lower extremity venous thrombosis and common cardiovascular disorders, the various thromboses outlined in this review have unique presentations, pathophysiology, workup, and treatments that all hematologists should be aware of. This review attempts to outline the most up to date literature on cerebral, retinal, upper extremity, hepatic, portal, splenic, mesenteric, and renal vein thrombosis, focusing on the incidence, pathophysiology, provoking factors, and current recommended treatments for each type of unusual thrombosis to provide a useful and practical review for the hematologist.
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Affiliation(s)
- Joseph J Shatzel
- Division of Hematology-Oncology, Oregon Health & Science University, Portland, Oregon
| | - Matthew O'Donnell
- Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon
| | - Sven R Olson
- Division of Hematology-Oncology, Oregon Health & Science University, Portland, Oregon
| | - Matthew R Kearney
- Department of Internal Medicine, Oregon Health & Science University, Portland, Oregon
| | - Molly M Daughety
- Division of Hematology-Oncology, Oregon Health & Science University, Portland, Oregon
| | - Justine Hum
- Division of Gastroenterology, Oregon Health & Science University, Portland, Oregon
| | - Khanh P Nguyen
- Division of Vascular Surgery, Oregon Health & Science University, Portland, Oregon
| | - Thomas G DeLoughery
- Division of Hematology-Oncology, Oregon Health & Science University, Portland, Oregon
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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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Singh SK, Sen Sarma M, Yadav R, Kumar S, Prasad R, Yachha SK, Srivastava A, Poddar U. Prognostic scoring systems and outcome of endovascular radiological intervention of chronic Budd-Chiari syndrome in children. Liver Int 2018; 38:1308-1315. [PMID: 29297972 DOI: 10.1111/liv.13683] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 12/19/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM Prognostic scoring systems (PSS) have not been validated in children with chronic Budd-Chiari syndrome (BCS). We aimed to analyse the long-term outcome of radiological intervention (RI) and validate the PSS in children. METHODS Chronic BCS children were analysed in four subgroups: (i) SI: successful intervention (primary or secondary stent patency) (ii) PO: poor outcome (refractory stent block or requirement of liver transplantation), (iii) NU: naïve unintervened (awaiting RI) and (iv) DBI: died before intervention. PSS analysed included Paediatric end-stage liver disease (PELD), Rotterdam, BCS-Transjuglar intrahepatic Portosystemic shunt (BCS-TIPS) index, Zeitoun, Child-Pugh and Model for end-stage liver disease. RESULTS Of 113 BCS children, 48 children underwent 53 successful primary RI. Actuarial probability of vascular patency was 87% at 1 year and 82% at 5 years follow-up. Four groups (SI: n = 40, PO: n = 7, NU: n = 13, DBI: n = 6) were analysed. Univariate analysis showed pre-intervention PELD score [PO: 11 (-1-23) vs SI: 2 (-8-25), P = .009] with a cut-off of 4 (AUC: 0.809, 86% sensitivity, 75% specificity) determined PO following intervention. In unintervened group (NU vs DBI), multivariate analysis demonstrated that Zeitoun score predicted death independently (OR 15.4, 95% CI: 1.17-203.56, P = .04) with a cut-off of 4.3 (AUC: 0.923, 83% sensitivity and 77% specificity). CONCLUSIONS Children with BCS have a favourable long-term outcome. Among those undergoing RI, pre-intervention PELD score determines the outcome. Survival is determined by Zeitoun score in those unintervened.
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Affiliation(s)
- Sumit K Singh
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Rajanikant Yadav
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sheo Kumar
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Raghunandan Prasad
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Surender K Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Mukund A, Mittal K, Mondal A, Sarin SK. Anatomic Recanalization of Hepatic Vein and Inferior Vena Cava versus Direct Intrahepatic Portosystemic Shunt Creation in Budd-Chiari Syndrome: Overall Outcome and Midterm Transplant-Free Survival. J Vasc Interv Radiol 2018; 29:790-799. [PMID: 29705227 DOI: 10.1016/j.jvir.2018.01.781] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/23/2018] [Accepted: 01/24/2018] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To assess overall outcome and midterm transplant-free survival of patients with Budd-Chiari syndrome (BCS) undergoing radiologic interventions including anatomic recanalization of the hepatic vein (HV) and inferior vena cava (IVC) and direct intrahepatic portosystemic shunt (DIPS) creation, both as combined and as independent groups. MATERIALS AND METHODS From November 2010 to October 2014, 136 patients with BCS were treated with HV/IVC recanalization (group 1) or DIPS creation (group 2). Both groups were periodically analyzed for stent patency on Doppler ultrasound, clinical outcome, biochemical parameters, and survival until death, liver transplantation, or last clinical evaluation. RESULTS Actuarial transplant-free survival for the entire cohort was 94% at 1 year and 5 years with no significant difference in overall survival. There was significant biochemical improvement in group 1 with decrease in mean serum bilirubin level (1.8 mg/dL to 1.4 mg/dL, P < .011), mean serum aspartate aminotransferase (48.6 IU/L to 33.2 IU/L, P < .05), and mean serum alanine aminotransferase (38.7 IU/L to 28.5 IU/L) and increase in mean serum albumin level (3.2 g/dL to 3.45 g/dL, P < .001) after 3 and 24 months. There were 4 deaths in each group at 1-year follow-up; all 4 patients had acute fulminant BCS at presentation. CONCLUSIONS Radiologic interventions for BCS lead to remarkable improvement of liver function and a good overall outcome and midterm transplant-free survival. Patients receiving anatomic recanalization show improved liver synthetic functions compared with patients treated with DIPS.
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Affiliation(s)
- Amar Mukund
- Department of Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India.
| | - Kartik Mittal
- Department of Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
| | - Aniket Mondal
- Department of Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
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Martín-Llahí M, Albillos A, Bañares R, Berzigotti A, García-Criado MÁ, Genescà J, Hernández-Gea V, Llop-Herrera E, Masnou-Ridaura H, Mateo J, Navascués CA, Puente Á, Romero-Gutiérrez M, Simón-Talero M, Téllez L, Turon F, Villanueva C, Zarrabeitia R, García-Pagán JC. Enfermedades vasculares del hígado. Guías Clínicas de la Sociedad Catalana de Digestología y de la Asociación Española para el Estudio del Hígado. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 40:538-580. [DOI: 10.1016/j.gastrohep.2017.03.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 03/29/2017] [Indexed: 12/11/2022]
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Abstract
AIM Outcomes of endovascular intervention in Budd-Chiari syndrome (BCS) have been reported with varied results. Clinical outcomes of endovascular interventions in BCS and role of various prognostic scores were critically evaluated in this study. METHODS This study retrospectively analyzed consecutive patients of BCS who underwent endovascular intervention between January 2007 and May 2016 at our center. Technical, clinical successes and complications were documented. The role of the prognostic scores such as Child-Turcotte-Pugh (CTP), model for end-stage liver disease (MELD), Rotterdam index, and original Clichy score in predicting mortality, clinical success, and need for re-interventions were also assessed. RESULTS A total of 88 patients were analyzed. The median follow up was 12 months (range 1-96 months). Thirteen (14.8%) patients had combined inferior vena cava (IVC) and hepatic vein (HV) obstruction; HV obstruction in 33 (37.5%) and inferior vena cava IVC obstruction in 42 (47.7%) patients. The following interventions were done: IVC angioplasty alone (n = 11), IVC angioplasty with stenting (n = 36), HV angioplasty with stenting (n = 26), combined HV and IVC stent (n = 2), and direct intrahepatic porto-systemic shunt (DIPS) (n = 13). Overall technical success was 87/88 (98.86%), and clinical success was 76/88 (86.36%). Immediate complications were noted in 8 patients (10%). The 1-, 2-, 3-, and 4-year stent patency rates were 90.91%, 81.08%, 74.59%, and 70.45%, respectively. Re-interventions were required in 15 (17%). Overall mortality was 6 (6.8%). Apart from MELD >14, none of the other prognostic score could predict mortality, clinical success, and need for re-interventions. CONCLUSION Endovascular interventions play an important role in the management of BCS, in properly selected patients, even if prognostic score is unfavorable.
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Diagnosis and treatment guidelines for aberrant portal hemodynamics: The Aberrant Portal Hemodynamics Study Group supported by the Ministry of Health, Labor and Welfare of Japan. Hepatol Res 2017; 47:373-386. [PMID: 28058764 DOI: 10.1111/hepr.12862] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 12/29/2016] [Accepted: 01/04/2017] [Indexed: 12/18/2022]
Abstract
Idiopathic portal hypertension (IPH), causing aberrant portal hemodynamics, is a disease with an as yet unidentified cause and no established treatment protocol. The Japanese research group on IPH in Japan was set up in 1975 by the Ministry of Health, Labor and Welfare. Extrahepatic portal obstruction and Budd-Chiari syndrome (BCS) have since been added to the group's research subjects. The aims of the research group are to accurately evaluate the current status of the three diseases in Japan, elucidate their etiology and pathogenesis, and develop new treatments. Due to the long-term efforts of the Japanese research group, aberrant portal hemodynamics has been investigated in a variety of aspects, from epidemiological and pathological studies to molecular biology analyses. As a result, it has been shown that there are abnormal genes in the liver, specific for IPH. In addition, pathological findings of BCS were internationally compared and the difference in findings between Japan and Europe (or North America) has been clarified. Furthermore, it was found that complication rates of hepatocellular carcinoma in BCS were higher in Japan. Based on the research, "Diagnosis and treatment of aberrant portal hemodynamics (2001)", including diagnostic criteria for aberrant portal hemodynamics, was published in 2001. In 2013, it was revised to "Diagnosis and treatment guidelines for aberrant portal hemodynamics (2013)" after the incorporation of diagnosis and treatment in accordance with its current status.
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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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Sakr M, Abdelhakam SM, Elsayed SA, Allam EH, Farid AM, Abdelmoaty W, Hassan AM, Shaker M, El-Gharib M, Eldorry A. Validation of prognostic indices in Egyptian Budd-Chiari syndrome patients: A single-center study. World J Gastroenterol 2017; 23:629-637. [PMID: 28216969 PMCID: PMC5292336 DOI: 10.3748/wjg.v23.i4.629] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 12/09/2016] [Accepted: 12/21/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To compare predictive ability of Budd-Chiari syndrome (BCS) prognostic indices (PIs) for one-year survival and Transjugular intrahepatic portosystemic shunt (TIPS) patency.
METHODS This retrospective study enrolled 194 Egyptian patients with primary BCS who presented to the Budd-Chiari Study Group of Ain Shams University Hospital. Calculation of the available PIs was performed using Child-Pugh and model for end-stage liver disease scores, BCS-specific PIs (Clichy, New Clichy and Rotterdam) for all patients, and BCS-TIPS PI only for patients who underwent TIPS. The overall one-year survival rate and the one-year shunt patency rate for TIPS were reported.
RESULTS The overall one-year survival rate was 69.6%, and the New Clichy PI revealed the best validity for its prediction at a cut-off value of 3.75, with sensitivity and specificity of 78% and 73.3%, respectively [area under receiver operating characteristic curve (AUC) = 0.806]. The one-year survival rate post-TIPS was 89.7%, and the BCS-TIPS score demonstrated validity for its prediction at a cut-off value of 3.92 (sensitivity and specificity were 71.4% and 64.5%, respectively) (AUC = 0.715). Logistic regression analysis revealed that the New Clichy PI (P = 0.030), high serum total bilirubin (P = 0.047) and low albumin (P < 0.001) were independent factors for predicting mortality within one year. The one-year shunt patency rate in TIPS was 80.2%, and none of the PIs exhibited significant validity for its prediction.
CONCLUSION The New Clichy score could independently predict the one-year survival in Egyptian BCS patients.
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Rathod K, Deshmukh H, Shukla A, Popat B, Pandey A, Gupte A, Gupta DK, Bhatia SJ. Endovascular treatment of Budd-Chiari syndrome: Single center experience. J Gastroenterol Hepatol 2017; 32:237-243. [PMID: 27218672 DOI: 10.1111/jgh.13456] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Percutaneous radiologic interventions are increasingly being used in management of Budd-Chiari syndrome (BCS). Minimal invasive approach has resulted in excellent long-term outcomes. We evaluated the treatment efficacy and safety of radiological intervention in patients with BCS. METHODS Between January 2008 and June 2014, 190 patients with BCS underwent endovascular procedures (hepatic vein, collateral vein or inferior vena cava [IVC] plasty with or without stenting, or transjugular intrahepatic portosystemic shunting [TIPSS]). Clinical features, biochemical profile, and stent patency were monitored pre-procedure and post-procedure, and for a median duration of 42 (12-88) months. RESULTS Of 190 patients (mean [SD] age = 26.9 [11.5] years; 102 men), imaging revealed hepatic vein obstruction in 147 patients, IVC obstruction in 40 patients, and concomitant hepatic vein and IVC obstruction in three patients. At presentation, the radiological interventions included hepatic vein plasty/stenting in 38 patients, collateral vein stenting in three patients, IVC plasty/stenting in 40 patients, both IVC and hepatic vein stenting in three patients, and TIPSS in 106 patients. Response was seen in 153 patients (80.5%). Repeat interventions were required in 19 patients (10.0%). Complications were noted in nine patients (4.7%). CONCLUSION Our study demonstrates that venous recanalization and TIPSS for BCS are safe and efficacious.
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Affiliation(s)
- Krantikumar Rathod
- Department of Radiology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Hemant Deshmukh
- Department of Radiology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Akash Shukla
- Department of Gastroenterology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Bhavesh Popat
- Department of Radiology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Ankur Pandey
- Department of Radiology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Amit Gupte
- Department of Gastroenterology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Deepak Kumar Gupta
- Department of Gastroenterology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Shobna J Bhatia
- Department of Gastroenterology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, India
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Abstract
Abdominal venous thrombosis is a rare form of venous thromboembolic disease in children. While mortality rates are low, a significant proportion of affected children may suffer long-term morbidity. Additionally, given the infrequency of these thrombi, there is lack of stringent research data and evidence-based treatment guidelines. Nonetheless, pediatric hematologists and other subspecialists are likely to encounter these problems in practice. This review is therefore intended to provide a useful guide on the clinical diagnosis and management of children with these rare forms of venous thromboembolic disease. Herein, we will thus appraise the current knowledge regarding major forms of abdominal venous thrombosis in children. The discussion will focus on the epidemiology, presentation, diagnosis, management, and outcomes of (1) inferior vena cava, (2) portal, (3) mesenteric, (4) hepatic, and (5) renal vein thrombosis.
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Affiliation(s)
- Riten Kumar
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States.,Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, United States
| | - Bryce A Kerlin
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States.,Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, United States.,Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
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Li WD, Yu HY, Qian AM, Rong JJ, Zhang YQ, Li XQ. Risk factors for and causes and treatment of recurrence of inferior vena cava type of Budd-Chiari syndrome after stenting in China: A retrospective analysis of a large cohort. Eur Radiol 2016; 27:1227-1237. [DOI: 10.1007/s00330-016-4482-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 06/07/2016] [Accepted: 06/21/2016] [Indexed: 12/18/2022]
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Shalimar, Kumar A, Kedia S, Sharma H, Gamanagatti SR, Gulati GS, Nayak B, Thakur B, Acharya SK. Hepatic venous outflow tract obstruction: treatment outcomes and development of a new prognostic score. Aliment Pharmacol Ther 2016; 43:1154-67. [PMID: 27060876 DOI: 10.1111/apt.13604] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 01/29/2016] [Accepted: 03/10/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Results of endovascular interventions in hepatic venous outflow tract obstruction (HVOTO) have been reported from limited studies. Treatment outcomes and prognostic scores need further validation. AIM To evaluate treatment outcomes and prognostic scores for hepatic venous outflow tract obstruction in an Indian population. METHODS Consecutive patients with hepatic venous outflow tract obstruction diagnosed at a tertiary centre were included. Technical success and clinical response after endovascular interventional therapy were documented. Predictors of survival were assessed with Cox-proportional model. A new score was derived from the factors significant on multivariate analysis and compared with Child-Turcotte-Pugh, model for end-stage liver disease (MELD), Rotterdam prognostic index (PI) and Budd-Chiari syndrome-transjugular intrahepatic portosystemic shunt ( BCS-TIPSS) PI. RESULTS Three hundred and thirty-four patients (56.6% males), median age 24 (3-62) years were included. Hepatic vein was the commonest site of block-isolated hepatic vonous block in 48%, combined hepatic venous-inferior vena cava block in 46%. Endovascular interventional therapy was performed in 233/334 (70%) with 90% technical success. Clinical response was complete in 166 (71.2%), partial in 58 (24.9%) and no response in nine (3.9%). Majority of cases with HV block did not require TIPSS and could be treated with angioplasty (with/without stenting). On Cox-proportional multivariate analysis, Child class C and response to intervention were independent predictors of outcome and used to derive the All India Institute of Medical Sciences (AIIMS) hepatic venous outflow tract obstruction score. The 5-year survival was 92% (95% CI, 81-97%) for score ≤3, 79% (95%CI, 63-88%) for score >3 and ≤4, and 39% (95% CI, 21-57%) for score >4. The performance of AIIMS hepatic venous outflow obstruction score was superior to other prognostic indices. CONCLUSIONS Advanced Child class and no response to intervention are associated with poor outcomes. The All India Institute of Medical Sciences hepatic venous outflow tract obstruction score predicts survival better than other prognostic scores.
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Affiliation(s)
- Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - A Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - S Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - H Sharma
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - S R Gamanagatti
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - G S Gulati
- Department of Cardiovascular and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - B Nayak
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - B Thakur
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - S K Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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EASL Clinical Practice Guidelines: Vascular diseases of the liver. J Hepatol 2016; 64:179-202. [PMID: 26516032 DOI: 10.1016/j.jhep.2015.07.040] [Citation(s) in RCA: 424] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 07/20/2015] [Indexed: 12/11/2022]
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De Stefano V, Qi X, Betti S, Rossi E. Splanchnic vein thrombosis and myeloproliferative neoplasms: molecular-driven diagnosis and long-term treatment. Thromb Haemost 2016; 115:240-9. [PMID: 26333846 DOI: 10.1160/th15-04-0326] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 07/15/2015] [Indexed: 02/07/2023]
Abstract
Splanchnic vein thrombosis (SVT) encompasses Budd-Chiari syndrome (BCS), extrahepatic portal vein obstruction (EHPVO), and mesenteric vein thrombosis. Philadelphia-negative myeloproliferative neoplasms (MPNS) are the leading systemic cause of non-cirrhotic and non-malignant SVT and are diagnosed in 40% of BCS patients and one-third of EHPVO patients. In SVT patients the molecular marker JAK2 V617F is detectable up to 87% of those with overt MPN and up to 26% of those without. In the latter, other MPN molecular markers, such as mutations in JAK2 exon 12, CALR and MPL genes, are extremely rare. Immediate anticoagulation with heparin is used to treat acute patients. Upon clinical deterioration, catheter-directed thrombolysis or a transjugular intrahepatic portosystemic shunt is used in conjunction with anticoagulation. Orthotopic liver transplantation is the only reliable option in BCS patients with a lack of a response to other treatments, without contraindication due to MPN. Long-term oral anticoagulation with vitamin K-antagonists (VKA) is recommended in all SVT patients with the MPN-related permanent prothrombotic state; the benefits of adding aspirin to VKA are uncertain. Cytoreduction is warranted in all SVT patients with an overt MPN, but its appropriateness is doubtful in those with molecular MPN without hypercythaemia.
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Affiliation(s)
- Valerio De Stefano
- Valerio De Stefano, MD, Institute of Hematology, Catholic University, Largo Gemelli 8, 00168 Rome, Italy, Tel.: +39 06 30154968, Fax: +39 06 30155209, E-mail:
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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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The Significance of Serum CA-125 Elevation in Chinese Patients with Primary Budd-Chiari Syndrome: A Multicenter Study. Gastroenterol Res Pract 2015; 2015:121060. [PMID: 26451141 PMCID: PMC4587407 DOI: 10.1155/2015/121060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 12/04/2014] [Indexed: 01/28/2023] Open
Abstract
Objective. To investigate the serum level of CA-125 and its corresponding clinical significance in Chinese patients with primary BCS. Methods. Serum CA-125 was measured in 243 patients with primary BCS receiving interventional treatment in the participating hospitals and in 120 healthy volunteers. The correlation between serum CA-125 levels and ascites volume, liver function, and prognosis was analyzed. Results. Serum CA-125 was significantly elevated in BCS patients compared to healthy volunteers (P < 0.001). Higher levels of CA-125 were found in BCS patients with abnormal hepatic function and low serum albumin levels and in patients with high volume of ascites compared to patients without these abnormalities. Serum CA-125 levels significantly correlated with ascites volume, serum level of alanine aminotransferase, aspartate aminotransferase, albumin, and Rotterdam BCS scores. The follow-up study indicated that the survival rate and asymptomatic survival rate after interventional treatment were lower in BCS patients with serum CA-125 > 175 U/mL (P < 0.05). Conclusion. Serum CA-125 was significantly higher in patients with primary BCS and had a positive correlation with the volume of ascites, severity of liver damage, and poor prognosis. Thus the serum CA-125 levels may be used to estimate the severity and prognosis of BCS in Chinese patients.
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Gao X, Gui E, Lu Z, Ning X, Zu M, Zhang P, Sun G. Risk factors of recurrence among 471 Chinese patients with Budd-Chiari syndrome. Clin Res Hepatol Gastroenterol 2015; 39:620-6. [PMID: 25656980 DOI: 10.1016/j.clinre.2014.12.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 12/11/2014] [Accepted: 12/31/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Budd-Chiari syndrome (BCS) is a rare form of vascular disease. There is limited literature available regarding the prognosis of this disease. The aim of this study was to characterize the cumulative recurrence rates and to investigate the risk factors of recurrence in Chinese patients with BCS. METHODS Four hundred and seventy-one patients were diagnosed as having BCS in the Affiliated Hospital of Xuzhou Medical College (Jiangsu, China) between January 2008 and December 2012. Follow-ups were conducted by phone calls or correspondence. Cumulative recurrence rates were assessed with the Kaplan-Meier curves. Independent risk factors of recurrence were calculated with the Cox's proportional hazards regression model. RESULTS Four hundred and twenty-five patients with BCS had complete follow-up data, in which 24 patients died, 98 patients had recurrence, with the median duration of follow-up being 19.3 months (range 3 to 61.4). The cumulative 1-, 2-, 3-, 4- and 5-year recurrence rates were 12%, 22%, 27%, 35% and 42%, respectively. Univariable and multivariable Cox's proportional hazards regression models showed that the risk factors of recurrence include: age ≤ 30 years (HR=2.261, 95% CI: 1.412-3.621), differentiated typology (hepatic vein type: HR=1.885, 95% CI: 1.045-3.402; combined type: HR=2.088, 95% CI: 1.233-3.536), elevated lactate dehydrogenase (LDH) levels (HR=1.125, 95% CI: 1.101-1.212) and the Child-Pugh class B/C (B: HR=1.758, 95% CI: 1.057-2.926; C: HR=2.626, 95% CI: 1.396-4.940). CONCLUSIONS Regardless of thrombophilia and haematological causes, exceptionally found in Chinese patients, the 5-year recurrence rate of BCS was as high as 42%. Age ≤ 30 years, hepatic vein type, combined type, increased LDH levels and the Child-Pugh class B/C were independent predictors of BCS recurrence.
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Affiliation(s)
- Xiuyin Gao
- School of Public Health, Xuzhou Medical College, Xuzhou, Jiangsu 221004, China.
| | - Er Gui
- School of Public Health, Xuzhou Medical College, Xuzhou, Jiangsu 221004, China; Department of Medical Records, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, China.
| | - Zhaojun Lu
- School of Public Health, Xuzhou Medical College, Xuzhou, Jiangsu 221004, China.
| | - Xin Ning
- School of Public Health, Xuzhou Medical College, Xuzhou, Jiangsu 221004, China.
| | - Maoheng Zu
- Department of Interventional Radiology, Affiliated Hospital of Xuzhou Medical College, Xuzhou, Jiangsu 221002, China.
| | - Peijin Zhang
- School of Public Health, Xuzhou Medical College, Xuzhou, Jiangsu 221004, China.
| | - Guixiang Sun
- School of Public Health, Xuzhou Medical College, Xuzhou, Jiangsu 221004, China.
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Qi X, Ren W, Wang Y, Guo X, Fan D. Survival and prognostic indicators of Budd-Chiari syndrome: a systematic review of 79 studies. Expert Rev Gastroenterol Hepatol 2015; 9:865-75. [PMID: 25754880 DOI: 10.1586/17474124.2015.1024224] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This paper aimed to systematically review the survival of Budd-Chiari syndrome and to identify the most robust prognostic predictors. Overall, 79 studies were included. According to the treatment modalities, the median 1-, 5- and 10-year survival rate was 93, 83 and 73% after interventional radiological treatment; 81, 75 and 72.5% after surgery other than liver transplantation; 82.5, 70.2 and 66.5% after liver transplantation and 68.1, 44.4% and unavailable after medical therapy alone. According to the publication years, the median 1-, 5- and 10-year survival rate was 68.6, 44.4% and unavailable before 1990; 75.1, 69.5 and 57% during the year 1991-1995; 77, 69.6 and 65.6% during the year 1996-2000; 86.5, 74 and 63.5% during the year 2001-2005 and 90, 82.5 and 72% after 2006. Bilirubin, creatinine and ascites were more frequently identified as significant prognostic factors in univariate analyses. But their statistical significance was less frequently achieved in multivariate analyses.
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Affiliation(s)
- Xingshun Qi
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, 110840, China
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Afredj N, Guessab N, Nani A, Faraoun SA, Ouled Cheikh I, Kerbouche R, Hannoun D, Amir ZC, Ait Kaci H, Bentabak K, Plessier A, Valla DC, Cazals-Hatem V, Denninger MH, Boucekkine T, Debzi N. Aetiological factors of Budd-Chiari syndrome in Algeria. World J Hepatol 2015; 7:903-909. [PMID: 25937867 PMCID: PMC4411532 DOI: 10.4254/wjh.v7.i6.903] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 08/29/2014] [Accepted: 03/05/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the clinical presentation of Budd-Chiari syndrome (BCS) and identify the aetiologies of this disease in Algeria.
METHODS: Patients with BCS, hospitalised in our unit from January 2004 until June 2010 were included and the aetiological factors were assessed. Patients presenting a BCS in the setting of advanced-stage cirrhosis or a liver transplantation were excluded from the study. The diagnosis was established when an obstruction of hepatic venous outflow (thrombosis, stenosis or compression) was demonstrated. We diagnosed myeloproliferative disease (MPD) by bone marrow biopsy and V617F JAK2 mutation. Anti-phospholipid syndrome (APLS) was detected by the presence of anticardiolipin antibodies, anti-β2 glycoprotein antibodies and Lupus anticoagulant. We also detected paroxysmal nocturnal haemoglobinuria (PNH) by flow cytometry. Celiac disease and Behçet disease were systematically investigated in our patients. Hereditary anticoagulant protein deficiencies were also assessed. We tested our patients for the G20210A mutation at Beaujon Hospital. Imaging procedures were performed to determine a local cause of BCS, such as a hydatid cyst or a liver tumour.
RESULTS: One hundred and fifteen patients were included. Mean follow up: 32.12 mo. Mean age: 34.41 years, M/F = 0.64. Chronic presentation was frequent: 63.5%. The revealing symptoms for the BCS were ascites (74.8%) and abdominal pain (42.6%). The most common site of thrombosis was the hepatic veins (72.2%). Involvement of the inferior vena cava alone was observed in 3 patients. According to the radiological investigations, BCS was primary in 94.7% of the cases (n = 109) and secondary in 5.2% (n = 6). An aetiology was identified in 77.4% of the patients (n = 89); it was multifactorial in 27% (n = 31). The predominant aetiology of BCS in our patients was a myeloproliferative disease, observed in 34.6% of cases. APLS was found in 21.7% and celiac disease in 11.4%. Other acquired conditions were: PNH (n = 4), systemic disease (n = 6) and inflammatory bowel disease (n = 5). Anticoagulant protein deficiency was diagnosed in 28% of the patients (n = 18), dominated by protein C deficiency (n = 13). Secondary BCS was caused by a compressing hydatic cyst (n = 5) and hepatocellular carcinoma (n = 1).
CONCLUSION: The main aetiologic factor of BCS in Algeria is MPD. The frequency of celiac disease justifies its consideration when BCS is diagnosed in our region.
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Akamatsu N, Sugawara Y, Kokudo N. Budd-Chiari syndrome and liver transplantation. Intractable Rare Dis Res 2015; 4:24-32. [PMID: 25674385 PMCID: PMC4322592 DOI: 10.5582/irdr.2014.01031] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 12/23/2014] [Accepted: 12/25/2015] [Indexed: 12/13/2022] Open
Abstract
Budd-Chiari syndrome involves obstruction of hepatic venous outflow tracts at various levels from small hepatic veins to the inferior vena cava and is the result of thrombosis or its fibrous sequelae. There is a conspicuous difference in its etiology in the West and the East. Myeloproliferative disease predominates in the West and obstruction of the vena cava predominates in the East. The clinical presentation and clinical manifestations are so varied that it should be suspected in any patient with acute or chronic liver dysfunction. It should be treated with step-wise management. First-line therapy should be anticoagulation with medical treatment of the underlying illness, and interventional revascularization and TIPS are indicated in the event of a lack of response to medical therapy. Liver transplantation may be indicated as a rescue treatment or for fulminant cases with promising results. This step-by-step strategy has achieved a 5-year transplant-free survival rate of 70% and a 5-year overall survival rate of 90%. Living donor liver transplantation can also be used for patients with Budd-Chiari syndrome if deceased donor livers are scarce, but it requires a difficult procedure particularly with regard to venous outflow reconstruction.
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Affiliation(s)
- Nobuhisa Akamatsu
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasuhiko Sugawara
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Address correspondence to: Dr. Yasuhiko Sugawara, Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. E-mail:
| | - Norihiro Kokudo
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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