Acute Budd-Chiari syndrome: treatment with transjugular intrahepatic portosystemic shunt

Interventional radiology in the management of Budd Chiari syndrome

Budd Chiari syndrome is an uncommon condition in the Western world but interventional radiology can contribute significantly to the management of the majority of patients. This review examines the role and technique of interventions including hepatic vein dilatation and stent insertion as well as thrombolysis and TIPS. Liver transplantation and surgical shunt surgery are discussed in relation to radiological interventions. With appropriate selection and technique, surgery is only required in a minority of patients.

Transjugular intrahepatic portosystemic shunt in the management of Budd Chiari syndrome

Budd Chiari syndrome presents with a wide range of severity and duration of symptoms. Transjugular intrahepatic portosystemic shunt has been used to treat selected Budd Chiari syndrome patients for several years. The technique of transjugular intrahepatic portosystemic shunt may be more challenging than in cirrhosis because of hepatic vein occlusion. Covered transjugular intrahepatic portosystemic shunt stents have reduced the requirement for follow-up interventions. Transjugular intrahepatic portosystemic shunt has been a successful bridge to liver transplant for Budd Chiari syndrome but is the definitive treatment in many cases. Patient selection is important to determine who will benefit from transjugular intrahepatic portosystemic shunt or other treatments such as hepatic vein recanalization or liver transplant.

Transjugular Intrahepatic Portosystemic Shunt Creation in Budd-Chiari Syndrome: Percutaneous Ultrasound-Guided Direct Simultaneous Puncture of the Portal Vein and Vena Cava

Budd-Chiari syndrome (BCS) is an uncommon disorder that can be life-threatening, depending on the degree of hepatic venous outflow obstruction. Transjugular intrahepatic portosystemic shunt (TIPS) provides decompression of the congested liver but the hepatic vein obstruction makes the procedure more difficult. We describe a modified method that involved a single percutaneous puncture of the portal vein and inferior vena cava simultaneously for TIPS creation in a patient with BCS.

Transjugular intrahepatic portosystemic shunts: experience in the oncology setting

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) placement has emerged as an effective and minimally invasive method of treating portal hypertension and its associated complications. To the authors' knowledge there is limited documentation of its use for percutaneous shunting in patients with hepatic and extrahepatic malignancies. The current study reports the authors' experience with TIPS in the oncology setting.

METHODS

Thirty-eight patients with cancer underwent TIPS procedures. Nineteen patients had a history of hepatic malignancy. All medical records and imaging studies were reviewed retrospectively. The indication for TIPS, the presence of malignancy, procedural details, complications, survival, and treatment success were assessed.

RESULTS

Primary technical success was accomplished in 37 of 38 patients (97%) without technical procedure-related complications. Hepatic encephalopathy occurred in 15 of 34 patients (44%), with 3 patients requiring shunt reduction. Premature shunt occlusion (< 30 days) occurred in 3 patients (8%). Recurrent hemorrhage occurred in 1 of 19 patients (5%), and ascites and hepatic hydrothorax resolved or improved subjectively in 9 of 12 patients (75%). Shunts traversed malignancy in 9 patients, and varying degrees of portal compromise were encountered in 12 patients (32%). The overall 30-day and 90-day survival rates were 84% and 60%, respectively. There was a statistically significant difference in 90-day survival rates for patients who had ascites and hepatic hydrothorax indications (27%) compared with patients who had variceal and portal gastropathy indications (84%; P = 0.0075). In addition, the 90-day survival rate was significantly lower in patients who had primary hepatic malignancies (36%) compared with the remainder of the study population (74%; P = 0.0077), and it was significantly lower in patients who had model for end-stage liver disease (MELD) scores > or = 12 (P = 0.0020).

CONCLUSIONS

TIPS was performed safely for patients with cancer without increasing rates of procedure-related complications. However, some patients subgroups, such at those with malignancy and ascites, primary hepatic malignancy, or MELD scores > or = 12, had the lowest 90-day survival rates.

The Budd-Chiari syndrome: outcome after treatment with the transjugular intrahepatic portosystemic shunt

BACKGROUND

The role of portosystemic shunting in the treatment of the Budd-Chiari syndrome is still under debate. Medical therapy and liver transplantation are alternative treatments. The aim of this study was to determine the outcome of a transjugular intrahepatic portosystemic shunt implantation.

METHODS

Thirty-five patients with severe Budd-Chiari syndrome and a Child-Pugh score of 9.2+/-1.9, who were not responsive to medical therapy, were elected for the transjugular shunt treatment, which was successfully accomplished in 33. Eleven patients had a fulminant/acute (history <2 months); 13, a subacute (<6 months); and 11, a chronic course of the disease. The shunt was established by using conventional self-expandable stents in 25 patients and polytetrafluoroethylene-covered stents in 8 patients. The mean follow-up was 37+/-29 months.

RESULTS

The shunt reduced the portosystemic pressure gradient from 29+/-7 to 10+/-4 mm Hg and improved the portal flow velocity from 9.2+/-11 to 51+/-17 cm/s. Clinical symptoms as well as the biochemical test results improved significantly during 4 weeks after shunt treatment. Three patients died and 2 received liver transplants. The cumulative 1- and 5-year survival rate without transplantation in all patients was 93% and 74%, respectively, and in patients with fulminant/acute disease 91% and 91% respectively (no deaths in this time period). On the average, 1.4+/-2.2 revisions per patient were needed during the mean follow-up of 3 years with a 1-year probability of 47%.

CONCLUSIONS

The transjugular shunt provides an excellent outcome in patients with severe fulminant/acute, subacute, and chronic Budd-Chiari syndrome. It may be regarded as a treatment for the acute and long-term management of these patients.

Transjugular intrahepatic portosystemic shunt by direct transcaval approach in patients with acute and hyperacute Budd-Chiari syndrome

When Budd-Chiari syndrome (BCS) is due to occlusion of all three hepatic veins, the standard transjugular intrahepatic portosystemic shunt (TIPS) technique can be extremely laborious. A feasible alternative is to use the direct transcaval approach, by which a shunt can be created directly between the intrahepatic inferior vena cava and the portal vein. We describe two patients (one with acute BCS and one with hyperacute BCS) who were successfully managed with this modified technique. Both patients recovered; one of them underwent elective liver transplantation 15 months after the procedure, whereas the other still had good hepatic function and a patent stent 24 months after the procedure. We conclude that, in selected patients with acute and hyperacute BCS, placement of a TIPS by the direct transcaval approach is a rapid and effective emergency procedure, which can either be curative or function as a bridge for elective liver transplantation.

TIPS is a useful long-term derivative therapy for patients with Budd-Chiari syndrome uncontrolled by medical therapy

Patients with Budd-Chiari syndrome (BCS) may require treatment with portal decompressive surgery or liver transplantation. Transjugular intrahepatic portosystemic shunt (TIPS) represents a new treatment alternative, but its long-term effect on BCS outcome has not been evaluated. Twenty-one patients with BCS consecutively admitted to our unit were evaluated. The mean follow-up was 4 +/- 3 years. Seven patients had nonprogressive forms and were successfully controlled with medical therapy; 1 case, with a short-length hepatic vein stenosis was successfully treated by angioplasty. All 8 patients are alive and asymptomatic. The remaining 13 patients, had a TIPS because of clinical deterioration (in one of them, because early TIPS thrombosis a successful side-to-side portacaval shunt [SSPCS] was performed) followed by an improvement in clinical condition. However, a patient with fulminant liver failure before TIPS insertion, died 4 months later and another patient with cirrhosis at diagnosis had liver transplantation 2 years later. The remaining 11 patients are alive and free of ascites. In 3 of these patients TIPS is patent after 3, 6, and 12 months. The remaining 8 patients developed late TIPS dysfunction. In two of these cases, after angioplasty and restenting, TIPS is patent after a follow-up of 9 and 80 months. In 5 other patients, recurring TIPS occlusion was not further corrected because no signs of portal hypertension were present. In conclusion, in patients with BCS uncontrolled with medical therapy, TIPS is a highly effective technique that is associated with long-term survival.

[TIPS - Transjugular intrahepatic portosystemic shunt. A review]

At the present time several therapeutic options are used for the treatment of bleeding esophageal varices in patients with portal hypertension. We will review the main medical publications on transjugular intrahepatic portosystemic shunt (TIPS), a procedure seldom used among us. TIPS works as a portocaval side-to-side shunt and decreases the risk of esophageal bleeding through lowering of the portal system pressure and a decrease of the portal hepatic pressure gradient. TIPS consists in the percutaneous insertion, through the internal jugular vein, of a metallic stent under fluoroscopic control in the hepatic parenchyma creating a true porta caval communication. There are several studies demonstrating the efficacy of TIPS, although only a few of them are randomized and control-matched to allow us to conclude that this procedure is safe, efficient and with a good cost benefit ratio. In this review, we search for the analysis of the TIPS utilization, its techniques, its major indications and complications. TIPS has been used in cases of gastroesophageal bleeding that has failed with pharmacologic or endoscopic treatment in patients Child-Pugh B and C. It can be used also as a bridge for liver transplantation. Others indications for TIPS are uncontrolled ascites, hepatic renal syndrome, and hepatic hydrothorax. The main early complications of TIPS using are related to the insertion site and hepatic encephalopathy and the stent occlusion is the chief late complication.

Treating Budd-Chiari Syndrome: making rational choices from a myriad of options

Budd-Chiari syndrome represents a spectrum of disorders characterized by obstruction to hepatic venous drainage. Originally described as an "obliterating endophlebitis of the hepatic veins," this condition has come to refer to the manifestations of hepatic venous outflow obstruction anywhere above the level of the hepatic venulae regardless of the etiology, position, or severity of the obstruction or of the clinical course. Depending on the nature and anatomy of the obstruction, the disease presents acutely, with a rapidly progressive course, or insidiously, with gradual development of symptoms. The optimal management strategy for a given patient with Budd-Chiari syndrome depends on the anatomy of the obstruction, its physiologic consequences, and the natural history of the specific lesion. The specific treatments available and their use in the treatment of Budd-Chiari syndrome are reviewed.

Successful treatment of chronic Budd-Chiari syndrome with a transjugular intrahepatic portosystemic shunt

Budd-Chiari syndrome is characterized by obstruction of the hepatic venous outflow tract. Therapeutic options for chronic Budd-Chiari syndrome are limited. We report the case of a 28-year-old woman who presented with recurrence of chronic Budd-Chiari syndrome with total obstruction of all major hepatic veins. Due to worsening liver function over the course of 1 year, she had to be listed for liver transplantation. Because of therapy-refractory ascites, declining renal function and severe esophageal varices, a transjugular intrahepatic portosystemic shunt (TIPS) was placed, planned as a bridge to transplantation. Following TIPS, a marked recovery of liver function could be observed, accompanied by disappearance of ascites, esophageal varices, and normalization of kidney function. Therefore, the patient could be removed from the waiting list for liver transplantation. This case demonstrates for the first time that the use of TIPS in chronic Budd-Chiari syndrome may result in marked recovery of liver function.

Transjugular intrahepatic portosystemic shunts (TIPS): a decade later

Since the introduction of transjugular intrahepatic portosystemic shunt (TIPS) 10 years ago, it has been used increasingly in the management of portal hypertension and its complications. TIPS is now considered the procedure of choice for management of refractory variceal bleeding. Its role in the management of refractory ascites, hepatic hydrothorax, hepatorenal syndrome, and hepatopulmonary syndrome still awaits further prospective studies. The two main complications of TIPS are hepatic encephalopathy and shunt malfunction. Generally, TIPS stenosis or occlusion is a major drawback requiring routine surveillance of TIPS with doppler ultrasound. Venography with balloon dilation of the stent or placement of serial or parallel stents may be required in some cases. Promising modalities of preventing TIPS malfunction (e.g., brachy-therapy, covered stents, or anti-platelet derived growth factor) are currently being investigated.