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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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2
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Herren JL, Shah KY, Patel M, Niemeyer MM. Intravascular Ultrasound for Transjugular Intrahepatic Portosystemic Shunt Creation: "TIPS" and Tricks. Semin Intervent Radiol 2023; 40:212-220. [PMID: 37333747 PMCID: PMC10275661 DOI: 10.1055/s-0043-1768609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Affiliation(s)
- Josi L Herren
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Ketan Y Shah
- Department of Radiology, MD Anderson Cancer Center, Houston, Texas
| | - Meet Patel
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Matthew M Niemeyer
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
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3
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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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Mukhiya G, Jiao D, Han X, Zhou X, Pokhrel G. Survival and clinical success of endovascular intervention in patients with Budd-Chiari syndrome: A systematic review. J Clin Imaging Sci 2023; 13:5. [PMID: 36751561 PMCID: PMC9899460 DOI: 10.25259/jcis_130_2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/14/2023] [Indexed: 01/26/2023] Open
Abstract
Budd-Chiari syndrome is a complex clinical disorder of hepatic venous outflow obstruction, originating from the accessory hepatic vein (HV), large HV, and suprahepatic inferior vena cava (IVC). This disorder includes both HV and IVC obstructions and hepatopathy. This study aimed to conduct a systematic review of the survival rate and clinical success of different types of endovascular treatments for Budd-Chiari syndrome (BCS). All participant studies were retrieved from four databases and selected according to the eligibility criteria for systematic review of patients with BCS. The survival rate, clinical success of endovascular treatments in BCS, and survival rates at 1 and 5 years of publication year were calculated accordingly. A total of 3398 patients underwent an endovascular operation; among them, 93.6% showed clinical improvement after initial endovascular treatment. The median clinical success rates for recanalization, transjugular intrahepatic portosystemic shunt (TIPS), and combined procedures were 51%, 17.50%, and 52.50%, respectively. The median survival rates at 1 and 5 years were 51% and 51% for recanalization, 17.50% and 16% for TIPS, and 52.50% and 49.50% for combined treatment, respectively. Based on the year of publication, the median survival rates at 1 and 5 years were 23.50% and 22.50% before 2000, 41% and 41% in 2000‒2005, 35% and 35% in 2006‒2010, 51% and 48.50% in 2010‒2015, and 56% and 55.50% after 2015, respectively. Our findings indicate that the median survival rate at 1 and 5 years of recanalization treatment is higher than that of TIPS treatment, and recanalization provides better clinical improvement. The publication year findings strongly suggest progressive improvements in interventional endovascular therapy for BCS. Thus, interventional therapy restoring the physiologic hepatic venous outflow of the liver can be considered as the treatment of choice for patients with BCS which is a physiological modification procedure.
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Affiliation(s)
- Gauri Mukhiya
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dechao Jiao
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xinwei Han
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Corresponding author: Xinwei Han, Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Xueliang Zhou
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Gaurab Pokhrel
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Cheng Z, Ju J, Zhu Q, Deng M, Zhang H. Intrahepatic hematoma secondary to transjugular intrahepatic portosystemic stent-shunt procedure: Case report and literature review. Medicine (Baltimore) 2022; 101:e31753. [PMID: 36397433 PMCID: PMC9666193 DOI: 10.1097/md.0000000000031753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
RATIONALE Transjugular intrahepatic portosystemic stent-shunt (TIPSS) is a minimally invasive procedure used for the treatment of portal hypertension. Intrahepatic hematoma is the rare complication caused by hepatic arterial injuries from TIPSS procedure. PATIENT CONCERNS This case report illustrated a 77-year-old man with hepatitis B virus-induced cirrhosis who underwent TIPSS. DIAGNOSES The patient suffered from intrahepatic hematoma and hepatic pseudoaneurysm because of the hepatic artery injury after TIPSS. INTERVENTIONS The hepatic artery laceration began at the level of the branch of the left hepatic artery was embolized. OUTCOMES The acute intrahepatic hematoma and hepatic pseudoaneurysm of the patient were cured. CONCLUSION In this report, we describe a cirrhosis patient with a large intrahepatic hematoma secondary to TIPSS, and a literature review is also presented. The intrahepatic hematoma and hepatic pseudoaneurysm should be paid more attention after TIPSS while early-stage prevention should be carried out.
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Affiliation(s)
- Ziyao Cheng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Jiayu Ju
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Qingliang Zhu
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Mingming Deng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
| | - Hailong Zhang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, China
- * Correspondence: Hailong Zhang, The Affiliated Hospital of Southwest Medical University, No. 25, Taiping Street, Luzhou, Sichuan Province 646000, China (e-mail: )
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6
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Budd–Chiari Syndrome Management: Controversies and Open Issues. Diagnostics (Basel) 2022; 12:diagnostics12112670. [DOI: 10.3390/diagnostics12112670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/26/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
Budd–Chiari Syndrome (BCS) is due to thrombosis of hepatic veins (HVs), inferior vena cava (IVC) or both, leading to impaired hepatic venous outflow [...]
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Giri S, Kale A, Shukla A. Efficacy and Safety of Transjugular Intrahepatic Portosystemic Shunt Creation for Budd-Chiari Syndrome: A Systematic Review and Meta-Analysis. J Vasc Interv Radiol 2022; 33:1301-1312.e13. [PMID: 35940361 DOI: 10.1016/j.jvir.2022.07.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 07/04/2022] [Accepted: 07/22/2022] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To assess the critical role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of Budd-Chiari syndrome (BCS), as the data with respect to the safety and outcome of TIPS in patients with BCS are scarce because of the rarity of the disease. MATERIALS AND METHODS A comprehensive search of literature of various databases from 2000 to October 2021 was conducted for studies evaluating the outcome of TIPS in patients with BCS. The primary outcomes of the analysis were technical and clinical success, adverse events and mortality associated with TIPS, dysfunction of TIPS, need for TIPS revision, need for liver transplantation (LT), and 1-year survival. RESULTS A total of 33 studies (1,395 patients) were included in this meta-analysis. The pooled rates and 95% confidence intervals of various outcomes were 98.6% (97.6-99.7) for technical success, 90.3% (86.0-94.6) for clinical success, 10.0% (6.5-13.6) for major adverse events, 0.5% (0.2-1.0) for TIPS-related mortality, 11.6% (7.8-15.4) for post-TIPS hepatic encephalopathy (HE), 40.1% (32.5-47.7) for TIPS dysfunction, 8.6% (4.9-12.4) for the need for TIPS revision, 4.5% (2.8-6.2) for the need for LT, and 94.6% (93.1-96.1) for 1-year survival. Publication bias was seen with all outcomes except for post-TIPS HE, TIPS dysfunction, and the need for LT. CONCLUSIONS The existing literature supports the feasibility, safety, and efficacy of TIPS in the treatment of BCS. Deciding the optimal timing of TIPS in BCS needs further studies.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India.
| | - Aditya Kale
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
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8
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Evaluation of outcome from endovascular therapy for Budd-Chiari syndrome: a systematic review and meta-analysis. Sci Rep 2022; 12:16166. [PMID: 36171454 PMCID: PMC9519873 DOI: 10.1038/s41598-022-20399-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 09/13/2022] [Indexed: 11/19/2022] Open
Abstract
This study was performed to evaluate the outcome of endovascular intervention therapy for Budd-Chiari syndrome (BCS) and compare recanalization, transjugular intrahepatic portosystemic shunt (TIPS)/direct intrahepatic portosystemic shunt (DIPS), and combined procedure treatment. For the meta-analysis, 71 studies were identified by searching four databases. The individual studies’ samples were used to calculate a confidence interval (CI 95%), and data were pooled using a fixed-effect model and random effect model. The pooled measure and an equal-weighted average rate were calculated in all participant studies. Heterogeneity between the studies was assessed with I2, and T2 tests, and publication bias was estimated using Egger’s regression test. A total of 4,407 BCS patients had undergone an endovascular intervention procedure. The pooled results were 98.9% (95% CI 97.8‒98.9%) for a technical success operation, and 96.9% (95% CI 94.9‒98.9%) for a clinical success operation. The re-intervention rate after the initial intervention procedure was 18.9% (95% CI 14.7‒22.9%), and the survival rates at 1 and 5 years after the initial intervention procedure were 98.9% (95% CI 96.8‒98.9%) and 94.9% (95% CI 92.9‒96.9%), respectively. Patients receiving recanalization treatment (98%) had a better prognosis than those with a combined procedure (95.6%) and TIPS/DIPS treatment (94.5%). The systematic review and meta-analysis further solidify the role of endovascular intervention treatment in BCS as safe and effective. It maintains high technical and clinical success and long-term survival rates. The recanalization treatment had a better prognosis and outcome than the combined procedures and TIPS/DIPS treatment.
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9
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Mancuso A. Timing of treatment and outcome of Budd-Chiari syndrome. Br J Radiol 2022; 95:20210284. [PMID: 34232733 PMCID: PMC10162071 DOI: 10.1259/bjr.20210284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/10/2021] [Indexed: 11/05/2022] Open
Affiliation(s)
- Andrea Mancuso
- Centro di Riferimento Regionale Malattie Rare, Sindrome di Budd-Chiari e Teleangectasia Emorragica Ereditaria, Medicina Interna 1, ARNAS Civico - Di Cristina -Benfratelli, Palermo, Italy
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10
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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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Zanetto A, Barbiero G, Battistel M, Sciarrone SS, Shalaby S, Pellone M, Battistella S, Gambato M, Germani G, Russo FP, Burra P, Senzolo M. Management of portal hypertension severe complications. Minerva Gastroenterol (Torino) 2020; 67:26-37. [PMID: 33140623 DOI: 10.23736/s2724-5985.20.02784-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Portal hypertension is a clinical syndrome characterized by an increase in the portal pressure gradient, defined as the gradient between the portal vein at the site downstream of the site of obstruction and the inferior vena cava. The most frequent cause of portal hypertension is cirrhosis. In patients with cirrhosis, portal hypertension is the main driver of cirrhosis progression and development of hepatic decompensation (ascites, variceal hemorrhage and hepatic encephalopathy), which defines the transition from compensated to decompensated stage. In decompensated patients, treatments aim at lowering the risk of death by preventing further decompensation and/or development of acute-on-chronic liver failure. Decompensated patients often pose a complex challenge which typically requires a multidisciplinary approach. The aims of the present review were to discuss the current knowledge regarding interventional treatments for patients with portal hypertension complications as well as to highlight useful information to aid hepatologists in their clinical practice. Specifically, we discussed the indications and contraindications of transjugular intra-hepatic portosystemic shunt and for the treatment of gastro-esophageal variceal hemorrhage in patients with decompensated cirrhosis (first section); we reviewed the use of interventional treatments in patients with hepatic vein obstruction (Budd-Chiari Syndrome) and in those with portal vein thrombosis (second section); and we briefly comment on the most frequent applications of selective splenic embolization in patients with and without underlying cirrhosis (third section).
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Affiliation(s)
- Alberto Zanetto
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Giulio Barbiero
- Department of Medicine, Institute of Radiology, University Hospital of Padua, Padua, Italy
| | - Michele Battistel
- Department of Medicine, Institute of Radiology, University Hospital of Padua, Padua, Italy
| | - Salvatore S Sciarrone
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Sarah Shalaby
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Monica Pellone
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Sara Battistella
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Martina Gambato
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Giacomo Germani
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Francesco P Russo
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Patrizia Burra
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Marco Senzolo
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy -
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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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13
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Shukla A, Jain A. Association of acute-on-chronic liver failure with vascular liver diseases. Hepatol Int 2019; 13:399-402. [PMID: 31172418 DOI: 10.1007/s12072-019-09958-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 05/24/2019] [Indexed: 01/20/2023]
Affiliation(s)
- Akash Shukla
- Department of Gastroenterology, LTMMC & LTMGH, Sion, Mumbai, India.
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14
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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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15
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Sonavane AD, Amarapurkar DN, Rathod KR, Punamiya SJ. Long Term Survival of Patients Undergoing TIPS in Budd-Chiari Syndrome. J Clin Exp Hepatol 2019; 9:56-61. [PMID: 30765940 PMCID: PMC6363956 DOI: 10.1016/j.jceh.2018.02.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 02/20/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There has been significant improvement in understanding the etiology and management of Budd-Chiari Syndrome (BCS). Patients with chronic or acute-on-chronic BCS need radiological interventions in the form of angioplasty, hepatic vein/inferior vena cava stenting or Transjugular Intrahepatic Portosystemic Shunt (TIPS). Data regarding the long term follow up of patients undergoing TIPS is limited. We thus prospectively followed-up BCS patients who underwent TIPS at our center. METHODS This study included 42 patients with BCS who underwent TIPS with a covered stent between 2004 and 2014. We analyzed the etiology, symptoms, severity, laboratory parameters and imaging pre and post TIPS. All patients underwent surveillance for hepatocellular carcinoma. RESULTS Patients demographics included 26 males and 16 females with a mean age of 40.5 years (19-68 years). The mean Model for End-Stage Liver Disease score of the entire cohort was 15.38 (range: 9-25). Thirty-four patients were grouped into Rotterdam Class 2 and remaining into Class 3. There was significant improvement in ascites, gastrointestinal bleed, renal function and transaminase levels post TIPS. There were 11 deaths over the follow-up period - 4 within one month, 2 within six months and the rest after 3 years following TIPS. Median duration from clinical presentation to TIPS was 2.1 weeks and median survival till follow-up was 45.5 months (0-130 months). 33/42 patients underwent TIPS prior to 2013, and their median survival till follow-up was 55 months. Six out of eleven deaths that occurred within six months post-TIPS were before 2006; when the technique of TIPS creation was evolving. The cumulative 1 year, 5 years and 10 years OLT-free survival was 86%, 81% and 76%, respectively. Two patients underwent a liver transplant at 4 and 7 years after TIPS. CONCLUSION Our results validate the role of TIPS in the management of patients with BCS. With the accessibility of TIPS, the requirement for liver transplantation has become rare.
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Key Words
- AT III, Antithrombin III
- BCS, Budd-Chiari Syndrome
- Budd Chiari syndrome
- CT, Computerized Tomography
- CTP, Child-Turcotte-Pugh
- HV, Hepatic Vein
- INR, International Normalized Ratio
- IVC, Inferior Vena Cava
- JAK-2, Janus Kinase 2
- MELD, Model for End-Stage Liver Disease
- MRI, Magnetic Resonance Imaging
- MTHFR, Methylene Tetrahydrofolate Reductase
- OLT, Orthotopic Liver Transplantation
- SD, Standard Deviation
- TIPS, Transjugular Intrahepatic Portosystemic Shunt
- TIPS-BCS PI score, BCS-TIPS Prognostic Index score
- long term survival
- orthotopic liver transplantation free survival
- transjugular intrahepatic portosystemic shunt
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Affiliation(s)
- Amey D. Sonavane
- Post-graduate Resident, Department of Gastroenterology, Bombay Hospital and Institute of Medical Sciences, Mumbai, India,Address for correspondence: Amey D. Sonavane, C-1804, Azziano, Rustomjee Urbania, Majiwada, Thane (West), Maharashtra 400601, India.
| | - Deepak N. Amarapurkar
- Consultant Gastroenterologist, Department of Gastroenterology, Bombay Hospital and Institute of Medical Sciences, Mumbai, India
| | - Krantikumar R. Rathod
- Consultant, Department of Vascular and Interventional Radiology, Bombay Hospital and Institute of Medical Sciences, Mumbai, India
| | - Sundeep J. Punamiya
- Consultant, Department of Vascular and Interventional Radiology, Tan Tock Seng Hospital, Singapore
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Transjugular intrahepatic portosystemic shunt as a bridge to liver transplant: Current state and future directions. Transplant Rev (Orlando) 2018; 33:64-71. [PMID: 30477811 DOI: 10.1016/j.trre.2018.10.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/27/2018] [Accepted: 10/29/2018] [Indexed: 02/07/2023]
Abstract
Liver transplantation is one of the mainstays of treatment for liver failure due to severe chronic liver disease. Bridging therapies, such as placement of a transjugular intrahepatic portosystemic shunt (TIPS), are frequently employed to control complications of portal hypertension such as ascites, hydrothorax, and variceal bleeding, and thereby reduce morbidity in patients awaiting transplant. There is no significant difference seen in either graft survival or patient survival between those receiving TIPS pre-transplant and those who do not, although those receiving TIPS placement on average have a longer waiting time on the transplant waitlist. Locoregional therapies, such as thermal ablation or chemoembolization, can be efficacious in patients with HCC and pre-existing TIPS; however there is a risk for increased adverse events in patients receiving these therapies who have TIPS compared to those who do not. In summary, TIPS is a safe, effective treatment that can be used to ameliorate the complications that are sequelae of portal hypertension. While it does not appear to improve survival post-transplant, TIPS placement pre-transplant may increase survival time to transplant, thus improving overall survival as well as quality of life.
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17
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Khan F, Mehrzad H, Tripathi D. Timing of Transjugular Intrahepatic Portosystemic Stent-shunt in Budd-Chiari Syndrome: A UK Hepatologist's Perspective. J Transl Int Med 2018; 6:97-104. [PMID: 30425945 PMCID: PMC6231303 DOI: 10.2478/jtim-2018-0022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Budd-Chiari syndrome (BCS) is a rare but fatal disease caused by the obstruction in hepatic venous outflow tract (usually by thrombosis) and is further classified into two subtypes depending on the level of obstruction. Patients with BCS often have a combination of prothrombotic risk factors. Clinical presentation is diverse. Stepwise management strategy has been suggested with excellent 5-year survival rate. It includes anticoagulation, treatment of identified prothrombotic risk factor, percutaneous recanalization, and transjugular intrahepatic portosystemic shunt (TIPS) to reestablish hepatic venous outflow and liver transplantation in unresponsive patients. Owing to the rarity of BCS, there are no randomized controlled trials (RCTs) precisely identifying the timing for TIPS. TIPS should be considered in patients with refractory ascites, variceal bleed, and fulminant liver failure. Liver replacement is indicated in patients with progressive liver failure and in those in whom TIPS is not technically possible. The long-term outcome is usually influenced by the underlying hematologic condition and the development of hepatocellular carcinoma. This review focuses on the timing and the long-term efficacy of TIPS in patients with BCS.
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Affiliation(s)
- Faisal Khan
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Homoyon Mehrzad
- Imaging and Interventional Radiology Department, Queen Elizabeth Hospital, Birmingham, UK
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18
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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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19
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Bansal V, Gupta P, Sinha S, Dhaka N, Kalra N, Vijayvergiya R, Dutta U, Kochhar R. Budd-Chiari syndrome: imaging review. Br J Radiol 2018; 91:20180441. [PMID: 30004805 DOI: 10.1259/bjr.20180441] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Budd-Chiari syndrome (BCS), also known as hepatic venous outflow tract obstruction includes a group of conditions characterized by obstruction to the outflow of blood from the liver secondary to involvement of one or more hepatic veins (HVs), inferior vena cava (IVC) or the right atrium. There are a number of conditions that lead to BCS-ranging from hypercoagulable states to malignancies. In up to 25% patients, no underlying disorder is identified. Diagnosis of BCS is based on a combination of clinical and imaging features. A major part of the literature in BCS has been devoted to interventions; however, a detailed description of various imaging manifestations of BCS is lacking. In this review, we highlight the importance of various imaging modalities in the diagnosis of BCS.
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Affiliation(s)
- Varun Bansal
- 1 Department of Radiodiagnosis and Imaging, Postgraduate Institute ofMedical Imaging and Research (PGIMER) , Chandigarh , India
| | - Pankaj Gupta
- 2 Deapartment of Gastroenterology, Postgraduate Institue of Medical Education and Research , Chandigarh , India
| | - Saroj Sinha
- 2 Deapartment of Gastroenterology, Postgraduate Institue of Medical Education and Research , Chandigarh , India
| | - Narender Dhaka
- 2 Deapartment of Gastroenterology, Postgraduate Institue of Medical Education and Research , Chandigarh , India
| | - Naveen Kalra
- 1 Department of Radiodiagnosis and Imaging, Postgraduate Institute ofMedical Imaging and Research (PGIMER) , Chandigarh , India
| | - Rajesh Vijayvergiya
- 3 Department of Cardiology, Postgraduate Institute of Medical Education and Research , Chandigarh , India
| | - Usha Dutta
- 2 Deapartment of Gastroenterology, Postgraduate Institue of Medical Education and Research , Chandigarh , India
| | - Rakesh Kochhar
- 2 Deapartment of Gastroenterology, Postgraduate Institue of Medical Education and Research , Chandigarh , India
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20
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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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Abstract
Acute liver failure (ALF) is a rare but highly fatal condition. The most common causes include drug-induced and viral hepatitis, but other less common etiologies, especially autoimmune hepatitis, Budd-Chiari syndrome, and Wilson disease, need to be considered. Because diagnosis is frequently tied to potential for reversibility of ALF and prognosis, early identification in a timely manner is crucial. Other causes of ALF are more easily recognizable based on specific circumstances, such as ALF in pregnancy or ischemic hepatitis. Ultimately, maintaining a wide differential diagnosis in patients with ALF is essential to identifying the proper treatment and prognosis.
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Affiliation(s)
- Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, 1305 York Avenue, 4th Floor, New York, NY 10021, USA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, 1305 York Avenue, 4th Floor, New York, NY 10021, USA.
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22
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Das CJ, Soneja M, Tayal S, Chahal A, Srivastava S, Kumar A, Baruah U. Role of radiological imaging and interventions in management of Budd-Chiari syndrome. Clin Radiol 2018; 73:610-624. [PMID: 29549997 DOI: 10.1016/j.crad.2018.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 02/08/2018] [Indexed: 02/06/2023]
Abstract
Budd-Chiari syndrome (BCS) is a clinical condition resulting from impaired hepatic venous drainage, in which there is obstruction to the hepatic venous outflow at any level from the small hepatic veins to the junction of the inferior vena cava and the right atrium leading to hepatic congestion. The diagnosis of BCS is based on imaging, which can be gathered from non-invasive investigations such as ultrasonography coupled with venous Doppler, triphasic computed tomography (CT) and magnetic resonance imaging (MRI). Apart from diagnosis, various interventional radiology procedures aid in the successful management of this syndrome. In this article, we present various imaging features of BCS along with various interventional procedures that are used to treat this diverse condition.
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Affiliation(s)
- C J Das
- Department of Radiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110029, India.
| | - M Soneja
- Department of Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110029, India
| | - S Tayal
- Department of Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110029, India
| | - A Chahal
- Department of Radiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110029, India
| | - S Srivastava
- Department of Gastroenterology, GB Pant Hospital, New Delhi - 110002, India
| | - A Kumar
- Department of Gastroenterology, GB Pant Hospital, New Delhi - 110002, India
| | - U Baruah
- Department of Anaesthesiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110029, India
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Mancuso A. Timing of Transjugular Intrahepatic Portosystemic Shunt for Budd-Chiari Syndrome: An Italian Hepatologist's Perspective. J Transl Int Med 2017; 5:194-199. [PMID: 29340275 PMCID: PMC5767708 DOI: 10.1515/jtim-2017-0033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Budd-Chiari syndrome (BCS) management flow-chart is derived from experts' opinion and is not evidence-based. Guidelines suggest BCS management should follow a stepwise strategy: medical therapy as first-line treatment, revascularization or transjugular intrahepatic portosystemic shunt (TIPS) if no response to medical therapy, and liver transplant as rescue therapy. Recent evidence suggests that only medical therapy results in a bad long-term outcome. The biggest criticism of guidelines is the indication that BCS should receive further treatment only when hemodynamic consequences of portal hypertension become clinically evident. Recent data support that in BCS liver fibrosis could arise from chronic microvascular ischemia. A reasoning model of BCS physiopathology is that impaired hepatic vein outflow has hemodynamic consequences on portal hypertension development and causes hepatic fibrosis and liver failure through chronic ischemic damage. On this assumption is the concept that relieving liver congestion could ameliorate liver function and prevent development of BCS complications. Recently, early interventional treatment with TIPS for BCS has been reported to be effective. Early TIPS seems to be the best option for BCS management. Future multicenter controlled studies should compare the outcome of BCS treated with early interventional treatment compared with stepwise strategy.
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Affiliation(s)
- Andrea Mancuso
- Medicina Interna 1, ARNAS Civico - Di Cristina - Benfratelli, Piazzale Leotta 4, Palermo, Italy
- Epatologia e Gastroenterologia, Ospedale Niguarda Ca’ Granda, Piazza Ospedale Maggiore 3, 20162Milano, Italy
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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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26
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Fagiuoli S, Bruno R, Debernardi Venon W, Schepis F, Vizzutti F, Toniutto P, Senzolo M, Caraceni P, Salerno F, Angeli P, Cioni R, Vitale A, Grosso M, De Gasperi A, D'Amico G, Marzano A. Consensus conference on TIPS management: Techniques, indications, contraindications. Dig Liver Dis 2017; 49:121-137. [PMID: 27884494 DOI: 10.1016/j.dld.2016.10.011] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 09/27/2016] [Accepted: 10/17/2016] [Indexed: 12/11/2022]
Abstract
The trans jugular intrahepatic Porto systemic shunt (TIPS) is no longer viewed as a salvage therapy or a bridge to liver transplantation and is currently indicated for a number of conditions related to portal hypertension with positive results in survival. Moreover, the availability of self-expandable polytetrafluoroethylene (PTFE)-covered endoprostheses has dramatically improved the long-term patency of TIPS. However, since the last updated International guidelines have been published (year 2009) new evidence have come, which have open the field to new indications and solved areas of uncertainty. On this basis, the Italian Association of the Study of the Liver (AISF), the Italian College of Interventional Radiology-Italian Society of Medical Radiology (ICIR-SIRM), and the Italian Society of Anesthesia, Analgesia and Intensive Care (SIAARTI) promoted a Consensus Conference on TIPS. Under the auspices of the three scientific societies, the consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Bergamo on June 4th and 5th, 2015. The final statements presented here were graded according to quality of evidence and strength of recommendations and were approved by an independent jury. By highlighting strengths and weaknesses of current indications to TIPS, the recommendations of AISF-ICIR-SIRM-SIAARTI may represent the starting point for further studies.
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Affiliation(s)
- Stefano Fagiuoli
- Gastroenterologia Epatologia e Trapiantologia, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Raffaele Bruno
- Dept. of Infectious Diseases, Hepatology Outpatients Unit, University of Pavia-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Wilma Debernardi Venon
- Gastroepatologia, AOU Città della Salute e della Scienza, Molinette Hospital, Torino, Italy
| | - Filippo Schepis
- Department of Gastroenterology University of Modena and Reggio Emilia, Italy
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Pierluigi Toniutto
- Medical Liver Transplant Section, Department of Medical Sciences Experimental and Clinical, Internal Medicine, University of Udine, Italy
| | - Marco Senzolo
- Unità di Trapianto Multiviscerale, Gastroenterologia, Dipartimento di Scienze Chirurgiche e Gastroenterologiche, Università-Ospedale di Padova, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Francesco Salerno
- Department of Internal Medicine, Policlinico IRCCS San Donato, University of Milan, Italy
| | - Paolo Angeli
- Internal Medicine and Hepatology Department of Medicine (DIMED), University of Padova, Italy
| | - Roberto Cioni
- Dipartimento di Radiologia Diagnostica e Interventistica, UO di Radiologia Interventistica, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Alessandro Vitale
- U.O.C. di Chirurgia Epatobiliare e del Trapianto Epatico, Azienda Ospedaliera Università di Padova, Italy
| | - Maurizio Grosso
- Department of Radiology S. Croce and Carle Hospital Cuneo, Italy
| | - Andrea De Gasperi
- 2° Servizio Anestesia e Rianimazione-Ospedale Niguarda Ca Granda, Milan, Italy
| | | | - Alfredo Marzano
- Gastroepatologia, AOU Città della Salute e della Scienza, Molinette Hospital, Torino, Italy
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Qi X, Han G, Guo X, De Stefano V, Xu K, Lu Z, Xu H, Mancuso A, Zhang W, Han X, Valla DC, Fan D. Review article: the aetiology of primary Budd-Chiari syndrome - differences between the West and China. Aliment Pharmacol Ther 2016; 44:1152-1167. [PMID: 27734511 DOI: 10.1111/apt.13815] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 07/27/2016] [Accepted: 09/12/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND China may have the largest number of Budd-Chiari syndrome (BCS) cases in the world (at least 1914 original papers were published, and at least 20 191 BCS patients were reported). Considering the discrepancy in the clinical profiles and preferred treatment selection of primary BCS between the West and China, understanding its aetiology in these two different regions is very important. AIM To review the data from large cohort studies and meta-analyses to illustrate the epidemiology of risk factors for BCS in the West and China. METHODS Relevant papers were identified by major English- and Chinese-language databases, conference abstracts, and by manual search. RESULTS Risk factors reviewed include myeloproliferative neoplasms (MPNs) and their related gene mutations, anti-phospholipid syndrome, paroxysmal nocturnal haemoglobinuria (PNH), hyperhomocysteinaemia and 5,10-methylenetetrahydrofolate reductase (MTHFR) C677T mutation, factor V Leiden (FVL) and prothrombin G20210A mutations, inherited anti-thrombin, protein C and protein S deficiencies, pregnancy and puerperium, poverty, and family history. CONCLUSIONS We examined the differences in the aetiological distribution of BCS between the West and China. Several recommendations should be considered in Chinese BCS patients: (i) screening for hyperhomocysteinaemia and MTHFR mutation should be regularly performed; (ii) screening for MPNs, PNH, and anti-phospholipid syndrome should be selectively performed; (iii) inherited anti-thrombin, protein C, and protein S deficiencies should be actively explored; (iv) screening for FVL and prothrombin G20210A mutations may be unnecessary; and (v) the clinical significance of pregnancy and puerperium, poverty with bacterial infections and unsanitary environments, and family history as possible risk factors should never be neglected.
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Affiliation(s)
- X Qi
- Xi'an, China.,Shenyang, China
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- Shenyang, China.,Shenzhen, China
| | | | - D C Valla
- Clichy-la-Garenne, France.,Paris, France
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Mancuso A. Management of Suprahepatic Inferior Vena Cava Obstruction. Cardiovasc Intervent Radiol 2016; 39:1665-1666. [DOI: 10.1007/s00270-016-1446-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/01/2016] [Indexed: 11/28/2022]
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Good Clinical Outcomes in Budd-Chiari Syndrome with Hepatic Vein Occlusion. Dig Dis Sci 2016; 61:3054-3060. [PMID: 27221497 DOI: 10.1007/s10620-016-4208-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/18/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Budd-Chiari syndrome (BCS) with hepatic vein (HV) occlusion is manifested by severe liver damage in acute cases and esophageal variceal bleeding or refractory ascites in chronic cases, which is difficult to differentiate from cirrhotic portal hypertension. AIMS To evaluate the clinical efficacy and safety of HV angioplasty and transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of BCS with HV occlusion. METHODS Between May 1995 and December 2014, 60 patients with HV occlusive BCS underwent HV angioplasty or TIPS. BCS was subacute or chronic in 55 patients and acute in 5 patients. HV angioplasty was performed in 18 patients with HV occlusion, combined HV and IVC angioplasty in 9 patients with HV and IVC occlusion, TIPS in 12 patients with HV occlusion, and modified TIPS in 21 patients with extensive HV occlusion. RESULTS The interventional procedure was successfully performed in all 60 patients. The portal pressure decreased from 41.23 ± 10.46 cmH2O preoperatively to 26.68 ± 6.46 cmH2O postoperatively, while the portal flow velocity increased from 14.31 ± 10.43 to 52.16 ± 13.68 cm/s in patients undergoing TIPS or modified TIPS. During hospitalization, two patients died from hepatic failure, and acute shunt occlusion occurred in two other patients during subsequent treatment with repeated intervention. During 82.25 ± 46.16 months of follow-up, three patients underwent re-intervention with a stenotic shunt, and other three with repeated dilation of the stenotic HV. CONCLUSION HV angioplasty and TIPS yield excellent long-term outcomes in patients with HV occlusive BCS.
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Abstract
BACKGROUND Portal vein thrombosis (PVT) is a complication of cirrhosis. However, whether PVT worsens cirrhosis outcome is a debated issue. AIM To report an update on the management of PVT. METHODS A review was performed on the outcome, prevention, and treatment of PVT. RESULTS Some studies suggest that PVT could worsen the rate of hepatic decompensation and survival of cirrhosis, whereas others report a non-negative impact of PVT in the outcome of cirrhosis. Therefore, the prognostic value of PVT in cirrhosis remains a gray zone. One single randomized-controlled trial reported that enoxaparin could prevent PVT, delay the occurrence of hepatic decompensation, and improve survival. However, no further study data confirmed this assumption and the issue is not actually generalizable. Numerous studies report that anticoagulation determines a relatively high rate of portal vein recanalization in cirrhotics PVT. However, further data are warranted to confirm the risk-to-benefit of anticoagulation, especially bleeding. Transjugular intrahepatic portosystemic shunt (TIPS) has been reported to be effective as a treatment of PVT in cirrhosis, with the advantage of avoiding the risk of bleeding linked to anticoagulation. However, there are no data comparing TIPS with anticoagulation as a treatment of PVT in cirrhosis. Furthermore, there is no evidence on whether both anticoagulation and TIPS improve survival. CONCLUSION It is uncertain whether PVT affects cirrhosis outcome. Further data are needed to weigh the risk/benefit ratio of enoxaparin for the prevention of PVT in cirrhosis. Anticoagulation or TIPS should probably be indicated in liver transplantation candidates, but avoided in patients not suitable for liver transplantation and with an otherwise poor prognosis. Future studies should evaluate which subgroup of cirrhotics with PVT may benefit from treatment. Management of PVT in cirrhosis should be personalized.
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Mancuso A. The ischemic liver cirrhosis theory and its clinical implications. Med Hypotheses 2016; 94:4-6. [PMID: 27515188 DOI: 10.1016/j.mehy.2016.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/02/2016] [Accepted: 06/08/2016] [Indexed: 12/26/2022]
Abstract
The canonical pathway theory of cirrhosis addresses inflammation as the main driver of hepatic fibrogenesis in hepatitis, so needing a further hypothesis for etiologies missing inflammation, for which parenchymal extinction is postulated. The present paper reports an alternative hypothesis suggesting a central role of micro-vascular ischemia in fibrogenesis and cirrhosis development, whatever is the aetiology of liver chronic injury. In fact, since chronic liver injury could finally result in endothelial damage and micro-vascular thrombosis, leading to a trigger of inappropriate hepatocyte proliferation and fibrosis, finally cirrhosis development could arise from chronic micro-vascular ischemia. Recently, some important confirmation of this hypothesis has been reported. In fact, in a murine experimental model of congestive hepatopathy, it was found that chronic hepatic congestion leads to sinusoidal thrombosis and strain, which in turn promote hepatic fibrosis. Furthermore, a study on a murine model of cirrhosis reported enoxaparin to reduce hepatic vascular resistance and portal pressure by having a protective role against fibrogenesis. In conclusion, the hypothesis giving a central role of micro-vascular ischemia in fibrogenesis and cirrhosis development could change the clinical scenario of chronic liver disease and have several main implications on management of various liver disease.
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Affiliation(s)
- Andrea Mancuso
- Medicina Interna 1, ARNAS Civico - Di Cristina - Benfratelli, Piazzale Liotti 4, Palermo, Italy; Epatologia e Gastroenterologia, Ospedale Niguarda Ca' Granda, Piazza Ospedale Maggiore 3, 20162 Milano, Italy.
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Endovascular treatment of symptomatic Budd-Chiari syndrome - in favour of early transjugular intrahepatic portosystemic shunt. Eur J Gastroenterol Hepatol 2016; 28:656-60. [PMID: 26958788 DOI: 10.1097/meg.0000000000000621] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Treatment of Budd-Chiari syndrome (BCS) has shifted from mainly medical treatment, with surgical shunt and orthotopic liver transplantation (OLT) as rescue, to medical treatment combined with an early endovascular intervention in the past two decades. PURPOSE To assess the safety and efficiency of endovascular treatment of symptomatic patients with BCS and to compare mortality with symptomatic BCS patients in the same region treated with only sporadic endovascular techniques. METHODS This was a retrospective review of clinical data, treatment and survival in 14 patients diagnosed with BCS and treated with endovascular methods from 2003 to 2015. A national epidemiology study of BCS from 1986 to 2003 was used for comparison. RESULTS Thirteen of the 14 patients eventually had transjugular intrahepatic portosystemic shunt (TIPS), four after previous liver vein angioplasty. TIPS were performed with polytetrafluoroethylene-covered stents and technical success was 100%. Calculated preinterventional prognostic indices indicated a high risk of TIPS dysfunction, OLT and death. However, only one patient died and one had an OLT, and the 1- and 2-year primary TIPS-patency was 85 and 67%, respectively. Episodes of de-novo hepatic encephalopathy occurred in three patients. Overall 1- and 5-year transplantation-free survival was 100 and 93% compared with 47 and 28%, respectively, in 1986 to 2003. CONCLUSION TIPS seems to be a safe and effective treatment for symptomatic BCS and there is an obvious improvement in transplantation-free survival compared with conservatory medical treatment. It should, therefore, be considered early, as first-line intervention, in patients with insufficient response to medical treatment.
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Long-term clinical outcome of Budd-Chiari syndrome in children after radiological intervention. Eur J Gastroenterol Hepatol 2016; 28:567-75. [PMID: 26904975 DOI: 10.1097/meg.0000000000000583] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Budd-Chiari syndrome (BCS) is an uncommon cause of chronic liver disease in children. The literature on the management of pediatric BCS is scarce. Our aim was to determine the long-term outcome of patients undergoing a radiological intervention for the treatment of BCS. METHODS Thirty-two children diagnosed with BCS between 2004 and 2014 were included. Data on the course of disease, medical management, response, and complications related to radiological interventions and outcome were collected. MAIN RESULTS Twenty-five patients who were on regular follow-up were analyzed. The median age of the patients at presentation was 9 months (4.5-214). Sixteen patients initially received anticoagulation alone. This was associated with a high failure rate of 66%. Twenty patients underwent a radiological intervention in the form of angioplasty (n=7), hepatic vein stenting (n=3) or transjugular intrahepatic portosystemic shunt (TIPS) (n=14). Success with angioplasty was achieved in 43% of cases. Hepatic vein stenting was successful in 66%, whereas TIPS was successful in 72% of cases. TIPS was feasible in all patients. The median follow-up duration was 44 months (5-132). Four patients developed hepatopulmonary syndrome after a median period of 3 years (1.5-5.25) and one patient developed hepatocellular carcinoma. CONCLUSION BCS commonly presents during infancy. Anticoagulation alone and angioplasty of the hepatic veins are associated with a high failure rate. Hepatic vein stenting or TIPS is feasible and efficacious in improving liver function, portal hypertension, and growth. It is associated with good long-term outcome and delays the need for liver transplantation, but may not prevent complications such as hepatopulmonary syndrome and hepatocellular carcinoma.
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The outcomes of interventional treatment for Budd-Chiari syndrome: systematic review and meta-analysis. ACTA ACUST UNITED AC 2015; 40:601-8. [PMID: 25248791 DOI: 10.1007/s00261-014-0240-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The purpose of this study was to conduct a systematic review with meta-analysis quantitatively assesses the outcomes of interventional treatment for Budd-Chiari syndrome (BCS). We evaluated the published studies on interventional treatment for BCS and reviewed reference lists from retrieved articles. Meta-analysis was applied to calculate the combined rates and their 95% confidence intervals. The risk of bias was assessed by the Egger test. As many as 29 articles on interventional treatment with BCS were selected according to the eligibility criteria and included in the meta-analysis, for a total of 2,255 BCS patients. The pooled results (95 % CI) were 93.7 % (92.6-4.8 %) for successful rate of interventional operation, 6.5 % (5.3-7.7 %) for restenosis rate of interventional treatment, and 92.0 % (89.8-94.3 %) and 76.4 % (72.5-80.4 %) for the survival rate at 1 and 5 years, respectively. The interventional therapy of major BCS patients is safe with successful operation, good patency, and long-term survival. Moreover, a step-wise management of BCS is proposed to manage and cure all BCS patients with personalized treatment.
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Affiliation(s)
- Andrea Mancuso
- Medicina Interna 1, ARNAS Civico - Di Cristina - Benfratelli, Palermo, Italy.,Epatologia e Gastroenterologia, Ospedale Niguarda Cà Granda, Milano, Italy
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Mancuso A. Outcome of Budd-Chiari syndrome in Behçet׳s syndrome. Semin Arthritis Rheum 2015; 45:e1. [PMID: 25953713 DOI: 10.1016/j.semarthrit.2015.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 04/03/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Andrea Mancuso
- Medicina Interna 1, ARNAS Civico-Di Cristina-Benfratelli, Piazzale Liotti 4, 90100 Palermo, Italy; Epatologia e Gastroenterologia, Ospedale Niguarda Cà Granda, Piazza Ospedale Maggiore 3, Milano, Italy.
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An update on the management of Budd-Chiari syndrome: the issues of timing and choice of treatment. Eur J Gastroenterol Hepatol 2015; 27:200-3. [PMID: 25590783 DOI: 10.1097/meg.0000000000000282] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Because of the rarity of Budd-Chiari syndrome (BCS), the flow chart of management comes from expert opinion and is not evidence based. To report an update on the management of BCS. I performed a review on published papers on BCS in an attempt to speculate in particular on the timing and the choice of treatment. Some authors suggest that the management of BCS should follow a step-wise strategy. Anticoagulation and medical therapy should be the first-line treatment. Revascularization or transjugular intrahepatic portosystemic shunt should be performed in case of no response to medical therapy. Orthotopic liver transplant should be used as a rescue therapy. The biggest criticism of this flow chart is that it is based on the assumption that patients with BCS should receive further treatment only when hemodynamic effects on portal hypertension become clinically evident, thus paying little attention to the chronic ischemic liver damage effects on hepatic function and to the possibility of preventing liver failure by relieving impaired hepatic veins outflow. Recently, I presented a proposal of a new algorithm for the management of BCS, in which medical therapy alone is suggested only for patients without any sign of portal hypertension, irrespective of whether early interventional treatment is suggested when either any symptoms or signs of portal hypertension appear, with the aim of preventing hepatic fibrosis development, disease progression, and finally improving outcome. Given that the benefit of treatments for BCS is not under debate, guidelines for the management of BCS should be re-evaluated and updated, with particular attention to both the timing and the choice of treatment.
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Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the complications of portal hypertension. The largest body of evidence for its use has been supported for recurrent or refractory variceal bleeding and refractory ascites. Its use has also been advocated for acute variceal bleed, hepatic hydrothorax, and hepatorenal syndrome. With the replacement of bare metal stents with polytetrafluoroethylene-covered stents, shunt patency has improved dramatically, thus, improving outcomes. Therefore, reassessment of its utility, management of its complications, and understanding of various TIPS techniques is important.
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Affiliation(s)
- Kavish R Patidar
- Department of Internal Medicine, Virginia Commonwealth University Hospital, 1200 East Broad Street, MCV Box 980342, Richmond, VA 23298-0342, USA
| | - Malcolm Sydnor
- Radiology, Virginia Commonwealth University Hospital, 1200 East Broad Street, MCV Box 980615, Richmond, VA 23298-0615, USA; Surgery, Virginia Commonwealth University Hospital, 1200 East Broad Street, Richmond, VA 23298, USA; Vascular Interventional Radiology, Virginia Commonwealth University Hospital, 1200 East Broad Street, Richmond, VA 23298, USA
| | - Arun J Sanyal
- Division of Gastroenterology, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, 1200 East Broad Street, MCV Box 980342, Richmond, VA 23298-0342, USA.
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Qi X, Guo W, He C, Zhang W, Wu F, Yin Z, Bai M, Niu J, Yang Z, Fan D, Han G. Transjugular intrahepatic portosystemic shunt for Budd-Chiari syndrome: techniques, indications and results on 51 Chinese patients from a single centre. Liver Int 2014; 34:1164-75. [PMID: 24256572 DOI: 10.1111/liv.12355] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 10/03/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND & AIMS In Western countries, transjugular intrahepatic portosytemic shunt (TIPS) is widely applied for the treatment of Budd-Chiari syndrome (BCS). However, the outcome of Chinese BCS patients treated with TIPS is extremely limited. Furthermore, the timing of conversion from percutaneous recanalization to TIPS remains uncertain. METHODS All consecutive BCS patients treated with TIPS between December 2004 and June 2012 were included. Patients were classified as the early and converted TIPS groups. Indications, TIPS-related complications, post-TIPS hepatic encephalopathy, shunt dysfunction and death were reported. RESULTS Of 51 patients included, 39 underwent percutaneous recanalization for 1024 days (0-4574) before TIPS. Early TIPS group (n = 19) has a shorter history of BCS and a lower proportion of prior percutaneous recanalization than converted TIPS group (n = 32). Main indications were diffuse obstruction of three HVs (n = 12), liver failure (n = 2), liver function deterioration (n = 8), refractory ascites (n = 10) and variceal bleeding (n = 19). Procedure-related intraperitoneal bleeding was reversible in three patients. The cumulative 1-year rate of being free of first episode of post-TIPS hepatic encephalopathy and shunt dysfunction was 78.38 and 61.69% respectively. The cumulative 1-, 2-, and 3-year survival rates were 83.82, 81.20 and 76.93% respectively. BCS-TIPS score, but not Child-Pugh, MELD, Clichy or Rotterdam score, could predict the survival. Age, total bilirubin and inferior vena cava thrombosis were also significantly associated with overall survival. Survival was similar between early and converted TIPS groups. CONCLUSIONS TIPS can achieve an excellent survival in Chinese patients in whom percutaneous recanalization is ineffective or inappropriate. BCS-TIPS score could effectively predict these patients' survival.
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Affiliation(s)
- Xingshun Qi
- Department of Liver Disease and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Affiliation(s)
- Andrea Mancuso
- Medicina Interna 1, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico - Di Cristina - Benfratelli, Piazzale Liotti 4, Palermo, 90100, Italy; Epatologia e Gastroenterologia, Ospedale Niguarda Cà Granda, Piazza Ospedale Maggiore 3, Milano, 20162, Italy
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Mancuso A. Budd-chiari syndrome management: Timing of treatment is an open issue. Hepatology 2014; 59:1213. [PMID: 23857382 DOI: 10.1002/hep.26619] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 06/08/2013] [Accepted: 06/13/2013] [Indexed: 12/07/2022]
Affiliation(s)
- Andrea Mancuso
- Epatologia e Gastroenterologia Ospedale Niguarda Ca' Granda, Milano, Italy; Medicina Interna 1 Ospedale Civico, Palermo, Italy
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Fitsiori K, Tsitskari M, Kelekis A, Filippiadis D, Triantafyllou K, Brountzos E. Transjugular intrahepatic portosystemic shunt for the treatment of Budd-Chiari syndrome patients: results from a single center. Cardiovasc Intervent Radiol 2013; 37:691-7. [PMID: 23860938 DOI: 10.1007/s00270-013-0697-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 06/09/2013] [Indexed: 12/13/2022]
Abstract
PURPOSE To evaluate the outcome of transjugular intrahepatic portosystemic shunt (TIPS) in patients with Budd-Chiari syndrome (BCS). PATIENTS AND METHODS Fourteen patients (11 female, mean age 45.8 years), with symptomatic BCS refractory to conventional therapy, were treated with TIPS placement in our department within a period of 9 years. Stent grafts were primarily used in 12 patients. Mean follow-up time was 38.1 ± 36.1 months (range 7-114). Model for end-stage liver disease (MELD) score, BCS Rotterdam index, and Child-Pugh score were calculated for all patients. In addition, the recently suggested BCS-TIPS prognostic index score (BSC-TIPS PI) was applied. RESULTS BCS-TIPS PI score was ≤7 in all patients. Most of our patients (12 of 14) had good or intermediate prognosis according to MELD, Rotterdam and Child-Pugh scores. Technical success was achieved in all 14 patients and was accompanied by complete resolution of the symptoms. In 3 patients, the procedure was complicated by hemoperitoneum, which was successfully treated in two patients with coils or stent-graft placement, whereas 1 patient was managed in the operating room. Thirteen patients are symptom and orthotopic liver transplantation-free. Primary patency was 92.8, 84.7, and 58.7 % at 6, 12, and 24 months, respectively. Secondary patency was 100, 100 and 84.6 % at 6, 12, and 24 months respectively. CONCLUSION In symptomatic BCS patients with moderate prognosis according to MELD, Child-Pugh, and BCS Rotterdam scores, as well as BCS-TIPS PI score ≤7, TIPS has high clinical success, low morbidity, and no mortality, and it offers durable mid-term resolution of the symptoms and OLT-free survival.
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Affiliation(s)
- Katerina Fitsiori
- 2nd Department of Radiology, Medical School, National and Kapodistrian University of Athens, 1, Rimini St, 12462, Athens, Greece,
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Qi X, Yang M, Fan D, Han G. Transjugular intrahepatic portosystemic shunt in the treatment of Budd-Chiari syndrome: a critical review of literatures. Scand J Gastroenterol 2013; 48:771-84. [PMID: 23506234 DOI: 10.3109/00365521.2013.777775] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
An increasing number of patients with Budd-Chiari syndrome (BCS) have undergone transjugular intrahepatic portosystemic shunt (TIPS). However, the critical role of TIPS in the treatment of BCS has not been systematically reviewed. The authors identified all relevant literatures via the PubMed, EMBASE and Cochrane library databases. Overall, 160 papers from 29 countries reported the application of TIPS for BCS. The number of publications was increased over time, but the level of evidence in this field was low. Common indications for TIPS in BCS patients included refractory ascites, recurrent variceal bleeding, diffuse hepatic vein thrombosis and progressive liver failure. Successful TIPS insertion could improve the hemodynamic and clinical parameters. TIPS procedure-related complications were not infrequent (range: 0-56%), but procedure-related death was rare. Shunt dysfunction rate appeared to be higher (range: 18-100%). Compared with bare stents, covered stents could significantly decrease the rate of shunt dysfunction. Hepatic encephalopathy rate after TIPS was relatively low (range: 0-25%). Short- and long-term prognosis of BCS-TIPS patients was excellent with 1-year cumulative survival rate of 80-100% and 5-year cumulative survival rate of 74-78%. In conclusions, existing literatures supported the feasibility, safety and efficacy of TIPS in the treatment of BCS. Prospective cohort studies or randomized controlled trials were difficult due to the rarity of BCS, but might be very necessary to precisely identify the timing of transition from medical therapy and/or percutaneous recanalization to TIPS insertion and the real candidates in whom early TIPS should be promptly employed with no need of any prior therapy.
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Affiliation(s)
- Xingshun Qi
- Department of Liver Disease and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Mancuso A, Martinelli L, De Carlis L, Rampoldi AG, Magenta G, Cannata A, Belli LS. A caval homograft for Budd-Chiari syndrome due to inferior vena cava obstruction. World J Hepatol 2013; 5:292-295. [PMID: 23717741 PMCID: PMC3664288 DOI: 10.4254/wjh.v5.i5.292] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 05/10/2013] [Indexed: 02/06/2023] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is the standard treatment of Budd-Chiari syndrome (BCS) non responsive to medical therapy. However, patients with inferior vena cava (IVC) obstruction proximal to the atrium do not benefit from TIPS and a surgical approach is mandatory. We report the case of BCS due to intrapericardial IVC obstruction. We describe a novel surgical approach using a fresh caval homograft. An attempt to balloon dilatation of the IVC obstruction was complicated by right atrial disruption with tamponade and ventricular fibrillation. Lately, the patient successfully underwent a reconstruction of the cavo-atrial continuity by the interposition of a fresh caval homograft, a novel surgical approach never described before for BCS. Further follow-up revealed progressive reduction and resolution of ascites, and overall clinical improvement. IVC obstruction near to the atrium can be surgically approached with a new technique consisting in inferior vena cava resection and replacement with a caval homograft.
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Neumann AB, Andersen SD, Nielsen DT, Holland-Fischer P, Vilstrup H, Grønbæk H. Treatment of Budd-Chiari syndrome with a focus on transjugular intrahepatic portosystemic shunt. World J Hepatol 2013; 5:38-42. [PMID: 23383365 PMCID: PMC3562725 DOI: 10.4254/wjh.v5.i1.38] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 08/04/2012] [Accepted: 12/23/2012] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate long-term complications and survival in patients with Budd-Chiari syndrome (BCS) referred to a Danish transjugular intrahepatic portosystemic shunt (TIPS) centre. METHODS Twenty-one consecutive patients from 1997-2008 were retrospectively included [15 women and 6 men, median age 40 years (range 17-66 years)]. Eighteen Danish patients came from the 1.8 million catchment population of Aarhus University Hospital and three patients were referred from Scandinavian hospitals. Management consisted of tests for underlying haematological, endocrinological, or hypercoagulative disorders parallel to initiation of specific treatment of BCS. RESULTS BCS was mainly caused by thrombophilic (33%) or myeloproliferative (19%) disorders. Forty-three percents had symptoms for less than one week with ascites as the most prevalent finding. Fourteen (67%) were treated with TIPS and 7 (33%) were manageable with treatment of the underlying condition and diuretics. The median follow-up time for the TIPS-treated patients was 50 mo (range 15-117 mo), and none required subsequent liver transplantation. Ascites control was achieved in all TIPS patients with a marked reduction in the dose of diuretics. A total of 14 TIPS revisions were needed, mostly of uncovered stents. Two died during follow-up: One non-TIPS patient worsened after 6 mo and died in relation to transplantation, and one TIPS patient died 4 years after the TIPS-procedure, unrelated to BCS. CONCLUSION In our BCS cohort TIPS-treated patients have near-complete survival, reduced need for diuretics and compared to historical data a reduced need for liver transplantation.
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Affiliation(s)
- Anders Bay Neumann
- Anders Bay Neumann, Stine Degn Andersen, Peter Holland-Fischer, Hendrik Vilstrup, Henning Grønbæk, Department of Medicine V (Gastroenterology and Hepatology), Aarhus University Hospital, DK-8000 Aarhus C, Denmark
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Bhogal HK, Sanyal AJ. Using transjugular intrahepatic portosystemic shunts for complications of cirrhosis. Clin Gastroenterol Hepatol 2011; 9:936-46; quiz e123. [PMID: 21699820 PMCID: PMC3200495 DOI: 10.1016/j.cgh.2011.06.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 06/01/2011] [Accepted: 06/05/2011] [Indexed: 02/07/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) decompresses the portal venous system. TIPS has been used to manage the complications of portal hypertension in cirrhosis, including variceal hemorrhage and refractory ascites. The uncoated TIPS stents are limited by stent stenosis; however, the introduction of coated stents has decreased this. With the introduction of coated stents, we must reevaluate the utility of TIPS in the management of complications of portal hypertension.
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Mancuso A. Budd-Chiari syndrome management: Lights and shadows. World J Hepatol 2011; 3:262-4. [PMID: 22059108 PMCID: PMC3208178 DOI: 10.4254/wjh.v3.i10.262] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 07/19/2011] [Accepted: 09/20/2011] [Indexed: 02/06/2023] Open
Abstract
Budd-Chiari syndrome (BCS) is a rare disease whose management should follow a step by step strategy. Anticoagulation and medical therapy should be the first line treatment. Revascularization or TIPS are indicated in case of no response to medical therapy. OLT should be indicated as a rescue therapy and anticoagulation be started soon after OLT. However, no clear indication can actually be given about the timing of different treatments. Moreover, there is some concern about treatment of some subgroup of patients, especially regarding the risk of recurrence after liver transplantation. The topic of this paper is to critically review the actual knowledge of BCS management.
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Affiliation(s)
- Andrea Mancuso
- Andrea Mancuso, Epatologia e Gastroenterologia, Ospedale Niguarda Ca' Granda, Milano 20162, Italy
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