Percutaneous intervention in portosystemic shunts in Budd-Chiari syndrome

Assessment of surgical portosystemic shunts and associated complications: The diagnostic and therapeutic role of radiologists

Surgical portosystemic shunting, the formation of a vascular connection between the portal and systemic venous circulation, has been used as a treatment to reduce portal venous pressure. Although the use of portosystemic shunt surgery in the management of portal hypertension has declined during the past decade in favour of alternative therapies, and subsequently surgeons and radiologists became less familiar with the procedure, it remains a well-established treatment. Knowledge of different types of surgical portosystemic shunts, their pathophysiology and complications will help radiologists improve communication with surgeons and enhance their understanding of the diagnostic and therapeutic role of radiology in the assessment and management of these shunts. Optimal assessment of the shunt is essential to determine its patency and allow timely intervention. Both non-invasive and invasive imaging modalities complement each other in the evaluation of surgical portosystemic shunts. Interventional radiology plays an important role in the management of complications, such as shunt thrombosis and stenosis. This article describes the various types of surgical portosystemic shunts, explains the anatomy and pathophysiology of these shunts, illustrates the pearls and pitfalls of different imaging modalities in the assessment of these shunts and demonstrates the role of radiologists in the interventional management of complications.

Vascular disorders of the liver

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

Stent angioplasty of narrowed portocaval shunt in Budd Chiari syndrome: a case report

BACKGROUND

Hepatic vein thrombosis (Budd-Chiari Syndrome) is a rare disorder resulting from an obstruction to the outflow of blood from the liver. Early decompression is needed to prevent liver dysfunction and death. Radiological intervention includes angioplasty of stenosis and webs and the placement of transjugular intrahepatic portosystemic shunts (TIPPS). Side-to-side portacaval shunt (SSPCS) remains the gold standard for achieving good long-term results.

CASE PRESENTATION

A 37-year old lady underwent side-to-side portacaval shunt for Budd Chiari syndrome. She had early shunt blockage and this was successfully treated with the placement of a metallic stent across the shunt.

CONCLUSION

At five years, she remains asymptomatic, with normal liver functions, no ascites, and normal flow through the stent on Colour Doppler examination.

Role of TIPS as a bridge to hepatic transplantation in Budd-Chiari syndrome

PURPOSE

To investigate the role of transjugular intrahepatic portosystemic shunt (TIPS) as a bridge to transplantation for patients with Budd-Chiari syndrome (BCS).

MATERIALS AND METHODS

Eight patients (five women, three men) with a mean age of 49.8 years (range, 20-61 years) were diagnosed with BCS by means of computed tomography, hepatic venography, and liver biopsy. One patient had acute liver failure, with subacute or chronic failure in seven. TIPS placement was attempted in all eight patients. Clinical follow-up and portograms were obtained in all patients until death or transplantation.

RESULTS

TIPS placement was completed in seven of eight patients (87.5%). During the follow-up period, TIPS occlusion occurred in four patients. TIPS revision in this patient, although successful, was complicated by hemorrhage and multiorgan failure, and the patient died. Assisted patency rate, excluding the technical failure, was 100%. Mean follow-up in the six survivors with TIPS was 342 days (range, 19-660 days). All six survivors had complete resolution of their ascites. Albumin levels improved an average of 0.43 g/dL (range, 0.3-1.4 g/dL). Bilirubin levels improved in five of six patients (83%), decreasing by an average of 5.6 mg/dL (range, 3.0-15.2 mg/dL). Of the six survivors, three underwent elective liver transplantation, one is awaiting transplantation, and one has been removed from the transplantation list because of clinical improvement. One patient was a candidate for transplantation but declined to be put on the list.

CONCLUSION

Hepatic synthetic dysfunction improves markedly after TIPS placement in patients with BCS. Significant improvement in ascites can also occur. TIPS can be an effective bridge to transplantation for patients with BCS.

A new use of the Simpson percutaneous atherectomy catheter: resection of retained valve cusps of an in-situ vein graft

An in-situ saphenous vein graft occluded because of retained valve cusps. After aspiration thrombectomy, percutaneous transluminal balloon angioplasty was performed, but reocclusion occurred 11 months later. Following a second aspiration thrombectomy, the restenosed retained cusps were resected using the Simpson percutaneous atherectomy catheter. The graft remained patent until the patient's death from unrelated causes 6 months later.