A 27-year experience with surgical treatment of Budd-Chiari syndrome

Evaluation of outcome from endovascular therapy for Budd-Chiari syndrome: a systematic review and meta-analysis

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.

[Budd-Chiari syndrome, review and illustration]

Budd-Chiari syndrome is a rare vascular disorder characterized by obstruction of the hepatic venous outflow. Various diseases causing coagulopathy play a role in aetiology, such as myeloproliferative disorders. Acute vascular occlusion may lead to acute phlebitis with fever. The classic triad of acute liver failure may be present with ascites, hepatomegaly, and abdominal pain. However, subacute courses of disease were also observed. Because of the variable symptoms and severity extent, depending on the acuity of the course and the extent of the affected vessels, diagnosis is often difficult. Sonography, as a ubiquitously available and cost-effective diagnostic tool, plays a leading role. Doppler ultrasonography can be used to visualize hemodynamics in particular. In acute thrombotic occlusion, the affected hepatic veins usually cannot or only partially be visualized. In non-occluding thrombi, turbulent flow patterns may develop in the area of venous outflow obstruction, and flow velocity is then increased in the area of stenosis. Contrast enhanced ultrasound offers even better specificity of diagnosis. Computed tomography and magnetic resonance imaging can directly visualize thrombi and the cause of obstruction. Once the diagnosis is confirmed, anticoagulation must be initiated, but therapy of the underlying disease must also be started. If symptom-controlling measures are not sufficient, angioplasty/stenting to reopen short-segment stenoses or implantation of a TIPSS device may be considered. Liver transplantation remains ultima ratio. As studies on the precision of diagnostic methods are controversial, the characteristics of imaging for BCS are therefore summarized in this review on the basis of several illustrating case reports.

Percutaneous transluminal angioplasty for symptomatic hepatic vein-type Budd-Chiari syndrome: feasibility and long-term outcomes

For management of Budd-Chiari syndrome (BCS), a step-wise therapeutic approach starting with medical treatment, followed by endovascular recanalization, transjugular intrahepatic portosystemic shunt, and finally liver transplantation has been adopted. We retrospectively analyzed 51 patients with symptomatic short segment (≤ 30 mm) hepatic vein (HV)-type BCS who underwent percutaneous transluminal balloon angioplasty (PTBA) with/without stenting to determine the feasibility, clinical effectiveness, and long-term outcomes. The intervention was technically successful in 94.1% of cases (48/51)—32 patients underwent PTBA and 16 patients underwent HV stenting. Procedure-related complications occurred in 14 patients (29.1%). The clinical success rate at 4 weeks was 91.7% (44/48). Nine patients underwent reintervention, six patients due to restenosis/occlusion and three patients with clinical failure. The mean primary patency duration was 64.6 ± 19.9 months (CI, 58.5–70.8; range, 1.2–81.7 months). The cumulative 1-, 2-, and 5-year primary patency rates were 85.4, 74.5, and 58.3%, respectively. The cumulative 1-, 2-, and 5-year secondary patency rates were 93.8, 87.2, and 75%, respectively. The cumulative 1-, 2-, and 5-year survival rates were 97.9, 91.5, and 50%, respectively. Percutaneous transluminal angioplasty with and without stenting is effective and achieves excellent long-term patency and survival rates in patients with symptomatic HV-type BCS. With its lower incidence of re-occlusion and higher clinical success rate, HV angioplasty combined with stenting should be the preferred option especially in patients with segmental HV-type BCS.

Venous thrombosis of the liver: current and emerging concepts in management

Venous thrombosis within the hepatic vasculature is associated with a distinct array of risk factors, characteristics, and potential complication. As such, it entails unique management considerations and strategies relative to the more common categories of venous thromboembolic disease. Although broadly divided into thrombosis of the afferent vasculature (the portal venous system) and efferent vasculature (the hepatic venous system), presentations and management strategies within these groupings are heterogeneous. Management decisions are influenced by a variety of factors including the chronicity, extent, and etiology of thrombosis. In this review we examine both portal vein thrombosis and hepatic vein thrombosis (and the associated Budd-Chiari Syndrome). We consider those factors which most impact presentation and most influence treatment. In so doing, we see how the particulars of specific cases introduce nuance into clinical decisions. At the same time we attempt to organize our understanding of such cases to help facilitate a more systematic approach. Critically, we must recognize that although increasing evidence is emerging to help guide our management strategies, the available data remain limited and largely retrospective. Indeed, current paradigms are based largely on observational experiences and expert consensus. As new and more rigorous studies emerge, treatment strategies are likely to be continually refined, and paradigm shifts are sure to occur.

Tratamiento endovascular del síndrome de Budd-Chiari, a propósito de un caso

El síndrome de Budd-Chiari consiste en la oclusión de la circulación de salida venosa del hígado, desde las sinusoides hepáticas hasta la unión de la vena cava inferior con la aurícula derecha. Esta entidad es muy rara. Las causas son primarias, obstrucción congénita de la vena cava o trombosis espontánea, o secundarias, compresión extrínseca. Si no se trata la obstrucción esta enfermedad, lleva a cirrosis hepática. Se presenta un caso del síndrome de Budd-Chiari de causa primaria por obstrucción membranosa, tratado por vía endovascular de manera exitosa y con resolución de todos los síntomas. Es el primer reporte en Colombia de este tipo de tratamiento.

Current knowledge in pathophysiology and management of Budd-Chiari syndrome and non-cirrhotic non-tumoral splanchnic vein thrombosis

Budd-Chiari syndrome and non-cirrhotic non-tumoral portal vein thrombosis are 2 rare disorders, with several similarities that are categorized under the term splanchnic vein thrombosis. Both disorders are frequently associated with an underlying prothrombotic disorder. They can cause severe portal hypertension and usually affect young patients, negatively influencing life expectancy when the diagnosis and treatment are not performed at an early stage. Yet, they have specific features that require individual consideration. The current review will focus on the available knowledge on pathophysiology, diagnosis and management of both entities.

Diagnostic accuracy of magnetic resonance angiography for Budd-Chiari syndrome: A meta-analysis

In recent years, the role of magnetic resonance angiography (MRA) in the diagnosis of Budd-Chiari Syndrome (BCS) has been the focus of various clinical studies. The purpose of the present study was to perform a meta-analysis of the diagnostic performance of MRA in patients with BCS by using digital subtraction angiography as a reference method. The search strategy for relevant research articles was based on the Cochrane Handbook for Systematic Reviews, and literature databases (including PubMed, Medline and China National Knowledge Infrastructure) and reference lists of retrieved studies published from 2000 to 2016 were searched. The Quality Assessment of Diagnostic Accuracy Studies tool was used to assess the methodological quality of these research studies by two reviewers independently. Summary estimates of the sensitivity, specificity, positive/negative likelihood ratio (LR+/-), diagnostic odds ratio (DOR) and the summary receiver operating characteristic (SROC) curve of MRA in identifying BCS were obtained. The pooled MRA estimates had a sensitivity of 97.6% [95% confidence interval (CI), 95.1-99.0%], a specificity of 70.7% (95% CI, 54.5-83.9%), an LR+ of 3.163 (95% CI, 2.03-4.94) and an LR- of 0.045 (95% CI, 0.02-0.09). The overall DOR was 94.053 (95% CI, 32.71-270.41). The area under the SROC curve was 0.972. In conclusion, MRA is an accurate modality for evaluating BCS.

Radical surgical treatment of Budd-Chiari syndrome through entire exposure of hepatic inferior vena cava

OBJECTIVE

Therapies for Budd-Chiari syndrome (BCS) can be divided into three main categories: medical, endovascular, and surgical. Surgery is applicable to the disease when other therapeutic options have failed. We introduce a surgical method of recanalization through exposure of the entire hepatic inferior vena cava (IVC) and hepatic vein (HV) outflow tract for BCS and investigate the long-term outcomes.

METHODS

From July 2002 to December 2015 in our center, 83 consecutive symptomatic BCS patients with failure of endovascular therapy were treated by radical surgical recanalization. IVC recanalization was the first goal for all patients, and recanalization of at least one HV was the second goal for selected patients at the same surgical operation. Patients were followed up, and data on technical and clinical success, survival, and patency of target vessels were analyzed.

RESULTS

Technical success of surgical recanalization was achieved in 80 patients (96.4%), with relief of clinical symptoms and improvement of liver function. During a mean follow-up of 84 ± 25.9 months, the cumulative 1-, 3-, and 5-year primary patency rates of the HV were 96.7%, 90.0%, and 83.3%, respectively. The cumulative 1-, 3-, and 5-year primary patency of the IVC was 86.7%, 71.7%, and 68.3%, respectively. No factor demonstrated significant association with recurrence of obstruction. During follow-up, 10 patients died, 8 of end-stage hepatic disease and 2 of unknown causes. The cumulative 1-, 3-, and 5-year all-cause survival rates were 91%, 90%, and 87%, respectively. Female sex, encephalopathy, severe ascites, and hypersplenism had an impact on survival in univariate analysis. With Cox regression, encephalopathy was the only independent determining factor for surgical survival.

CONCLUSIONS

Surgical recanalization through exposure of the entire hepatic IVC for BCS is suitable for most primary BCS patients after failure of endovascular therapies.

Image-guided treatment of Budd-Chiari syndrome: a giant leap from the past, a small step towards the future

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.

Mesoatrial Shunt for Budd-Chiari Syndrome

BACKGROUND

The long-term efficacy of mesoatrial shunt (MAS) for Budd-Chiari syndrome (BCS) is not well studied. The purpose of our study was to investigate the long-term outcome and efficacy of MAS for BCS.

METHODS

We retrospectively evaluated 11 patients who underwent MAS for BCS from April 1986 to November 1995. Records of patients' clinical presentations, laboratorial investigation, Doppler duplex ultrasonography, radiologic image, and treatment outcomes were all retrieved and analyzed.

RESULTS

Follow-up intervals ranged from 1 year and 2 months to 30 years and 2 months (mean, 17 years and 8 months). Portal pressure decreased significantly from 35.72 ± 3.52 cm H₂O to 27.86 ± 5.83 cm H₂O post-MAS (P = 0.001). The 5-year, 10-year, and 20-year patency were 72.7%, 54.5%, 36.4%, respectively; 63.3% of patients had survived for more than 10 years and 45.5% for more than 20 years. A male has been alive with patent shunt for 28 years and 1 month.

CONCLUSIONS

The MAS with enforced rings is an effective therapeutic modality for BCS with cautious perioperative management.

Diagnosis and treatment guidelines for aberrant portal hemodynamics: The Aberrant Portal Hemodynamics Study Group supported by the Ministry of Health, Labor and Welfare of Japan

Idiopathic portal hypertension (IPH), causing aberrant portal hemodynamics, is a disease with an as yet unidentified cause and no established treatment protocol. The Japanese research group on IPH in Japan was set up in 1975 by the Ministry of Health, Labor and Welfare. Extrahepatic portal obstruction and Budd-Chiari syndrome (BCS) have since been added to the group's research subjects. The aims of the research group are to accurately evaluate the current status of the three diseases in Japan, elucidate their etiology and pathogenesis, and develop new treatments. Due to the long-term efforts of the Japanese research group, aberrant portal hemodynamics has been investigated in a variety of aspects, from epidemiological and pathological studies to molecular biology analyses. As a result, it has been shown that there are abnormal genes in the liver, specific for IPH. In addition, pathological findings of BCS were internationally compared and the difference in findings between Japan and Europe (or North America) has been clarified. Furthermore, it was found that complication rates of hepatocellular carcinoma in BCS were higher in Japan. Based on the research, "Diagnosis and treatment of aberrant portal hemodynamics (2001)", including diagnostic criteria for aberrant portal hemodynamics, was published in 2001. In 2013, it was revised to "Diagnosis and treatment guidelines for aberrant portal hemodynamics (2013)" after the incorporation of diagnosis and treatment in accordance with its current status.

Successful Treatment of Ascites using a Denver® Peritoneovenous Shunt in a Patient with Paroxysmal Nocturnal Hemoglobinuria and Budd-Chiari syndrome

A 56-year-old man was diagnosed with aplastic anemia and paroxysmal nocturnal hemoglobinuria at 43 years of age and treatment with cyclosporin A was started. Liver cirrhosis, ascites, and thrombus in the hepatic veins were found at 56 years of age and Budd-Chiari syndrome (BCS) was diagnosed according to angiography findings. He was treated with diuretics and paracentesis was performed several times, but with limited efficacy. A Denver^® peritoneovenous shunt (PVS) was inserted into the right jugular vein; his ascites and renal function improved immediately and his general condition has remained good for 12 months since starting the above treatment regimen. A PVS is a treatment option for ascites due to BCS.

Long-term safety and outcome of percutaneous transhepatic venous balloon angioplasty for Budd-Chiari syndrome

BACKGROUND AND AIMS

The restenosis following percutaneous transluminal balloon angioplasty (PTBA) is high for Budd-Chiari syndrome (BCS) patients with hepatic venous obstruction (HVO). We aim to evaluate the safety and long-term outcome of PTBA with a large balloon catheter in a large series of patients with HVO.

METHODS

Between January 2005 and December 2013, 93 consecutive BCS patients with HVO were referred for PTBA and subsequently underwent color Doppler ultrasonography or angiography follow-up. Data were retrospectively collected, and follow-up observations were performed at 1-, 2-, 2- to 5-, and 5- to 8-years postoperatively.

RESULTS

Percutaneous transluminal balloon angioplasty was technically successful in all patients. Ninety-one patients (97.85%) were treated with PTBA and two with PTBA and stent. Major procedure-related complications occurred in six of the 93 patients (6.45%). The cumulative 1-, 2-, 2- to 5-, and 5- to 8-year primary patency rates were 97.5%, 92.9%, 90%, and 86.5%, respectively. Cumulative 1-, 2-, 2- to 5-, and 5- to 8-year secondary patency rates were 100%, 100%, 98.6%, and 97.3%, respectively. Mean and median primary patency rates were 51.50 ± 3.01 months and 55.0 ± 3.63 months, respectively. Cumulative 1-, 2-, 2- to 5-, and 5- to 8-year survival rates were 98.75%, 98.6%, 100%, and 100%, respectively. Mean and median survival times were 53.10 ± 3.04 months and 55.0 ± 3.64 months, respectively.

CONCLUSION

Percutaneous transluminal balloon angioplasty with a large balloon is a safe and effective treatment that could provide excellent rates of long-term patency and survival for the majority of Chinese patients with BCS and HVO.

Sonographic Evaluation of Budd-Chiari Syndrome With Intracaval Stent

Budd-Chiari syndrome (BCS) with an intracaval stent is a rare presentation. In most Western patients with BCS, it is predominantly the hepatic veins that are involved, not the inferior vena cava (IVC). In the case presented, the patient had antiphospholipid syndrome with BCS that involved the IVC and required an intracaval stent. Presented with the case study are scanning techniques for BCS and the IVC to help sonographers evaluate the normal and abnormal anatomy and hemodynamics of this system.

Survival and prognostic indicators of Budd-Chiari syndrome: a systematic review of 79 studies

This paper aimed to systematically review the survival of Budd-Chiari syndrome and to identify the most robust prognostic predictors. Overall, 79 studies were included. According to the treatment modalities, the median 1-, 5- and 10-year survival rate was 93, 83 and 73% after interventional radiological treatment; 81, 75 and 72.5% after surgery other than liver transplantation; 82.5, 70.2 and 66.5% after liver transplantation and 68.1, 44.4% and unavailable after medical therapy alone. According to the publication years, the median 1-, 5- and 10-year survival rate was 68.6, 44.4% and unavailable before 1990; 75.1, 69.5 and 57% during the year 1991-1995; 77, 69.6 and 65.6% during the year 1996-2000; 86.5, 74 and 63.5% during the year 2001-2005 and 90, 82.5 and 72% after 2006. Bilirubin, creatinine and ascites were more frequently identified as significant prognostic factors in univariate analyses. But their statistical significance was less frequently achieved in multivariate analyses.

Placement of a caudal vena cava stent for treatment of Budd-Chiari-like syndrome in a 4-month-old Ragdoll cat

CASE DESCRIPTION

A 16-week-old 1.5-kg (3.3-lb) sexually intact male Ragdoll kitten that had a 9-week history of marked modified transudate ascites was evaluated. A membranous obstruction of the caudal vena cava at the cranial aspect of the liver was identified via CT angiography.

CLINICAL FINDINGS

Physical examination findings included a markedly distended abdomen and panting. Testing for circulating FIV antibody and FeLV antigen, a PCR assay for feline coronavirus performed on a sample of peritoneal fluid, and fecal flotation yielded negative results. A diagnosis of Budd-Chiari-like syndrome secondary to a membranous obstruction of the caudal vena cava was made.

TREATMENT AND OUTCOME

The cat was anesthetized, and the subhepatic portion of the caudal vena cava was identified and accessed via median celiotomy and direct venipuncture. A 6F 8 × 24-mm balloon-expandable nitinol biliary stent was placed across the stenotic area under fluoroscopic guidance. The patient remained free of clinical signs at the last follow-up 13 months following the procedure.

CLINICAL RELEVANCE

Budd-Chiari-like syndrome is a rare phenomenon in veterinary medicine, and congenital malformations should be considered in young feline patients with ascites. Computed tomography angiography proved to be a helpful adjunctive imaging technique to establish a diagnosis in this case. To the authors' knowledge, this is the first report of successful treatment of a congenital caudal vena cava obstruction by means of stent placement in a juvenile cat.

Budd-Chiari syndrome and liver transplantation

Budd-Chiari syndrome involves obstruction of hepatic venous outflow tracts at various levels from small hepatic veins to the inferior vena cava and is the result of thrombosis or its fibrous sequelae. There is a conspicuous difference in its etiology in the West and the East. Myeloproliferative disease predominates in the West and obstruction of the vena cava predominates in the East. The clinical presentation and clinical manifestations are so varied that it should be suspected in any patient with acute or chronic liver dysfunction. It should be treated with step-wise management. First-line therapy should be anticoagulation with medical treatment of the underlying illness, and interventional revascularization and TIPS are indicated in the event of a lack of response to medical therapy. Liver transplantation may be indicated as a rescue treatment or for fulminant cases with promising results. This step-by-step strategy has achieved a 5-year transplant-free survival rate of 70% and a 5-year overall survival rate of 90%. Living donor liver transplantation can also be used for patients with Budd-Chiari syndrome if deceased donor livers are scarce, but it requires a difficult procedure particularly with regard to venous outflow reconstruction.

Surgical portosystemic shunts in the era of TIPS and liver transplantation are still relevant

BACKGROUND

The surgical portosystemic shunts (PSS) are a time-proven modality for treating portal hypertension. Recently, in the era of liver transplantation and the transjugular intrahepatic portosystemic shunts (TIPS), use of the PSS has declined.

OBJECTIVES

This study was conducted to evaluate changes in practice, referral patterns, and short- and longterm outcomes of the use of the surgical PSS before and after the introduction of the Model for End-stage Liver Disease (MELD).

METHODS

A retrospective analysis of 47 patients undergoing PSS between 1996 and 2011 in a single university hospital was conducted.

RESULTS

Subgroups of patients with cirrhosis (53%), Budd-Chiari syndrome (13%), portal vein thrombosis (PVT) (26%), and other pathologies (9%) differed significantly with respect to shunt type, Child-Pugh class, MELD score and perioperative mortality. Perioperative mortality at 60 days was 15%. Five-year survival was 68% (median: 70 months); 5-year shunt patency was 97%. Survival was best in patients with PVT and worst in those with Budd-Chiari syndrome compared to other subgroups. Patency was better in the subgroups of patients with cirrhosis and other pathologies compared with the PVT subgroup. Substantial changes in referral patterns coincided with the adoption of the MELD in 2002, with decreases in the incidence of cirrhosis and variceal bleeding, and increases in non-cirrhotics and hypercoagulopathy.

CONCLUSIONS

Although the spectrum of diseases benefiting from surgical PSS has changed, surgical shunts continue to constitute an important addition to the surgical armamentarium. Selected subgroups with variceal bleeding in well-compensated cirrhosis and PVT benefit from the excellent longterm patency offered by the surgical PSS.

Nuclear medicine dynamic investigations in the diagnosis of Budd-Chiari syndrome

AIM

To investigate the hepatic hemodynamics in the Budd-Chiari syndrome (BCS) using per-rectal portal scintigraphy (PRPS) and liver angioscintigraphy (LAS).

METHODS

Fourteen consecutive patients with BCS were evaluated by PRPS between 2003 and 2012. Ten of them underwent LAS and liver scan (LS) with Tc-99m colloid. Eleven patients had clinical manifestations and three were asymptomatic, incidentally diagnosed at PRPS. The control group included 15 healthy subjects. We used new parameters at PRPS, the liver transit time of portal inflow and the blood circulation time between the right heart and liver. PRPS offered information on the hepatic areas missing venous outflow or portal inflow, length and extent of the lesions, open portosystemic shunts (PSS), involvement of the caudate lobe (CL) as an intrahepatic shunt and flow reversal in the splenic vein. LAS was useful in the differential diagnosis between the BCS and portal obstructions, highlighting the hepatic artery buffer response and reversed portal flow. LS offered complementary data, especially on the CL.

RESULTS

We described three hemodynamic categories of the BCS with several subtypes and stages, based on the finding that perfusion changes depend on the initial number and succession in time of the hepatic veins (HVs) obstructions. Obstruction of one hepatic vein (HV) did not cause opening of PSS. The BCS debuted by common obstruction of two HVs had different hemodynamic aspects in acute and chronic stages after subsequent obstruction of the third HV. In chronic stages, obstruction of two HVs resulted in opening of PSS. The BCS, determined by thrombosis of the terminal part of the inferior vena cava, presented in the acute stage with open PSS with low speed flow. At least several weeks are required in the obstructions of two or three HVs for the spontaneous opening of dynamically efficient PSS. The CL seems to have only a transient important role of intrahepatic shunt in several types of the BCS.

CONCLUSION

Dynamic nuclear medicine investigations assess the extent and length of hepatic venous obstructions, open collaterals, areas without portal inflow, hemodynamic function of the CL and reverse venous flow.

TIPS: 25 years later

In the 25 years since the first TIPS intervention has been performed, technical standards, indications, and contraindications have been set up. The previous considerable problem of shunt failure by thrombosis or intimal proliferation in the stent or in the draining hepatic vein has been reduced considerably by the availability of polytetrafluoroethylene (PTFE)-covered stents resulting in reduced rebleeding and improved survival. Unfortunately, most clinical studies have been performed prior to the release of the covered stent and, therefore, do not represent the present state of the art. In spite of this, TIPS has gained increasing acceptance in the treatment of the various complications of portal hypertension and vascular diseases of the liver.

Prevalence of covert duplicate publications in Budd-Chiari syndrome articles in China: a systematic analysis

BACKGROUND

Covert duplicate publication is unquestionably unethical and problematic. Approximately 3000 articles describing Budd-Chiari syndrome in China have been published. However, no study has yet explored the prevalence of covert duplicate publications among these articles.

METHODS

We retrieved original articles regarding Budd-Chiari syndrome in China via the PubMed, Chinese Scientific and Technological Journal (VIP), and China National Knowledge Infrastructure databases. The prevalence of covert duplicate publications was evaluated across publication dates, institutional grades, and academic levels of the journals.

RESULTS

Overall, 1914 articles were included in our analysis. These articles were produced by 632 institutions and published in 463 journals. Overall, 10% (184/1914) of the articles, 10% (62/632) of the institutions, and 26% (119/463) of the journals were involved in covert duplicate publications. A decreasing trend in the prevalence of covert duplicate publications over time was observed. The prevalence of covert duplicate publications was significantly higher in tertiary hospitals than in primary hospitals or unclassified institutions (10.0% vs 3.8%, P = .038), but the prevalence was similar between tertiary and secondary hospitals (10.0% vs 9.3%, P = .72). The prevalence of covert duplicate publications was significantly higher in Science Citation Index journals than in Chinese Academic Core journals (23.9% vs 10.3%, P = .001) and other journals (23.9% vs 8.3%, P < .001).

CONCLUSIONS

Covert duplicate publications are relatively common among articles on Budd-Chiari syndrome in China. The high prevalence of covert duplicate publication in Science Citation Index journals should remind English-language journal editors to verify whether the articles submitted by Chinese researchers have been published in Chinese-language journals.

Budd-Chiari syndrome following vaginal delivery in a patient with Crohn’s disease: a case report and review of the literature

Introduction: The association of Budd-Chiari syndrome (BCS), Crohn’s disease (CD) and pregnancy is extremely rare. The successful medical treatment of BCS in the postpartum period in a woman with CD is presented.

Case report: A 28-year-old woman with CD presented with fever of 42°C and gross abdominal distention 2 days following delivery. On sonographic examination, massive ascites and hepatosplenomegaly were noted. Color Doppler ultrasonography and contrast-enhanced computed tomography revealed a thrombus in the suprahepatic inferior vena cava causing significant luminal obstruction. She was diagnosed with BCS. Medical treatment with spironolactone, furosemide, imipenem, metronidazole, and enoxaparin improved the clinical picture.

Conclusion: In a pregnant woman with CD, extreme thromboembolic events such as BCS might occur. If diagnosed early and treated in the acute phase, prognosis is fair.

Staged management of Budd-Chiari syndrome caused by co-obstruction of the inferior vena cava and main hepatic veins

BACKGROUND

Collateralized intra- and extra-hepatic routes in patients with Budd-Chiari syndrome (BCS) were important. This study aimed to investigate the feasibility and clinical outcomes of the staged management of BCS based on the degree of compensation provided by intra- or extra-hepatic collateral circulations.

METHODS

A total of 103 adult patients with BCS caused by co-obstruction of the inferior vena cava (IVC) and main hepatic veins (MHVs) between March 2001 and October 2009 were enrolled in this study. Based on the pathological classification and degree of hemodynamic compensation by collateral circulations, treatment priority for IVC hypertension was determined in the first-stage treatment. Patients were deemed eligible for second-stage treatment when the first-stage treatment failed to relieve.

RESULTS

Imaging results revealed that most patients had collateral circulations to different extents. Based on the degree of compensation provided by these collateral circulations, 74 patients underwent single-stage treatment for IVC hypertension, i.e., radiologic intervention (RI) for 61 patients and surgical procedures (SPs) for 13. One patient was treated for portal hypertension. Twenty-nine patients underwent second-stage treatment (25 underwent RI and SP, and 4 only SP). The general morbidity and mortality after all procedures were 8.3% and 1.5%, respectively. After a median follow-up of 35 months, 4 patients underwent second-stage treatment and 7 underwent recanalization of the IVC/MHVs. Two patients died of hepatocellular carcinoma and 1 died of graft obstruction.

CONCLUSION

Staged management produces excellent outcomes for patients with BCS caused by co-obstruction of the IVC and MHVs.

Treatment of Budd-Chiari syndrome with inferior vena cava thrombosis

The aim of this study was to evaluate the initial results of 41 patients with Budd-Chiari syndrome (BCS) with inferior vena cava (IVC) thrombosis, with regard to the clinical safety and feasibility of the therapeutic approaches selected according to the classification of the condition. Forty-one patients with BCS and IVC thrombosis were admitted for retrospective analysis. All 41 patients were classified as having one of three types of BCS. Interventional therapy was used successfully in 28 patients (68.3%), 7 patients (17.1%) were given conservative treatment and 6 patients (14.6%) were treated with surgical shunts. The interventional approach was used in 29 patients in total and was successful in 28 patients (all those of types I and II, and 3 of the 4 patients of type III with acute thrombosis; 96.6%). None of these 28 patients had pulmonary embolism, pericardial tamponade or intra-abdominal bleeding. After 1–5 years, 4 patients (9.8%) had a second dilation of the IVC. In the 7 cases treated in a conservative manner, 2 cases succumbed to upper gastrointestinal bleeding and 1 case succumbed to liver and kidney failure. This study indicates that the classification of BCS patients with IVC thrombosis is helpful in selecting a therapeutic approach. Interventional therapy is the first therapeutic choice for BCS patients with IVC thrombosis of type I, type II or type III with acute thrombosis. For the patients of type III with an obsolete thrombus, surgical shunts or conservative treatment are the main therapeutic methods.

An update on the diagnosis and management of Budd-Chiari syndrome

Budd-Chiari syndrome is a rare disorder caused by hepatic venous outflow obstruction and resulting hepatic dysfunction. Despite a lack of prospective randomized trials, much progress has been made in its management over the last 20 years. The main goals of treatment are to ameliorate hepatic congestion and prevent further thrombosis. The selective use of anticoagulation, vascular stents, transjugular intrahepatic portosystemic stent-shunt and liver transplant has resulted in a significant increase in survival. The diagnosis, initial management and long-term follow-up of patients with Budd-Chiari syndrome is reviewed. The concept of individualization of treatment and a stepwise approach to invasive procedures is also discussed.

[Portosystemic shunt surgery between TIPS and liver transplantation]

Portosystemic shunt surgery in addition to transjugular intrahepatic portosystemic shunt (TIPS) insertion must still be regarded as a current treatment option for portomesenteric decompression in patients with pharmacological and endoscopic treatment failure, where liver transplantation is not imminent. This applies to secondary prophylaxis of rebleeding from varices in patients with well preserved liver function, e.g. liver cirrhosis CHILD A or extrahepatic portal vein thrombosis. Even if emergency endoscopy represents the treatment of choice in the acute bleeding situation, latest data from San Diego on emergency portacaval shunt surgery are encouraging. Likewise, portacaval shunt procedures can be an attractive alternative to TIPS or liver transplantation for acute Budd-Chiari syndrome or veno-occlusive disease.This article is an update on the systematics and methodology of portacaval shunt surgery, emphasizing the significance of this treatment option based on latest studies.

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

BACKGROUND

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

AIMS AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Budd-Chiari syndrome revisited: 38 years' experience with surgical portal decompression

OBJECTIVE

Ten years ago, we reported our results with what remains as the largest clinical experience with surgical portal decompression for Budd-Chiari syndrome (BCS) in the West. Since then, our series has expanded to 77 patients, and there has been an explosion of interest in and publications about BCS. The objectives of this study are to assess the validity of our observations and conclusions regarding BCS reported 10 years ago by expansion of our series of patients and observations of outcomes over an additional decade of close follow-up.

METHODS

Seventy-seven patients with BCS were allocated to three groups: group I, 39 had hepatic vein occlusion alone, treated by side-to-side portacaval shunt (SSPCS); group II, 26 had inferior vena cava occlusion treated by mesoatrial shunt in eight and combined SSPCS and cavoatrial shunt (CAS) in 18; and group III, 12 had decompensated cirrhosis too late for portal decompression who were listed for liver transplantation (LT). An extensive diagnostic workup included angiography with pressure measurements and needle liver biopsy. Follow-up was 100%, lasting 5-38 years.

RESULTS

In group I, long-term survival is 95% with 36 free of ascites, leading lives of good quality 5-38 years post-SSPCS. In group II, mesoatrial shunt was discontinued after 1990 because of a high failure rate, but combined SSPCS-CAS has resulted in 100% survival for 5-25 years. In group III, six patients (50%) are alive and well for more than 5 years post-LT. Serial liver biopsies following portal decompression have shown long-term reversal of the lesions of BCS.

CONCLUSIONS

Long-term survival following portal decompression of BCS in the West has not been equaled by any other form of therapy, medical or surgical. It is imperative to perform surgical portal decompression early in the course of BCS in order to avoid irreversible liver damage.

Diagnosis of Budd-Chiari syndrome: three-dimensional dynamic contrast enhanced magnetic resonance angiography

OBJECTIVE

To investigate the characteristics and diagnostic value of three-dimensional contrast-enhanced magnetic resonance angiography (3D CE-MRA) in the diagnosis of Budd-Chiari syndrome (BCS).

METHODS

One hundred thirty-three BCS patients underwent 3D CE-MRA, 64 patients had primary BCS, and 69 had secondary BCS.

RESULTS

Fifty five cases (41.4%) showed a segmental stenosis of the inferior vena cava, 9 cases (6.8%) a membranous obstruction of the inferior vena cava, 5 cases (3.8%) an unobstructed inferior vena cava and hepatic veno-occlusive condition, 16 cases (12.0%) an inferior vena cava stenosis and hepatic veno-occlusive disease, and 48 cases (36.1%) an intraluminal filling defect in the inferior vena cava. In 52 cases (39.1%), collateral blood vessels were formed, with deep, medium, and shallow portal veins and intrahepatic collateral veins in 88 groups. Among these, 41 (46.6%) had deep venous collateral channels, 24 (27.3%) had medium venous collateral channels, 9 (10.2%) had superficial venous collateral channels, 5 (5.7%) had portal vein collateral channels, and 9 (10.2%) had intrahepatic venous collateral channels.

CONCLUSION

3D CE-MRA is important in the clinical diagnosis and treatment planning of BCS and displays hepatic veins, the inferior vena cava system, and collateral vessels.

Surgical treatment of Budd-Chiari syndrome: analysis of 221 cases

BACKGROUND

Budd-Chiari syndrome (B-CS) refers to post-hepatic portal hypertension and/or inferior vena cava hypertension caused by obstruction of blood flow at the portal cardinal hepatic vein. The treatments of B-CS include operations on pathological membrane lesions, shunting and combined operations. Studies have shown that China, Japan, India and South Africa have a high incidence of B-CS. In China, the Yellow River Basin in Henan, Shandong, Jiangsu and Anhui Provinces also have a high incidence, around 10 per 100 000.

METHODS

The clinical data of 221 B-CS patients were analyzed retrospectively. We focused on pathological types, surgical methods, effectiveness and complications of treatment, and follow-up.

RESULTS

Based on imaging findings such as color ultrasonography, angiography or magnetic resonance angiography, the 221 patients were divided into 3 types (five subtypes): type Ia (72 patients), type Ib (20), type II (72), type IIIa (33), and type IIIb (24). Surgical procedures included balloon membranotomy with or without stent (65 patients), improved splenopneumopexy (18), radical resection of membrane and thrombus (17), inferior vena cava bypass [29, with cavocaval transflow (13) and cavoatrial transflow (16)], mesocaval shunt (41), splenocaval shunt (25), splenoatrial shunt (12), splenojugular shunt (6), and combined methods (8). The complication rate was 9.05% (20/221) and the perioperative death rate was 2.26% (5/221). All of the patients were followed up from 6 months to 5 years. The success rate was 84.6% (187/221), and the recurrence rate was 8.9% (9/101) and 13.5% (13/96) after 1- and 5-year follow-up, respectively.

CONCLUSION

The rational choice of surgical treatment based on B-CS pathological typing may increase the success rate and decrease the recurrence.

Acute liver failure and liver assist devices

Survival of patients presenting with acute liver failure (ALF) has improved over the past decades due to earlier disease recognition, advances in supportive measures, intensive care, and liver transplantation. Liver assist devices may have a role in future care of patients with ALF, bridging them to recovery or to transplantation. A multidisciplinary team approach to the care of patients with ALF is critical for achieving good patient outcomes.

Superior mesenteric vein-caval-right atrium Y shunt for treatment of Budd-Chiari syndrome with obstruction to the inferior vena cava and the hepatic veins--a study of 62 patients

OBJECTIVE

To explore the use of superior mesenteric vein-caval-right atrium Y shunt (SMV-CV-RA Y shunt) as a treatment for Budd-Chiari syndrome (B-CS) with a long stenotic segment of IVC ≥ 2 cm and complete obstruction of all major hepatic veins with no compensating hypertrophy of the small hepatic veins that drain from the liver into the inferior vena cava (IVC) (type IIIB mixed pattern of B-CS).

METHODS

The clinical data of 101 consecutive patients with this mixed pattern of B-CS treated by surgery using artificial vascular grafts were retrospectively studied: 62 patients were treated with SMV-CV-RA Y shunt compared with historical groups of 26 patients treated with splenic vein-caval shunt and 13 patients with superior mesenteric vein-caval shunt.

RESULTS

On follow-up, the clinical results assessed to be good/improved for the groups of patients who received SMV-CV-RA Y shunt, splenic vein-caval shunt, and superior mesenteric vein-caval shunt were 57/62 (91.9%), 11/26 (42.3%), and 5/13 (38.5%), respectively (P < 0.05). The patency rates of the artificial vascular grafts were 95.2% (59/62), 69.2% (18/26), and 38.4% (5/13), respectively (P > 0.05). Compared with patients who received splenic vein-caval shunt and superior mesenteric vein-caval shunt, the platelet count of the 62 patients who received SMV-CV-RA Y shunt increased significantly 1 mo after surgery (P < 0.05). The portal venous pressure of the patients with SMV-CV-RA Y shunt decreased significantly than before shunting (P < 0.05), although this pressure decrease in patients who received splenic vein-caval shunt and superior mesenteric vein-caval shunt were insignificant (P > 0.05).

CONCLUSION

Compared with the historical splenic vein-caval shunt and superior mesenteric vein-caval shunt, SMV-CV-RA Y shunt more satisfactorily improved clinical results of patients with a special mixed pattern of B-CS, and in reducing the portal and inferior vena venous pressures. The shunt could reverse hypersplenism. The splenic vein-caval shunt and superior mesenteric vein-caval shunt were not useful for this type of patients.

Budd-Chiari syndrome: long term success via hepatic decompression using transjugular intrahepatic porto-systemic shunt

Background

Budd-Chiari syndrome (BCS) generally implies thrombosis of the hepatic veins and/or the intrahepatic or suprahepatic inferior vena cava. Treatment depends on the underlying cause, the anatomic location, the extent of the thrombotic process and the functional capacity of the liver. It can be divided into medical treatment including anticoagulation and thrombolysis, radiological procedures such as angioplasty and transjugular intrahepatic porto-systemic shunt (TIPS) and surgical interventions including orthotopic liver transplantation (OLT). Controlled trials or reports on larger cohorts are limited due to rare disease frequency. The aim of this study was to report our single centre long term results of patients with BCS receiving one of three treatment options i.e. medication only, TIPS or OLT on an individually based decision of our local expert group.

Methods

20 patients with acute, subacute or chronic BCS were treated between 1988 and 2008. Clinical records were analysed with respect to underlying disease, therapeutic interventions, complications and overall outcome.

Results

16 women and 4 men with a mean age of 34 ± 12 years (range: 14-60 years) at time of diagnosis were included. Myeloproliferative disorders or a plasmatic coagulopathy were identified as underlying disease in 13 patients, in the other patients the cause of BCS remained unclear. 12 patients presented with an acute BCS, 8 with a subacute or chronic disease. 13 patients underwent TIPS, 4 patients OLT as initial therapy, 2 patients required only symptomatic therapy, and one patient died from liver failure before any specific treatment could be initiated. Eleven of 13 TIPS patients required 2.5 ± 2.4 revisions (range: 0-8). One patient died from his underlying hematologic disease. The residual 12 patients still have stable liver function not requiring OLT. All 4 patients who underwent OLT as initial treatment, required re-OLT due to thrombembolic complications of the graft. Survival in the TIPS group was 92.3% and in the OLT group 75% during a median follow-up of 4 and 11.5 years, respectively.

Conclusion

Our results confirm the role of TIPS in the management of patients with acute, subacute and chronic BCS. The limited number of patients with OLT does not allow to draw a meaningful conclusion. However, the underlying disease may generate major complications, a reason why OLT should be limited to patients who cannot be managed by TIPS.

Modified transjugular intrahepatic portosystemic shunt in the treatment of Budd-Chiari syndrome

AIMS

The aim of this study was to determine the outcome of a modified transjugular intrahepatic portosystemic shunt (MTIPS) in the treatment of the Budd-Chiari syndrome (BCS, occlusion of the hepatic veins).

METHODS

Eleven patients with severe BCS were selected for MTIPS treatment. Three patients had an acute history (< 2 months) and eight had a subacute or a chronic course of the disease. All patients were associated with variceal bleeding and massive ascites. The diagnosis of BCS was established by duplex sonography, computed tomography scan, magnetic resonance imaging, angiography of hepatic veins and inferior vena cava, and liver biopsy. The shunt was established using conventional self-expandable stents with diameter of 10 cm in all patients. The mean follow-up was 60.55 +/- 42.76 months.

RESULTS

The shunt reduced the portosystemic pressure gradient from 30.32 +/- 7.69 to 9.08 +/- 3.43 mmHg and improved the portal flow velocity from 11.24 +/- 2.75 to 52.16 +/- 13.68 cm/s. Clinical symptoms as well as the biochemical test results improved significantly during 3 weeks after shunt treatment except for one death caused by hepatic failure. Ten patients are alive without clinical symptoms. Three revisions in two patients were needed during the follow-up. The inflation of stenosised shunt was performed in one patient, and the inflation of stenosised shunt and the reimplantation of stent in another patient. The other eight patients had no revisions.

CONCLUSIONS

Modified transjugular intrahepatic portosystemic shunt provides an excellent outcome in patients with BCS (occlusion of the hepatic veins). It may be regarded as an option for the acute and long-term managements of these patients.

Rapid development of a hepatocellular carcinoma in isolated thrombosis of hepatic veins (classic Budd-Chiari syndrome): case report and review of literature

Budd-Chiari syndrome and membranous obstruction of the inferior vena cava frequently result in the development of mostly benign hepatic lesions. In cases of membranous obstruction of the inferior vena cava, which is prevalent mostly in the East, these lesions often progress to hepatocellular carcinoma. In contrast, malignant transformation has not yet been recognised in patients with isolated hepatic vein thrombosis. We report the case of a 37-year-old male Caucasian who presented with acute Budd-Chiari syndrome without involvement of the inferior vena cava. Despite porto-caval shunting, a hepatocellular carcinoma developed within several months. Three hepatic lesions were treated by radiofrequency thermal ablation until liver transplantation was performed. This report emphasises the possibility of malignant transformation of regenerative nodules in patients with disturbed hepatic perfusion in general. Physicians must be aware of this when assessing regenerative nodules, especially as no unambiguous predictors for the development of hepatocellular carcinoma have been identified so far.

Rotterdam score predicts early mortality in Budd-Chiari syndrome, and surgical shunting prolongs transplant-free survival

BACKGROUND

Budd-Chiari syndrome carries significant mortality, but factors predicting this outcome are uncertain.

AIM

To determine factors associated with 3-month mortality and compare outcomes after surgical shunting or liver transplantation.

METHODS

From 1985 to 2008, 51 patients with Budd-Chiari syndrome were identified.

RESULTS

By logistic regression analysis, features associated with higher risk of 3-month mortality were Rotterdam class III, Clichy >6.6, model for end-stage liver disease (MELD) >20 and Child-Pugh C. Rotterdam class III had the best performance to discriminate 3-month mortality with sensitivity of 0.89 and specificity of 0.63, whereas Clichy >6.60 had sensitivity of 0.78 and specificity of 0.69; MELD >20 had sensitivity of 0.78 and specificity of 0.75 and Child-Pugh C had sensitivity of 0.67 and specificity of 0.72. Eighteen patients underwent surgical shunts and 14 received liver transplantation with no significant differences in survival (median survival 10 +/- 3 vs. 8 +/- 2 years; log-rank, P = 0.9).

CONCLUSIONS

Rotterdam score is the best discrimination index for 3-month mortality in Budd-Chiari syndrome and should be used preferentially to determine treatment urgency. Surgical shunts constitute an important therapeutic modality that may help save liver grafts and prolong transplantation-free survival in a selected group of patients with Budd-Chiari syndrome.

ICU management of acute liver failure

Survival of patients presenting with acute liver failure (ALF) has improved because of earlier disease recognition, better understanding of pathophysiology of various insults leading to ALF, and advances in supportive measures including a team approach, better ICU care, and liver transplantation. This article focuses on patient management and evaluation that takes place in the ICU for patients who have acute liver injury. An organized team approach to decision making about critical care delivered during this period of time is important for achieving a good patient outcome.

Diagnostic and interventional radiology for Budd-Chiari syndrome

Budd-Chiari syndrome is a heterogeneous group of disorders characterized by hepatic venous outflow obstruction that involves one or more draining hepatic veins. Its occurrence in populations in the western hemisphere is commonly associated with hypercoagulative states. Clinical manifestations in many cases are nonspecific, and imaging may be critical for early diagnosis of venous obstruction and accurate assessment of the extent of disease. If Budd-Chiari syndrome is not treated promptly and appropriately, the outcome may be dismal. Comprehensive imaging evaluations, in combination with pathologic analyses and clinical testing, are essential for determining the severity of disease, stratifying risk, selecting the appropriate therapy, and objectively assessing the response. The main goal of treatment is to alleviate hepatic congestion, thereby improving hepatocyte function and allowing resolution of portal hypertension. Various medical, endovascular, and surgical treatment options are available. Percutaneous and endovascular procedures, when performed in properly selected patients, may be more effective than medical treatment methods for preserving liver function and arresting disease progression in the long term. In addition, such procedures are associated with lower morbidity and mortality than are open surgical techniques.

Portal vein thrombosis and budd-Chiari syndrome

Venous thrombosis results from the convergence of vessel wall injury and/or venous stasis, known as local triggering factors, and the occurrence of acquired and/or inherited thrombophilia, also known as systemic prothrombotic risk factors. Portal vein thrombosis (PVT) and Budd-Chiari syndrome (BCS) are caused by thrombosis and/or obstruction of the extrahepatic portal veins and the hepatic venous outflow tract, respectively. Several divergent prothrombotic disorders may underlie these distinct forms of large vessel thrombosis. While cirrhotic PVT is relatively common, especially in advanced liver disease, noncirrhotic and nontumoral PVT is rare and BCS is of intermediate incidence. In this article, we review pathogenic mechanisms and current concepts of patient management.

Mesoatrial shunt in Budd-Chiari syndrome

Background. Budd-Chiari syndrome (BCS) represents partial or total occlusion of the hepatic veins with or without simultaneous obstruction of vena cava inferior (VCI). The symptoms of BCS are abdominal pain, hepatomegaly, ascites, varices of the abdominal wall, sometimes bleeding from the upper part of gastointestinal tract (GIT), lower limbs swelling and jaundice. Primary BSC is a relatively rare condition occurring in one per 100 000 of the population worldwide. Case report. A male patient, 25-year-old, facing tooth postextraction complications, was presented with acute BCS. On admission, physical examination revealed pale-grayish complexion, more pronounced veins over the thorax and abdomen, ascites, enlarged liver rising 8 cm below the right costal arch and having a minor pleural effusion by the right side. The patient was submitted to Doppler sonography and computed tomography (CT) that verified the right leg deep veins thrombosis, as well as the presence of a thrombus in the intrahepatic portion of the VCI. Multislice computed tomography (MSCT) showed occlusion of hepatic veins (Budd-Chiari syndrome) and thrombosis of the VCI in the retrohepatic part 6 cm long. Also, increased values of transaminases and gamma GT and reduced values of albumines and serum ferrum were registered. Molecular examination revealed Factor V Leiden mutation - heterozygote. After preoperative preparations a mesocaval shunt was made using Gore- Tex ring graft of 12 mm. Intraoperatively, the blue enlarged liver was found with almost black zones of tense capsule. After a graft making, liver congestion decreased followed by the change of colour and volume. Within postoperative course metabolic and synthetic liver functions were obvious. Conclusion. In patients with BCS medicamentous treatment does not yield adequate results, but even causes worsening of general condition. Surgical therapy in the presented patient was performed timely regarding the stage of the disease due to which irreversible liver changes were prevented while decompression of the portal system provided time overbridging up to liver transplantation.