Transjugular intrahepatic portosystemic shunt (TIPS) for Budd-Chiari syndrome or portal vein thrombosis: review of indications and problems

Transjugular intrahepatic portosystemic shunt for pediatric portal hypertension: A meta-analysis

To evaluate the feasibility of transjugular intrahepatic portosystemic shunt (TIPS) in children with portal hypertensive complications, PubMed and Cochrane Library were queried to identify clinical studies evaluating TIPS in patients <18 years old. Baseline clinical characteristics, laboratory values, and clinical outcomes were extracted. Eleven observational studies totaling 198 subjects were included in the study. The pooled technical success rate and hemodynamic success rate were 94% (95% confidence interval [CI]: 86-99%) and 91% (95% CI: 82-97%), respectively; ongoing variceal bleeding resolved in 99.5% (95% CI: 97-100%); refractory ascites was improved in 96% (95% CI: 69-100%); post-TIPS bleeding rate was 14% (95% CI: 1-33%); 88% of patients were alive or successfully received liver transplant (95% CI: 79-96%); and shunt dysfunction rate was 27% (95% CI: 17-38%). Hepatic encephalopathy occurred in 10.6% (21/198), though 85.7% (18/21) resolved with medical management only. In conclusion, based on moderate levels of evidence, TIPS is a safe and effective intervention that should be considered in pediatric patients with portal hypertensive complications. Future comparative studies are warranted.

TIPS for Adults Without Cirrhosis With Chronic Mesenteric Venous Thrombosis and EHPVO Refractory to Standard-of-Care Therapy

BACKGROUND AND AIMS

Extrahepatic portal vein occlusion (EHPVO) from portal vein thrombosis is a rare condition associated with substantial morbidity and mortality. The purpose of this study is to investigate the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) for the treatment of chronic EHPVO, cavernomatosis, and mesenteric venous thrombosis in adults without cirrhosis who are refractory to standard-of-care therapy.

APPROACH AND RESULTS

Thirty-nine patients with chronic EHPVO received TIPS. Laboratory parameters and follow-up were assessed at 1, 3, 6, 12, and 24 months, and every 6 months thereafter. Two hepatologists adjudicated symptom improvement attributable to mesenteric thrombosis and EHPVO before/after TIPS. Kaplan-Meier was used to assess primary and overall TIPS patency, assessing procedural success. Adverse events, radiation exposure, hospital length-of-stay and patency were recorded. Cavernoma was present in 100%, with TIPS being successful in all cases using splenic, mesenteric, and transhepatic approaches. Symptom improvement was noted in 26 of 30 (87%) at 6-month follow-up. Twelve patients (31%) experienced TIPS thrombosis. There were no significant long-term laboratory adverse events or deaths. At 36 months, freedom from primary TIPS thrombosis was 63%; following secondary interventions, overall patency was increased to 81%.

CONCLUSIONS

TIPS in chronic, noncirrhotic EHPVO with cavernomas and mesenteric venous thrombosis is technically feasible and does not adversely affect liver function. Most patients demonstrate subjective and objective benefit from TIPS. Improvement in patency rates are needed with proper timing of adjuvant anticoagulation.

Transjugular intrahepatic portosystemic shunts in portal vein thrombosis: A review

The presence of portal vein thrombosis (PVT) has previously been considered a contraindication to the insertion of transjugular intrahepatic portosystemic shunts (TIPSS). However, patients with PVT may have portal hypertension complications and may thus benefit from TIPSS to reduce portal venous pressure. There is an increasing body of literature that discusses the techniques and outcomes of TIPSS in PVT. This review summarizes the techniques, indications and outcomes of TIPSS in PVT in published case reports, case series and comparative trials, especially regarding the reduction in portal hypertensive complications such as variceal bleeding. A comprehensive literature search was conducted using MEDLINE and PubMed databases. Manuscripts published in English between 1 January 1990 and 1 March 2021 were used. Abstracts were screened and data from potentially relevant articles analyzed. TIPSS in PVT has been reported with high levels of technical success, short-term portal vein recanalization and long-term PV patency and TIPSS patency outcomes. Several comparative studies, including randomized controlled trials, have shown favorable outcomes of TIPSS compared with non-TIPSS treatment of PVT complications. Outcomes of TIPSS with PVT appear similar to those in TIPSS without PVT. However, TIPSS may be more technically difficult in the presence of PVT, and such procedures should be performed in expert high-volume centers to mitigate the risk of procedural complications. The presence of PVT should no longer be considered a contraindication to TIPSS. TIPSS for PVT has been acknowledged as a therapeutic strategy in recent international guidelines, although further studies are needed before recommendations can be strengthened. KEY POINTS: Portal vein thrombosis (PVT) is no longer a contraindication to the insertion of transjugular intrahepatic portosystemic shunts (TIPSS) TIPSS often leads to the spontaneous dissolution of PVT, but can be combined with mechanical or pharmacological thrombectomy TIPSS reduces portal hypertensive complications of PVT, such as variceal bleeding, and can also facilitate liver transplantation where PVT may otherwise interfere with vascular anastomoses Studies have shown favorable long-term outcomes of TIPSS compared with TIPSS without PVT; as well as compared with non-TIPSS treatment of PVT complications TIPSS in PVT should be performed in high-volume specialist centers due to technical difficulties.

Retrospective comparative study of efficacy, safety and outcome of percutaneous intervention for Budd-Chiari syndrome patients with bilirubin less than 3 and 3-6 mg/dl

OBJECTIVE

Comparing the efficacy, safety and outcome of percutaneous intrervention for Budd-Chiari Syndrome (BCS) patients with bilirubin less than 3 and 3-6 mg dl^-1.

METHODS AND MATERIALS

188 BCS patients having serum bilirubin ≤6 mg dl^-1 and underwent percutaneous interventions were divided into two groups based on bilirubin level: 151 patients having bilirubin <3 mg dl^-1 were included in Group 1; and 37 patients having bilirubin 3-6 mg dl^-1 were included in Group 2. Both group were compare for technical success (successful recanalization of hepatic venous stenosis or creation of portocaval shunt with post-procedure gradient ≤5 mm of Hg), Safety (procedure-related mortality/morbidity or patient required transplantation) and outcome (resolution of clinical symptoms and survival).

RESULTS

Technical success was 94.7% in Group 1-89.1% in Group 2 with overall success rate was 93.6%. No significant differences observed between the two groups in regards to procedure related complication. Overall transplant-free survival at 1 and 5 years after intervention in both groups was 96.3 and 91.2% respectively. 1-year and 5-year survivals in Group 1 was 96.7%, and 93.1%, whereas Group 2 was 94.6 and 90.1% with no statically significantly difference between the two groups (p = 0.59). Percutaneous intervention results are good in patients having bilirubin up to 6 mg dl^-1, i.e. mild to moderate liver dysfunctions.

CONCLUSION

Technical success, survival and outcome of percutaneous intervention in BCS patients having serum bilirubin 3-6 mg dl^-1 was comparable to patients having bilirubin level <3 mg dl^-1.

ADVANCES IN KNOWLEDGE

Percutaneous intervention treatment is suitable for treatment for symptomatic BCS patients having bilirubin up to 6 mg  dl^-1.

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.

Techniques and long-term effects of transjugular intrahepatic portosystemic shunt on liver cirrhosis-related thrombotic total occlusion of main portal vein

Portal vein hypertension (PVH) in liver cirrhosis complicated with portal venous thrombosis (PVT) has been mainly treated with transjugular intrahepatic portosystemic shunt (TIPS). The clinical effects of TIPS have been confirmed, however, no large-scale studies have been focused on technical analyses and a long-term follow-up, especially on thrombotic total occlusion of main portal vein (MPV). To demonstrate critical techniques and clinical outcome of TIPS on liver cirrhosis-related thrombotic total occlusion of MPV, 98 patients diagnosed with liver cirrhosis related thrombotic total occlusion of MPV and treated with TIPS from January 2000 to January 2010 were retrospectively analyzed. Twenty-three (23.5%) patients had MPV (single site) thrombosis, 55 (56.1%) had multiple site-thrombosis (MPV and other), 17 (17.3%) had cavernous transformation of portal vein, and 3 (3.1%) had post-transplant thrombosis. The successful rate of TIPS was 90.7%, without any procedure-related deaths or severe complications. Mean portal pressure was dropped from 33.08 ± 1.38 mmHg preoperatively to 20.18 ± 0.83 mmHg postoperatively (p < 0.001). Collectively, TIPS is safe and effective in treating liver cirrhosis-related thrombotic total occlusion of MPV. This complex procedure requires combination of indirect portography and percutaneous transhepatic portal techniques to increase the rate of success.

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.

In vivo validation of 4D flow MRI for assessing the hemodynamics of portal hypertension

PURPOSE

To implement and validate in vivo radial 4D flow MRI for quantification of blood flow in the hepatic arterial, portal venous, and splanchnic vasculature of healthy volunteers and patients with portal hypertension.

MATERIALS AND METHODS

Seventeen patients with portal hypertension and seven subjects with no liver disease were included in this Health Insurance Portability and Accountability Act (HIPAA)-compliant and Institutional Review Board (IRB)-approved study. Exams were conducted at 3T using a 32-channel body coil with large volumetric coverage and 1.4 mm isotropic true spatial resolution. Using postprocessing software, cut-planes orthogonal to vessels were used to quantify flow (L/min) in the hepatic and splanchnic vasculature.

RESULTS

Flow quantification was successful in all cases. Portal vein and supraceliac aorta flow demonstrated high variability among patients. Measurements were validated indirectly using internal consistency at three different locations within the portal vein (error = 4.2 ± 3.9%) and conservation of mass at the portal confluence (error = 5.9 ± 2.5%) and portal bifurcation (error = 5.8 ± 3.1%).

CONCLUSION

This work demonstrates the feasibility of radial 4D flow MRI to quantify flow in the hepatic and splanchnic vasculature. Flow results agreed well with data reported in the literature, and conservation of mass provided indirect validation of flow quantification. Flow in patients with portal hypertensions demonstrated high variability, with patterns and magnitude consistent with the hyperdynamic state that commonly occurs in portal hypertension.

Transjugular intrahepatic portosystemic shunt in the treatment of portal vein thrombosis: a critical review of literature

Reports of successful transjugular intrahepatic portosystemic shunt (TIPS) surgery in patients with portal vein thrombosis (PVT) are considered anecdotal owing to the technical difficulty of the procedure and potential procedure-related complications. A literature review was undertaken to determine the feasibility and safety of TIPS in the treatment of PVT. All studies in which TIPS was attempted in patients with PVT were identified by searching through the PUBMED and MEDLINE databases. A total of 424 PVT patients undergoing TIPS were reported in 54 articles. The success rate of TIPS insertion was 67-100% in 19 case series. Further, 85 patients with portal cavernoma underwent successful TIPS insertions. Three therapeutic strategies of TIPS placement were used: (1) TIPS placement followed by portal vein recanalization via the shunt, (2) portal vein recanalization via percutaneous approaches followed by TIPS placement, and (3) TIPS insertion between a hepatic vein and a large collateral vessel without portal vein recanalization. Four approaches were used to access the portal vein: transjugular, transhepatic, transsplenic, and transmesenteric. Intra-abdominal hemorrhage secondary to hepatic capsule perforation was lethal in only three patients. No episode of pulmonary embolism was reported. Other procedure-related complications were reversible. The overall incidence of shunt dysfunction and hepatic encephalopathy was 8-33% and 0-50%, respectively. In conclusion, the reviewed studies uniformly support the feasibility and safety of TIPS for PVT even in the presence of portal cavernoma. Further, several major issues that remain unresolved are discussed.

Bacteremia and "Endotipsitis" following transjugular intrahepatic portosystemic shunting

AIM

To identify all cases of bacteremia and suspected endotipsitis after Transjugular intrahepatic portosystemic shunting (TIPS) at our institution and to determine risk factors for their occurrence.

METHODS

We retrospectively reviewed records of all patients who underwent TIPS in our institution between 1996 and 2009. Data included: indications for TIPS, underlying liver disease, demographics, positive blood cultures after TIPS, microbiological characteristics, treatment and outcome.

RESULTS

49 men and 47 women were included with a mean age of 55.8 years (range 15-84). Indications for TIPS included variceal bleeding, refractory ascites, hydrothorax and hepatorenal syndrome. Positive blood cultures after TIPS were found in 39/96 (40%) patients at various time intervals following the procedure. Seven patients had persistent bacteremia fitting the definition of endotipsitis. Staphylococcus species grew in 66% of the positive cultures, Candida and enterococci species in 15% each of the isolates, and 3% cultures grew other species. Multi-variate regression analysis identified 4 variables: hypothyroidism, HCV, prophylactic use of antibiotics and the procedure duration as independent risk factors for positive blood cultures following TIPS (P < 0.0006, 0.005, 0.001, 0.0003, respectively). Prophylactic use of antibiotics before the procedure was associated with a decreased risk for bacteremia, preventing mainly early infections, occurring within 120 d of the procedure.

CONCLUSION

Bacteremia is common following TIPS. Risk factors associated with bacteremia include failure to use prophylactic antibiotics, hypothyroidism, HCV and a long procedure. Our results strongly support the use of prophylaxis as a means to decrease early post TIPS infections.

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.

Treatment of Budd-Chiari syndrome with transjugular intrahepatic portosystemic shunt (TIPS)

PURPOSE

This study was performed to evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of patients affected by Budd-Chiari syndrome (BCS).

MATERIALS AND METHODS

From January 1999 to December 2006, 15 patients (seven male and eight female subjects, age range 7-52 years) with BCS uncontrolled by medical therapy were treated with TIPS placement. In seven cases BCS was idiopathic, in four it was caused by myeloproliferative disorders and in four by other disorders. One patient also had portal vein thrombosis. In 5/15 cases TIPS was created through a transcaval approach. Eight patients (53.4%) received a bare stent, and seven (46.6%) received a stent graft. The follow-up lasted a median of 29.4 (range 3.2-68) months.

RESULTS

Technical success was achieved in all patients without major complications. TIPS was very effective in decreasing the portosystemic pressure gradient from 26.2+/-5.8 to 10+/-6.2 mmHg. All patients but two were alive at the time of writing. Acute leukaemia was the cause of the single early death and was unrelated to the procedure. The patient with portal vein thrombosis underwent thrombolysis before TIPS, but the vein occluded again after 3 weeks, and the patient died 6 months later. The other patients showed significant improvements in liver function, ascites and symptoms related to portal hypertension. Primary patency was 53.3%, and primary assisted patency was 93.3%. No patient required or was scheduled for liver transplantation.

CONCLUSIONS

TIPS is an effective and safe treatment for BCS and may be considered a valuable alternative to traditional surgical portosystemic shunting or liver transplantation.

Changing spectrum of Budd-Chiari syndrome in India with special reference to non-surgical treatment

AIM: To evaluate patterns of obstruction, etiological spectrum and non-surgical treatment in patients with Budd-Chiari syndrome in India.

METHODS: Forty-nine consecutive cases of Budd-Chiari syndrome (BCS) were prospectively evaluated. All patients with refractory ascites or deteriorating liver function were, depending on morphology of inferior vena cava (IVC) and/or hepatic vein (HV) obstruction, triaged for radiological intervention, in addition to anticoagulation therapy. Asymptomatic patients, patients with diuretic-responsive ascites and stable liver function, and patients unwilling for surgical intervention were treated symptomatically with anticoagulation.

RESULTS: Mean duration of symptoms was 41.5 ± 11.2 (range = 1-240) mo. HV thrombosis (HVT) was present in 29 (59.1%), IVC thrombosis in eight (16.3%), membranous obstruction of IVC in two (4%) and both IVC-HV thrombosis in 10 (20.4%) cases. Of 35 cases tested for hypercoagulability, 27 (77.1%) were positive for one or more hypercoagulable states. Radiological intervention was technically successful in 37/38 (97.3%): IVC stenting in seven (18.9%), IVC balloon angioplasty in two (5.4%), combined IVC-HV stenting in two (5.4%), HV stenting in 11 (29.7%), transjugular intrahepatic portosystemic shunt (TIPS) in 13 (35.1%) and combined TIPS-IVC stenting in two (5.4%). Complications encountered in follow-up: death in five, re-stenosis of the stent in five (17.1%), hepatic encephalopathy in two and hepatocellular carcinoma in one patient. Of nine patients treated medically, two showed complete resolution of HVT.

CONCLUSION: In our series, HVT was the predominant cause of BCS. In the last five years with the availability of sophisticated tests for hypercoagulability, etiologies were defined in 85.7% of cases. Non-surgical management was successful in most cases.

Hepatic venous outflow obstruction: Three similar syndromes

Our goal is to provide a detailed review of veno-occlusive disease (VOD), Budd-Chiari syndrome (BCS), and congestive hepatopathy (CH), all of which results in hepatic venous outflow obstruction. This is the first article in which all three syndromes have been reviewed, enabling the reader to compare the characteristics of these disorders. The histological findings in VOD, BCS, and CH are almost identical: sinusoidal congestion and cell necrosis mostly in perivenular areas of hepatic acini which eventually leads to bridging fibrosis between adjacent central veins. Tender hepatomegaly with jaundice and ascites is common to all three conditions. However, the clinical presentation depends mostly on the extent and rapidity of the outflow obstruction. Although the etiology and treatment are completely different in VOD, BCS, and CH; the similarities in clinical manifestations and liver histology may suggest a common mechanism of hepatic injury and adaptation in response to increased sinusoidal pressure.

Imaging of Budd-Chiari syndrome

Budd-Chiari syndrome occurs when venous outflow from the liver is obstructed. The obstruction may occur at any point from the hepatic venules to the left atrium. The syndrome most often occurs in patients with underlying thrombotic disorders such as polycythemia rubra vera, paroxysmal nocturnal hemoglobinuria and pregnancy. It may also occur secondary to a variety of tumours, chronic inflammatory diseases and infections. Imaging plays an important role both in establishing the diagnosis of Budd-Chiari syndrome as well as evaluating for underlying causes and complications such as portal hypertension. In this review article, we discuss the role of modern imaging in the evaluation of Budd-Chiari syndrome.

Transjugular intrahepatic portosystemic shunt patency and clinical outcome in patients with Budd-Chiari syndrome: covered versus uncovered stents

PURPOSE

To retrospectively compare primary patency and reintervention rates, clinical outcome, and improvement in hepatic dysfunction (Child-Pugh score) in patients with Budd-Chiari syndrome treated with transjugular intrahepatic portosystemic shunt (TIPS) using bare stents or expanded polytetrafluoroethylene (PTFE)-covered stents.

MATERIALS AND METHODS

Approval of study and treatment protocol and waiver of informed consent for the retrospective study were obtained from institutional review board. Informed consent was obtained from each patient before procedure. Four male and nine female consecutive patients (mean age, 35.7 years) with Budd-Chiari syndrome treated with TIPS from January 1994 to November 2003 were included. In six patients, TIPS creation was performed with bare stents (group A). After April 2001, TIPS creation was performed in seven patients with expanded PTFE-covered stent-grafts (group B). Follow-up (group A mean, 22.7 months +/- 10.53 [standard deviation]; group B mean, 23.1 months +/- 7.81) was performed at 7 days, 30 days, and 3 months and subsequently every 3 months. Liver function was evaluated every 3 months. Primary end points were 6- and 12-month TIPS patency rates. Secondary end points were reintervention rate and clinical outcome. Patency rates were estimated (Kaplan-Meier method) and compared (log-rank test). Continuous (Mann-Whitney U test) and categoric (chi(2) test) data were compared. Significant differences before and after treatment were determined (Wilcoxon test).

RESULTS

Mean primary patency duration was 4.46 months +/- 3.40 in group A and 22.29 months +/- 8.15 in group B. In group B, a significant increase in primary patency rate (100% and 85.7% vs 16.7% and 0% at 6 and 12 months; P < .001, log-rank test) and a decrease in reintervention rate (0.29 +/- 0.49 vs 6.17 +/- 1.72, P < .001) were observed. Both groups had a significantly decreased Child-Pugh score; group B had a more persistent and significantly higher reduction.

CONCLUSION

Expanded PTFE-covered stent-grafts significantly increased primary patency rate of TIPS in patients with Budd-Chiari syndrome, with reduced reintervention rate and prolonged clinical improvement.

Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation

BACKGROUND

Treatment options for patients with portal vein thrombosis are limited.

AIM

To evaluate the feasibility and efficacy of transjugular intrahepatic portosystemic shunt for portal vein thrombosis with/without cavernomatous transformation.

METHODS

A survey of such patients, referred for transjugular intrahepatic portosystemic shunt between 1994 and 2005, was performed. Success rates, complications, transjugular intrahepatic portosystemic shunt patency and clinical progression were examined.

RESULTS

Transjugular intrahepatic portosystemic shunt was attempted in 28 patients (13 cirrhotics). Indications were: presurgery/transplantation (2), worsening of ascites (2), variceal bleeding (15 - 8 elective), refractory ascites (3), portal biliopathy (3) and portal vein thrombosis complicating Budd-Chiari syndrome (2). Transjugular intrahepatic portosystemic shunt was placed successfully in 19 of 28 (73%); 23 of 28 had complete portal vein thrombosis and 9 of 23 had cavernous transformation and transjugular intrahepatic portosystemic shunt was successfully placed in six of these. In the 19 patients with transjugular intrahepatic portosystemic shunt, the mean follow-up was 18.1 months (range 5-70): six patients had stent revisions; three had liver transplantation, one died of bleeding. Most cirrhotic patients had an improvement in the Child-Pugh score. In the failed transjugular intrahepatic portosystemic shunt group, two of nine died, and three had further bleeding.

CONCLUSIONS

Transjugular intrahepatic portosystemic shunt should be considered for selected patients with symptomatic complete portal vein thrombosis with/without cavernous transformation, as clinical improvement and less rebleeding occur when transjugular intrahepatic portosystemic shunt placement is successful.

Pathogenesis and treatment of Budd-Chiari syndrome combined with portal vein thrombosis

OBJECTIVES

Combined Budd-Chiari syndrome and Portal Vein Thrombosis (BCS-PVT) is a challenging clinical condition with as yet unknown outcome. The aim of the present study was to investigate etiology, treatment options, and prognosis of patients with BCS-PVT.

METHODS

Patients diagnosed with nonmalignant BCS between 1984 and 2001 were identified in a large international study and classified into isolated BCS (n = 204), BCS-PVT without spleno-mesenteric vein thrombosis (SMVT; n = 15), and BCS-PVT with SMVT (n = 18).

RESULTS

Multifactorial etiology was present in 58% of patients with combined BCS-PVT. Number of etiological factors increased significantly with the extent of thrombosis (p = 0.002). Main treatment options included anticoagulation and portosystemic shunting, of which extended TIPS showed the most beneficial results. Five-year survival was 59% (95% CI 39-80%) in BCS-PVT versus 85% (95% CI 76-88%) in isolated BCS (p = 0.11). Survival tended to be worse in BCS-PVT patients with SMVT as compared to patients without SMVT (RR = 3.47, p = 0.11).

CONCLUSIONS

In BCS, extension of thrombosis into the splanchnic venous bed was significantly related to the number of etiological factors, and was associated with poor outcome. These results strongly support a liberal use of anticoagulants, which so far had been widely debated. Alternatively, derivative shunt procedures appear difficult, yet not impossible.

High incidence of recurrence and hematologic events following liver transplantation for Budd-Chiari syndrome

BACKGROUND

Most cases of Budd-Chiari syndrome (BCS) in Western countries are related to underlying hematologic diseases with inherent thrombogenic propensity. We evaluated the long-term outcome, risks for recurrent disease, and other hematologic complications following orthotopic liver transplantation (OLT) for BCS.

METHODS

Clinical data from 11 consecutive patients with BCS who underwent OLT were retrospectively reviewed. Four patients had a prior transjugular intrahepatic portosystemic shunt and one had a surgical shunt procedure. All patients were started on intravenous heparin within the first 24 h following OLT. All except one patient who had protein C deficiency were maintained on long-term oral anticoagulation.

RESULTS

The Kaplan-Meier survival rates at 1, 5 and 10 yr were 81, 65 and 65%, respectively. Three patients developed BCS recurrence, including two who died as a consequence of rapid graft failure within days after OLT. Three patients developed other thrombotic events, including splenic vein thrombosis associated with gastric variceal hemorrhage requiring splenectomy, portal vein thrombosis and pulmonary embolism. Four patients experienced severe bleeding complications within 7 d after OLT requiring exploratory laparotomy. One patient died after transformation of polycythemia vera to acute myelogenous leukemia at 2.1 yr after OLT.

CONCLUSION

We observed a high incidence of recurrent BCS and complications related to the underlying hematologic disorder or anticoagulation after OLT for BCS. The present series also included the first two cases of rapid recurrence of BCS and graft failure within days after OLT.

Imaging and radiological interventions of portal vein thrombosis

Portal vein thrombosis (PVT) is diagnosed by imaging methods. Once diagnosed by means of ultrasound, Doppler ultrasound can be performed to distinguish between a benign and malignant thrombus. If further information is required, magnetic resonance angiography or contrast-enhanced computed tomography is the next step, and if these tests are unsatisfactory, digital subtraction angiography should be performed. Many papers have been published dealing with alternative methods of treating PVT, but the material is fairly heterogeneous. In symptomatic non-cavernomatous PVT, recanalization using local methods is recommended by many authors. Implantation of transjugular intrahepatic portosystemic shunt is helpful in cirrhotic patients with non-cavernomatous PVT in reducing portal pressure and in diminishing the risk of re-thrombosis. In noncirrhotic patients with recent PVT, some authors recommend anticoagulation alone. In chronic thrombotic occlusion of the portal vein, local measures may be implemented if refractory symptoms of portal hypertension are evident.

The utility of TIPS in the management of Budd-Chiari syndrome

BACKGROUND AND AIM

Budd-Chiari syndrome (BCS) is a rare condition associated with hepatic venous outflow obstruction classically treated with portosystemic shunts or liver transplantation. Recent reports indicate promising results with the use of transjugular intrahepatic portosystemic shunts (TIPS) in the treatment of these patients.

PATIENTS AND METHODS

We reviewed a 10-year single-institution experience with TIPS in patients diagnosed with BCS.

RESULTS

Eleven patients with BCS underwent TIPS procedures, 3 of whom carried a diagnosis of paroxysmal nocturnal hemoglobinuria, a relative contraindication for liver transplantation. One TIPS procedure was unsuccessful for technical reasons. No patient suffered mortality or major morbidity related to the TIPS procedure. The mean reduction of portal venous pressures was 43.7%, with a mean decrease of 73% in the pressure gradient. Of the 7 patients where long-term follow-up was available, 57% had shunts which remained patent but required several nonsurgical revisions for occlusion, with an average assisted patency of 37.5 months.

CONCLUSIONS

TIPS is an effective modality in the treatment of patients with BCS, especially for those who are not candidates for liver transplantation. TIPS can be successfully used as a bridge to surgical portosystemic shunting, as well as liver transplantation, but may cause technical difficulties when performing transplantation.

Transjugular intrahepatic cavoportal shunt for Budd-Chiari syndrome

Budd-Chiari syndrome (BCS) is characterized by obstruction of the hepatic venous outflow tract. Therapeutic options for BCS are limited. We report a case of a 21-year-old woman with protein S and C deficiency with gross ascites. Treatment with transjugular intrahepatic portosystemic shunt (TIPS) was attempted, which revealed occluded hepatic veins, so transcaval TIPS was performed. No serious procedure-related complication occurred. After successful shunt creation, the patient's symptoms subsided and she was discharged and followed up for 6 months.

Quantification of changes in electroencephalographic power spectra in a patient with Budd-Chiari-syndrome after implantation of a transjugular intrahepatic portosystemic stent shunt (TIPSS)

We examined a 41-year-old female with a subacute Budd-Chiari Syndrome (BCS) before and after implantation of a transjugular intrahepatic portosystemic stent shunt (TIPSS) by means of digital electroencephalography (EEG). After TIPSS implantation hepatic decompression had been achieved and the liver function as well as the clinical status improved daily. Simultaneously, the digital EEG showed a decrease in the power of the theta band and an increase in the physiological alpha frequency band. The theta/alpha ratio decreased after TIPSS, despite an elevated arterial ammonia level. The patient had a well-preserved liver parenchyma before the occurrence of the BCS. After portal decompression by TIPSS, the liver function normalized and the liver resumed efficient synthesis and parts of its detoxification task. This regeneration capacity was documented by a rise in cholinesterase after TIPSS. After temporary substitution of albumin the serum albumin concentration returned to normal. Thus, some neurotoxic substances with high albumin-binding capacity may not be absorbed by the central nervous system (CNS). Furthermore, it appears likely that the length of time the brain is exposed to neurotoxic substances plays a role in the clinical and electroencephalographic changes. Compared to the conventional EEG the theta/alpha ratio reflected better metabolically conditioned electroencephalographic changes after TIPSS.

Long-term effect of stent placement in 115 patients with Budd-Chiari syndrome

AIM: To report the long-term effect of stent placement in 115 patients with Budd-Chiari syndrome (BCS).

METHODS: One hundred and fifteen patients with BCS were treated by percutaneous stent placement. One hundred and two patients had IVC stent placement, 30 patients had HV stent placement, 17 of them underwent both IVC stent and HV stent. All the procedures were performed with guidance of ultrasound.

RESULTS: The successful rates in placing IVC stent and HV stent were 94% (96/102) and 87% (26/30), respectively. Ninety-seven patients with 112 stents (90 IVC stents, 22 HV stents) were followed up. 96.7% (87/90) IVC stents and 90.9% (20/22) HV stents remained patent during follow up periods (mean 49 mo, 45 mo, respectively). Five of 112 stents in the 97 patients developed occlusion. Absence of anticoagulants after the procedure and types of obstruction (segmental and occlusive) before the procedure were related to a higher incidence of stent occlusion.

CONCLUSION: Patients with BCS caused by short length obstruction can be treated by IVC stent placement, HV stent placement or both IVC and HV stent placement depending on the sites of obstruction. The long-term effect is satisfactory. Anticoagulants are strongly recommended after the procedure especially for BCS patients caused by segmental occlusion.

Vascular liver diseases

This article reviews the primary circulatory liver diseases, which include Budd-Chiari syndrome, obstruction of the hepatic portion of the inferior vena cava, portal vein thrombosis, sinusoidal obstruction syndrome (veno-occlusive disease), nodular regenerative hyperplasia, and peliosis hepatis. In addition, two systemic cardiovascular diseases that impair hepatic circulation, ischemic hepatitis and congestive hepatopathy, are briefly discussed. A characteristic of the primary circulatory liver diseases is that portal hypertension usually precedes liver dysfunction; however, this is not the case with the primary parenchymal liver diseases, in which liver dysfunction always progresses before portal hypertension is manifested. Significant overlap exists among the diseases and risk factors that predispose patients to the primary circulatory liver diseases, though the pathogenesis of individual diseases varies.

Budd-Chiari Syndrome

Many options are available to diagnose and treat patients with the Budd-Chiari syndrome who present with either thrombotic or non-thrombotic occlusion of the major hepatic veins and or vena cava. The goal of therapy is to alleviate venous obstruction and to preserve hepatic function. Low-sodium diets, diuretics, and therapeutic paracentesis are generally ineffective, except for the rare patient who presents with volume overload and incomplete hepatic venous occlusion. Anticoagulants and thrombolytics may be appropriate for selected patients with acute thrombotic venous obstruction. Percutaneous transluminal angioplasty (PTA) of hepatic venous stenoses or caval webs with or without placement of intraluminal stents yield excellent short-term results, but additional studies are warranted to assess long-term efficacy. Transjugular intrahepatic portosystemic shunts (TIPS) may be effective for patients with subacute or chronic disease and ascites refractory to sodium restriction and diuretics. Intrahepatic stents may also serve as a bridge to transplantation for selected patients presenting with fulminant hepatic failure consequent to hepatic venous occlusion. Additional studies will be necessary to assess the role of TIPS in the armamentarium of therapies for patients with the Budd-Chiari syndrome. Decompressive shunts, reconstruction of the vena cava and hepatic venous ostia, transatrial membranotomy, and dorsocranial resection of the liver with hepatoatrial anastomosis are appropriate options for patients with acute or subacute disease who are not candidates for, or fail less invasive therapies. The majority of patients benefit with improvement in liver function tests, ascites, and liver histology; however, hepatic function may deteriorate in patients with marginal reserve. Liver transplantation is reserved for patients with Budd-Chiari syndrome who present with fulminant hepatic failure or end-stage liver disease with portal hypertensive complications. Transplantation is also appropriate for patients who deteriorate after failed attempts at surgical shunting.