Percutaneous Transhepatic Hepatic Vein Angioplasty in Budd–Chiari Syndrome After Transvenous Failure

Abstract

Purpose:

To evaluate the safety and efficacy of percutaneous transhepatic route creation for hepatic vein (HV) angioplasty in Budd–Chiari syndrome (BCS).

Patients and Methods:

Between April 2012 and August 2016, a total of 19 BCS patients underwent percutaneous transhepatic route creation for HV angioplasty after transvenous catheterization failure in this study. Color Doppler ultrasonography was required in all patients after admission and during follow-up. Data were retrospectively collected, and follow-up observations were performed.

Results:

Technical and clinical success was achieved in 18 patients. Except for 1 failure of route creation, 19 routes were successfully created in 18 patients, with a technology success rate of 95.0%. Twenty-two balloon angioplasties were performed in 18 patients, with a mean balloon diameter of 13.6 ± 0.5 mm. Blood pressure and length of occlusive HV decreased significantly, and blood flow velocity and diameter of HV increased significantly after procedure. Abdominal distension/pain and ascites decreased significantly after procedure. One procedure-related death occurred, who died of gastrointestinal bleeding 6 days later. Except for the failure case, the rest of 18 patients were successfully followed up. The remaining 18 patients survived during follow-up, with a 5-year survival rate of 94.9%. One patient had a restenosis of HV after 47 days, and had undergone successful dilation. The 5-year primary and second patency rates were 94.1% and 100%, respectively.

Conclusion:

Percutaneous transhepatic route creation is safe and effective for HV angioplasty, and can be used to treat BCS patients after transvenous catheterization failure.

Introduction

Budd–Chiari syndrome (BCS) is a rare disease in Western countries,¹ and hepatic vein (HV) thrombosis is the most frequent cause in Asia.^2,3 Interestingly, in the majority of China, it is a mixed type of HV and inferior vena cava (IVC) involvement,³ and membranous webs are more common.⁴ BCS with HV obstruction may cause severe liver damage in acute patients and an esophageal variceal bleeding and refractory ascites in chronic patients.⁵ Various treatments, such as surgical shunts, transjugular intrahepatic portosystemic shunt (TIPS), and liver transplantation are potential options for BCS.^1,6–8 Percutaneous HV recanalization by balloon angioplasty and stenting is a relatively simple, safe, and effective method for patients with BCS due to HV obstruction.^4,8–11 However, HV recanalization sometimes is quite difficult due to the long-segment obstruction or complete occlusion of HV outlet, with a high failure rate of 31% to 100%.^4,9 Additionally, there is a risk of reobstruction even after successful management.⁴ Currently, there is no specific study to systematically report on the technology outcomes of percutaneous transhepatic route creation for HV angioplasty after transvenous catheterization failure. In this study, we present our initial clinical results of route creation for HV recanalization in 19 patients with failure of transvenous catheterization.

Materials and Methods

This retrospective study was approved by our Institutional Review Board. All procedures were performed in accordance with the ethical standards. Written informed consents for the procedure were obtained from all patients in this study.

Study design and patient selection

From April 2012 to August 2016, a total of 131 patients underwent HV recanalization in our department; of which, 112 patients were successfully treated by the transvenous approach, and the remaining 19 BCS patients with failure of HV recanalization by transvenous approach were enrolled in this study. The inclusion criteria are a definite diagnosis of BCS due to HV obstruction and a failure of HV recanalization by transvenous approach. Patients with severe liver function failure, HV obstruction caused by malignancy, terminal hepatic carcinoma, and massive ascites making difficulty in percutaneous transhepatic puncture, severe dysfunction of blood coagulation, active infection, or bleeding were excluded from this study. Patient characteristics, the main clinical symptoms and technology outcomes were collected and analyzed.

Diagnosis and definition

Diagnosis was established by reviewing the patients' history as well as the results of magnetic resonance angiography, contrast-enhanced CT angiography, or color Doppler ultrasonography. The HV and IVC angiography confirmed diagnosis during interventional procedure. Failure of transvenous catheterization was defined as an unsuccessful catheterization through the femoral vein (FV) approach, or internal jugular vein (IJV) approach, or both approaches. Technical success was defined as a complete elimination of HV obstruction confirmed by venography. Clinical success was defined as a stable or improved symptom within 1 week of technically successful HV recanalization.

Percutaneous transhepatic route creation

The patients lay in a supine position. All procedures were performed under local anesthesia with 2% lidocaine and fluoroscopic guidance. The hunter head catheter was first catheterized to the lesion HV for percutaneous transluminal balloon angioplasty. Then percutaneous transhepatic puncture performed if catheterization failed. A 0.014-inch platinum micro guide wire (Cook, Bloomington, IN) was introduced into the HV through the sheath of a Chiba needle (Cook). A 5F vascular sheath was implanted; a 5F catheter was introduced through the sheath. The guide wire successfully catheterized the involved HV and was introduced into the IVC. Then 12–14F-long sheaths were introduced through the FV (Fig. 1) or IJV (Fig. 2). Amplatz gooseneck snare (Microvena, MN) was used to capture the guide wire and to drag it out through the long sheath, to successfully establish the percutaneous transhepatic route. The occlusive segment of HV was dilated by using a balloon of 8–18 mm diameter and 40–60 mm length (Venous balloon; Cook Medical). The balloon was dilated twice, and each dilation lasted ∼30 seconds. HV/Accessory HV (AHV) pressure was measured by using a piezometric tube before and after angioplasty. After stent angioplasty, the procedure path was sealed with an embolization coil or gelatin sponge.

FIG. 1.

Balloon angioplasty through percutaneous HV/FV track. (A) HV obstruction was shown by angiography after percutaneous picture. (B) Amplatz gooseneck snare was used to capture guide wire and to drag it out through the long sheath, to establish a percutaneous HV/FV track. (C) Angioplasty of HV was performed by using a balloon of 14 mm in diameter. (D) Patency of HV was confirmed by second angiography. FV, femoral vein; HV, hepatic vein.

FIG. 2.

Balloon angioplasty of left main HV through percutaneous HV/IJV track. (A) Left HV obstruction was shown by angiography. (B) Percutaneous HV/IJV track was established for angioplasty. (C) Balloon angioplasty was performed by using a balloon of 14 mm in diameter. (D) Patency of HV was confirmed by second angiography. HV, hepatic vein; IJV, internal jugular vein.

Perioperative care and medicine

Heart rate, blood pressure, oxygen saturation, and respiratory rate were monitored throughout the procedure. The low-molecular-weight heparin of 5100 U was subcutaneously injected every 12 hours for 4–5 days. Patients were monitored for 1–2 days postoperatively to observe complications, including bleeding. All patients took oral warfarin (Xinyi Pharmaceutical Co.) for anticoagulation from the second day following treatment for 2 years, with international normalized ratio of 2 to 3.

Follow-up

All patients were followed by abdominal Doppler ultrasound with or without CT angiography about 1 week after procedure, and every 3–6 months to confirm the patency of the HV (Fig. 3). Patient's conditions were ascertained by contacting the patients or their family every 3 months after treatment.

FIG. 3.

Color Doppler ultrasonography after procedure. The patency of left HV and IVC was confirmed by color Doppler ultrasonography during follow-up. HV, hepatic vein; IVC, inferior vena cava.

Statistical analysis

All data were expressed as mean ± SEM. Student t test was used for statistical analysis (Prism 5.0; GraphPad Software, Inc., San Diego, CA). Differences were considered statistically significant at P < .05.

Results

Patient characteristics

A total of 19 patients, including 11 males and 8 females (mean age 37.1 ± 3.0 years) were enrolled in this study. Ten patients (52.6%) had a combined IVC and HV involvement, and 11 (55.0%) patients had a complete occlusion of HVs or AHVs. Eight patients had a duration of symptom within 1 year, and 5 patients had a duration more than 10 years. Abdominal distension and pain were the most common symptom and sign, which were shown in 68.4% of cases (Table 1).

Table 1.

General Situation of Patients at Admission

Variables	Data
Male, n (%)	11 (57.9)
Mean age (range), years	37.1 ± 3.0 (18–59)
Lesion types, n (%)
IVC and HVs involvement	10 (52.6)
Isolated HVs involvement	9 (47.4)
Severe stenosis of HV/AHV	9 (45.0)
Complete occlusion of HV/AHV	11 (55.0)
Duration of symptom, n (%)
Less than 1 year	8 (42.1)
Between 1 and 10 years	6 (31.6)
More than 10 years	5 (26.3)
Liver function before procedure, n (%)
Child–Pugh A	11 (55.0)
Child–Pugh B	6 (31.6)
Child–Pugh C	2 (10.5)

AHV, accessory hepatic vein; HV, hepatic vein; IVC, inferior vena cava.

Percutaneous transhepatic route creation

Transvenous catheterization failures included 11 of FV approaches, 6 of IJV approaches, and 2 of both approaches. One failure of route creation was found in 1 patient with all 3 HV occlusions, 19 routes were successfully created in the remaining 18 patients. Percutaneous HV/FV route was successfully created in half of patients. The technology success rate was 95.0% (19/20). Clinical success was achieved in 18 patients (94.7%). Twenty-two balloon angioplasties were performed in 18 patients, with a mean balloon diameter of 13.6 ± 0.5. Nineteen HVs/AHVs were successfully dilated, including 4 AHVs (Table 2).

Table 2.

Percutaneous Transhepatic Route Creation

Variables	Data
Type of percutaneous transhepatic route	n = 20
Percutaneous HV/FV route	10 (50.0%)
Percutaneous HV/IJV route	6 (30.0%)
Percutaneous AHV/FV route	3 (15.0%)
Percutaneous AHV/IJV route	1 (5.0%)
Failure catheterization by routine approach	n = 19
Failure of FV approach	11 (57.9%)
Failure of IJV approach	6 (31.6%)
Failure of both approaches	2 (10.5%)
Success in balloon angioplasty for HV/AHV	n = 19
Right main HV	4 (21.1%)
Middle main HV	4 (21.1%)
Left main HV	6 (31.6%)
AHV	4 (21.1%)
Mean diameter of balloons, mm (n = 22)	13.6 ± 0.5 (range 8–18)

AHV, accessory hepatic vein; FV, femoral vein; HV, hepatic vein; IJV, internal jugular vein.

Change of HV/AHV and symptoms/signs

The mean pressure of HV/AHV decreased from 40.8 ±2.8 cm H₂O before treatment to 27.0 ± 1.8 cm H₂O after treatment (P = .0006). Length of occlusive HV decreased significantly after procedure (P < .0001). Blood flow velocity and diameter of HV increased significantly after procedure (P < .01). Abdominal distension/pain and ascites decreased significantly after procedure (P < .01). Other symptoms, such as lower extremity edema/pain did not change significantly (Table 3).

Table 3.

Change of Hepatic Vein/Accessory Hepatic Vein and Symptoms/Signs After Procedure

Variables	Before procedure	After procedure	P
Length of occlusive HV/AHV	26.6 ± 7.6 (9–45)	1.1 ± 1.1 (0–16)	<.0001
Diameter of HV/AHV	1.2 ± 0.5 (0–7)	6.5 ± 0.5 (0–10)	<.0001
HV/AHV pressure (cm H₂O)	40.8 ± 2.8 (29–54)	27.0 ± 1.8 (19–37)	.0006
Blood speed of HV/AHV (cm/s)	8.5 ± 8.5 (0–153)	62.3 ± 18.6 (0–220)	.0066
Symptoms and signs, n (%)
Lower extremity edema/pain	4 (21.1)	0 (0.0)	.1050
Abdominal distension/pain	13 (68.4)	1 (5.3)	<.0001
Ascites	13 (68.4)	3 (15.8)	.0025
Lower limbs pigmentation	1 (5.3)	1 (5.3)	1.0000
Gastrointestinal bleeding	3 (15.8)	0 (0.0)	.2297
Varicose veins in lower limbs/abdomen	3 (15.8)	1 (5.3)	.3544

AHV, accessory hepatic vein; HV, hepatic vein.

Perioperative complications and follow-up

One procedure-related death was found, who died of gastrointestinal bleeding 6 days after leaving hospital. One patient had mild skin anaphylaxis after the procedure, and the symptoms disappeared after the immediate administration of 10 mg of dexamethasone. This procedure did not result in further thrombosis or increase in the portal pressure and variceal bleeding. Except for failure 1, all 18 patients were successfully followed up, with a mean duration of 47.7 ± 5.1 months; the rest of 18 patients survived during follow-up, with a 5-year survival rate of 94.9%. One patient had a restenosis of HV after 47 days, and had undergone successful dilation again. The 5-year primary and second patency rates were 94.1% and 100%, respectively (Fig. 4).

FIG. 4.

Patency rate and survival rate follow-up. The 5-year survival rate was 94.9%. The 5-year primary and second patency rates were 94.1% and 100%, respectively.

Discussions

The interventional treatments for BCS with HV lesions include balloon angioplasty, stent implantation, and TIPS. Since initial success in balloon angioplasty in 1974¹² and stent placement in 1990,¹³ interventional treatments have proven efficacy for BCS. Unfortunately, HV recanalization sometimes is quite difficult due to long-segment obstruction or complete occlusion of HV outlet.^4,9

This study evaluated the safety and efficacy of percutaneous transhepatic route creation for HV angioplasty in BCS patients after transvenous catheterization failure. The initial results were satisfactory, demonstrating high technical and clinical success rates. During a 5-year follow-up, the 5-year primary and second patency rates were 94.1% and 100%, respectively. These positive results may be attributable to the following factors: first, percutaneous transhepatic routes help to improve the support of the catheter thus increase the success rate of angioplasty. Second, AHV dilates to compensate and function as drainage vessels after main HV obstruction. These AHVs also received angioplasty to maximize the clinical efficacy and avoid TIPS or surgical shunt. Although TIPS has been used for BCS due to HV obstruction to decrease the portal vein pressure,^8,14 hepatic encephalopathy and shunt dysfunction are troublesome problems.^8,15

Currently, HV recanalization has been increasingly used for the treatment of BCS to relieve the symptoms and hepatic congestion.^4,9,16,17 However, the challenges and difficulties of HV recanalization may encounter owing to the following factors: first, it is not so easy to cut through the HV obstruction, especially the long segment of obstruction through transvenous approaches.^4,9 Second, stump or outlet of HV may disappear in BCS patient with severe stenosis or complete obstruction of the HV, making the catheterization difficult.

To shorten the operation time and avoid an excessive X-ray radiation, it is unnecessary to take too long to canalize the occluded HVs. According to our experience, percutaneous transhepatic route should be created due to transvenous catheterization failure. Besides, the balloon diameter selection for HV still lacks unified standards. Early clinical experience shows that a high recurrence rate was found after the use of 12 mm balloon catheter. Nowadays, a larger diameter balloon expansion is performed. No stents were used to avoid long-term complications in our study, which was different from the report in the literature.¹¹

There are some limitations to this study: First, the present report was a retrospective case analysis, and the sample size was small. Second, it is not a comparative study. However, the purpose of this study was to provide an additional treatment option for patients with BCS due to long-segment obstruction of HV.

In conclusion, percutaneous transhepatic route creation is safe and effective for HV angioplasty, and can be used to treat BCS patients after transvenous catheterization failure.

Footnotes

Acknowledgments

This work is supported by the National Natural Science Foundation of China (Grant No. 81501569). The authors extend their appreciation to Dr. Linxia GU, Department of Mechanical and Materials Engineering, University of Nebraska–Lincoln, Lincoln, NE 68588–0656, USA, for her valuable comments and English editing.

Disclosure Statement

No competing financial interests exist.

References

Darwish Murad

, Valla

, de Groen

, Zeitoun

, Hopmans

, Haagsma

, van Hoek

, Hansen

, Rosendaal

, Janssen

. Determinants of survival and the effect of portosystemic shunting in patients with Budd-Chiari syndrome. Hepatology, 2004; 39:500–508.

Okuda

. Obliterative hepatocavopathy-inferior vena cava thrombosis at its hepatic portion. Hepatobiliary Pancreat Dis Int, 2002; 1:499–509.

Zhou

, Ren

, Han

, Wu

, Zhang

, Ding

, Bi

. Initial imaging analysis of Budd-Chiari syndrome in Henan province of China: Most cases have combined inferior vena cava and hepatic veins involvement. PLoS One, 2014; 9:e85135.

, Zhai

, Pang

, Ma

, Cao

, Bai

, Wang

, Zhang

. Feasibility and midterm outcomes of percutaneous transhepatic balloon angioplasty for symptomatic Budd-Chiari syndrome secondary to hepatic venous obstruction. J Vasc Surg, 2009; 50:1079–1084.

Plessier

, Valla

. Budd-Chiari syndrome. Semin Liver Dis, 2008; 28:259–269.

Sang

, Li

. Endovascular treatment of Budd-Chiari syndrome with hepatic vein obstruction in China. J Laparoendosc Adv Surg Tech A, 2014; 24:846–851.

Rosenqvist

, Sheikhi

, Eriksson

, Rajani

, Rorsman

, Sangfelt

, Nyman

. Endovascular treatment of symptomatic Budd-Chiari syndrome—In favour of early transjugular intrahepatic portosystemic shunt. Eur J Gastroenterol Hepatol, 2016; 28:656–660.

Eapen

, Velissaris

, Heydtmann

, Gunson

, Olliff

, Elias

. Favourable medium term outcome following hepatic vein recanalisation and/or transjugular intrahepatic portosystemic shunt for Budd Chiari syndrome. Gut, 2006; 55:878–884.

Zhang

, Fu

, Xu

, Zhang

, Jia

, Liu

, Qin

, Zhu

. Long-term effect of stent placement in 115 patients with Budd-Chiari syndrome. World J Gastroenterol, 2003; 9:2587–2591.

10.

Fan

, Liu

, Che

, Wang

, Wu

, Cao

, Li

. Good clinical outcomes in Budd-Chiari syndrome with hepatic vein occlusion. Dig Dis Sci, 2016; 61:3054–3060.

11.

Cui

, Fu

, Li

, Xu

. Percutaneous recanalization for hepatic vein-type Budd-Chiari syndrome: Long-term patency and survival. Hepatol Int, 2016; 10:363–369.

12.

Eguchi

, Takeuchi

, Asano

. Successful balloon membranotomy for obstruction of the hepatic portion of the inferior vena cava. Surgery, 1974; 76:837–840.

13.

Furui

, Sawada

, Irie

, Makita

, Yamauchi

, Kusano

, Ibukuro

, Nakamura

, Takenaka

. Hepatic inferior vena cava obstruction: Treatment of two types with Gianturco expandable metallic stents. Radiology, 1990; 176:665–670.

14.

Neumann

, Andersen

, Nielsen

, Holland-Fischer

, Vilstrup

, Gronbaek

. Treatment of Budd-Chiari syndrome with a focus on transjugular intrahepatic portosystemic shunt. World J Hepatol, 2013; 5:38–42.

15.

Parvinian

, Bui

, Knuttinen

, Minocha

, Gaba

. Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites. Diagn Interv Radiol, 2014; 20:58–64.

16.

Han

, Qi

, Zhang

, He

, Yin

, Wang

, Xia

, Xu

, Guo

, Niu

, Wu

, Fan

. Percutaneous recanalization for Budd-Chiari syndrome: An 11-year retrospective study on patency and survival in 177 Chinese patients from a single center. Radiology, 2013; 266:657–667.

17.

Beckett

, Olliff

. Interventional radiology in the management of Budd Chiari syndrome. Cardiovasc Intervent Radiol, 2008; 31:839–847.