Vascular Imaging
Figure 3: Coronal Computed Tomography showing Inferior Vena Cava Thrombus, Nodular Liver Contour, Ascites, Splenomegaly and Intrahepatic Veno-venous and Extrahepatic Portosystemic Collateal Vessels in a Patient with Chronic Budd–Chiari Syndrome
anticoagulation with heparin and subsequently warfarin, treatment of the underlying thrombophilic condition and supportive therapy for the sequela of liver disease, such as ascites.7
However, in most
cases the patient’s symptoms and signs at presentation are more severe, or there is evidence of disease progression on medical therapy alone, in which case further intervention is required to restore hepatic outflow. Options include venous angioplasty, local thrombolysis, portosystemic shunt insertion (surgical or radiological) or, ultimately, liver transplantation.
Venous Angioplasty
Focal stenoses and short-segment occlusions of the hepatic veins or IVC respond well to angioplasty and this is normally the initial procedure of choice.6,26
Access is usually gained via transjugular
catheterization but if the occluded segment cannot be crossed using this approach, ultrasound-guided percutaneous hepatic vein puncture can be performed. Stent insertion is advocated when there are significant residual or recurrent stenoses following angioplasty.
Local thrombolytic therapy directly into the thrombosed vein, often in combination with angioplasty, may be considered in acute BCS, or if new thrombus forms shortly after an apparently successful angioplasty.
Figure 4: Axial Arterial-phase Computed Tomography Showing hypervascular Large Regenerative Nodules in the Left Lobe of a Patient with Chronic Budd–Chiari Syndrome
Transjugular Intrahepatic Portosystemic Shunt If attempts at adequate recanalisation by these methods fail, an alternative method of relieving hepatic congestion is required. Transjugular intrahepatic portosystemic shunt (TIPS) insertion is a well-established means of treating BCS and was first described in 1993.27
The TIPS stent is inserted through the liver parenchyma between the hepatic vein and portal vein, with the optimal location of the proximal end of the stent at the hepatocaval junction.28
In
this way, the TIPS provides venous decompression by allowing outflow into the suprahepatic IVC, irrespective of intrahepatic IVC obstruction.6
It results in significant improvement in hepatic synthetic function and resolution of the sequela of portal hypertension with associated improvement in clinical symptoms.6,29
Figure 5: Hepatic Venogram Demonstrating the Typical ‘Spider Web’ Appearance of Collateral Vessels
Technical issues particular to BCS include difficulty obtaining hepatic vein access, but this may be overcome using direct transcaval puncture.30
Nonetheless, surveillance of these patients is vital, with regular Doppler ultrasounds of the TIPS stent and, if necessary, angiographic TIPSograms with ballooning/stent reinsertion if indicated.
Angiography can also be used to assess the degree of intrahepatic IVC stenosis caused by caudate lobe hypertrophy.
Treatment and the Role of Interventional Radiology In patients with mild symptoms and no evidence of liver necrosis, medical therapy alone may be sufficient.5
38 Surgical Portosystemic Shunts This consists of
If TIPS insertion is technically unsuccessful/unfeasible and transplantation is not an available option, creation of a surgical portosystemic shunt may be considered. These include portocaval, mesocaval, splenorenal and mesoatrial shunts. Surgical shunts have a number of disadvantages
US RADIOLOGY
Originally, bare stents were used in creating TIPS, but, due to the pro-coagulant tendencies of patients with BCS, there were high rates of thrombosis and occlusion requiring repeated revisions. Previously, TIPS was therefore largely considered a holding measure until transplantation could be performed. More recently, expanded polytetrafluoroethylene (ePTFE)-coated stents have been developed, which demonstrate better patency rates and persistent clinical improvement in the long term, potentially avoiding the need for transplantation.30,31
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