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Published on: May 7, 2015
Percutaneous transjugular direct porto-caval shunt in patients with Budd-Chiari syndrome
1Department of Diagnostic and Interventional Radiology, Charité Campus Virchow Clinic, Universitätsmedizin Berlin, 13353 Berlin, Germany.
Insights
Direct transhepatic porto-caval shunts offer a feasible and effective treatment for Budd-Chiari syndrome (BCS) when hepatic veins are inaccessible for transjugular intrahepatic portosystemic shunt (TIPSS) procedures. This approach shows promise for managing acute liver failure in BCS patients.
Area of Science:
- Interventional Radiology
- Hepatology
- Vascular Surgery
Background:
- Budd-Chiari syndrome (BCS) can lead to acute liver failure, often necessitating portosystemic shunting.
- Conventional transjugular intrahepatic portosystemic shunt (TIPSS) is not feasible when hepatic veins are inaccessible.
- Alternative shunting techniques are crucial for managing BCS with inaccessible hepatic veins.
Purpose of the Study:
- To evaluate the feasibility and effectiveness of direct porto-caval shunts in BCS patients with inaccessible hepatic veins.
- To assess the safety and outcomes of a transhepatic approach for TIPSS creation in this specific patient group.
Main Methods:
- Six consecutive patients with fulminant/acute BCS and inaccessible hepatic veins underwent direct transhepatic porto-caval shunt creation.
- Procedures were guided by ultrasound.
- Patients were monitored through clinical examinations, laboratory tests, and Doppler ultrasound.
Main Results:
- Successful TIPSS implantation from the inferior vena cava (IVC) was achieved in all six patients (100%).
- Early shunt occlusion occurred in 50% of patients, but all were successfully recanalized.
- Five patients experienced durable resolution of liver failure and ascites without reintervention over a mean follow-up of 15 months.
Conclusions:
- Direct transhepatic porto-caval shunting is a safe and effective option for BCS patients with acute liver failure and inaccessible hepatic veins.
- Ultrasound guidance facilitates this procedure.
- Further research with larger cohorts is needed to compare the patency of these shunts with conventional TIPSS.
Abstract:
The purpose of the study was to evaluate the feasibility and effectiveness of direct porto-caval shunts in patients with Budd-Chiari syndrome (BCS) in whom there is no access to the hepatic veins during transjugular intrahepatic portosystemic shunt (TIPSS). We included six consecutive patients with fulminant/acute Budd-Chiari syndrome (mean age: 35 years) in whom a conventional TIPSS was not possible due to inaccessible hepatic veins. We performed a direct porto-caval shunt via a transhepatic approach. Patients were followed up by means of clinical examination, laboratory investigations, and Doppler ultrasound. TIPSS implantation from the inferior vena cava (IVC) was successful in all six patients (100%). The median transhepatic shunt length was 9 cm (8-10 cm). No procedure-related complications were observed in our patients. Early shunt occlusion occurred in three out of six patients (50%). In all three of these patients, the stent used to stabilize the shunt ended 1-2 cm before reaching the IVC. All occlusions were successfully recanalized. One of these patients developed recurrent early shunt as well as mesenteric and splenic vein occlusions. She died 7 days after TIPSS placement due to an unmanageable coagulation disorder. The remaining five patients were followed up by planned clinical examination and laboratory investigations (mean follow-up time was 15 months; patient 1 was followed up for 13 months, patient 2 for 14 months, patient 3 for 15 months, and patients 4 and 5 for 16 months) and all displayed a complete and durable resolution of liver failure and ascites without reintervention. In patients with acute liver failure originating from BCS and inaccessible hepatic veins, a direct transhepatic porto-caval shunt can be performed safely and effectively under ultrasound guidance. Future studies in larger patient groups should investigate if the patency of transcaval TIPSS with long transhepatic shunt segments is similar compared to conventional TIPSS via the hepatic vein.
