Portal Hypertension · IR Playbook

Hepatic Venous Outflow Angioplasty and Stenting for Budd–Chiari Syndrome (HV recanalisation (BCS))

Percutaneous recanalisation of an obstructed hepatic vein (HV) or hepatic segment of the inferior vena cava (IVC) by balloon angioplasty with or without self-expanding stent placement, performed for symptomatic primary Budd-Chiari syndrome that has not responded to anticoagulation. The mechanism is restoration of physiological antegrade hepatic venous drainage: relieving a short obstruction collapses the sinusoidal-to-right-atrial pressure gradient, decompresses the congested sinusoids and abolishes the intrahepatic collateral network, so the complication profile is dominated by capsular and vascular injury during blind traversal of the occluded segment, embolisation of thrombus at the moment of dilatation, and re-thrombosis of a low-flow recanalised channel. Technical success is 94-98% in reported series, with 1-year and 5-year primary patency of 85.4% and 58.3% and secondary patency of 93.8% and 75% in a 51-patient HV-type cohort. The dominant late problem is re-obstruction, not procedural death; overall procedure-related complications in that cohort were 29.1% and all were SIR class A or B.

Learning objectives

• Select the target hepatic vein from cross-sectional imaging using occlusion length, calibre and course
• Distinguish hepatic-vein-type, IVC-type and combined-type Budd-Chiari and choose the corresponding recanalisation strategy
• Size and deploy balloons and stents for hepatic venous outflow lesions
• Recognise the venographic and manometric endpoints that mandate stenting rather than angioplasty alone
• Manage capsular haemorrhage, pulmonary embolism and acute re-thrombosis after recanalisation

Indications

• Symptomatic primary Budd-Chiari syndrome with short-segment (under 3 cm) or membranous hepatic vein obstruction that has not responded to anticoagulation and diuretics
• Membranous or short-segment obstruction of the hepatic IVC with a demonstrable pressure gradient
• Combined-type disease in which relief of an IVC lesion plus recanalisation of one hepatic vein will restore drainage
• Obstructed but compensatory accessory hepatic vein when the three main hepatic veins are unsuitable targets
• Restenosis or stent occlusion after previous recanalisation, where repeat intervention will restore secondary patency

Absolute contraindications

• Malignant obstruction of the hepatic venous outflow tract
• Fulminant hepatic failure requiring emergency transplantation rather than decompression
• Uncorrectable coagulopathy in a patient requiring transhepatic access

Relative contraindications

• Long-segment (over 3 cm) or diffuse thrombosis of all hepatic veins, where TIPS or DIPS is the appropriate decompressive procedure
• Established cirrhosis with decompensation, where restoring outflow may not reverse liver dysfunction
• Extensive portal vein thrombosis
• Severe contrast allergy or renal impairment
• Tense ascites not amenable to pre-procedural drainage when a transhepatic route is planned

Equipment

• Ultrasound machine with vascular and abdominal probes
• Micropuncture set and 10 Fr jugular sheath
• Rosch-Uchida transjugular liver access set for traversing the occluded hepatic vein segment
• 5 Fr straight multi-side-hole catheter for cavography
• 5 Fr Cobra 2 and 4 Fr Headhunter selective catheters
• 0.035 inch angled and straight hydrophilic guidewires, standard and stiff
• 0.035 inch extra-stiff exchange guidewire for balloon and stent delivery
• 21 G Chiba needle or Neff percutaneous access set for transhepatic puncture
• Gooseneck snare for through-and-through wire capture
• Angioplasty balloons 8-14 mm diameter, 40-60 mm length (and 16-24 mm for the IVC when required)
• Self-expanding metallic stents 10-14 mm diameter, 40-60 mm length
• Pressure transducer or water manometer for hepatic vein and IVC pressures
• Gelfoam strips for transhepatic tract embolisation
• Unfractionated heparin

Procedure steps

1. Puncture the right internal jugular vein under direct ultrasound guidance and place a 10 Fr sheath. Use the left internal jugular vein only if the right is thrombosed.
2. Advance a 5 Fr straight multi-side-hole catheter and perform cavography in AP and lateral projections, then pull back a pressure trace from the right atrium through the hepatic IVC. You are looking for a web, a segmental stenosis or extrinsic caudate compression, and for the ostia of the hepatic veins and any accessory vein. A gradient across the hepatic IVC means the cava must be treated as well as, or before, the hepatic vein - opening the vein into a hypertensive cava will not decompress the liver.Pearl: Reflux of contrast into a large accessory hepatic vein on cavography identifies the vessel that is currently draining the liver and may itself be the best target.
3. Correlate the cavogram with the pre-procedural CT or MR venogram and select the vein with the shortest occluded segment, a calibre of 7 mm or more and a straight course. Prefer the right hepatic vein when veins are equivalent. Confirm the choice with a selective ostial injection before committing to traversal.Pearl: Recanalising one vein is enough in the great majority of cases because intrahepatic collaterals redistribute drainage - do not plan a two-vein procedure at the outset.
4. Engage the ostial stump with a Cobra 2 or Headhunter catheter and probe with an angled hydrophilic wire. If the soft wire will not cross, use the Rosch-Uchida needle directed by the pre-procedural anatomy, or advance the stiff back end of the guidewire under continuous fluoroscopy and road-mapping, limiting each advance to about 3 mm. Watch for the wire tracking outside the expected venous course and for the patient developing pain, either of which means you are heading for the capsule. The step is complete when the wire and a catheter lie freely in the peripheral hepatic vein and hand injection opacifies vein rather than parenchyma.Pearl: Road-map from a prior peripheral injection so the stiff wire is advanced along a mapped lumen rather than an assumed one.
5. Drain tense ascites first, then puncture the target hepatic vein under ultrasound with a 21 G Chiba needle or Neff set and place a 6 Fr sheath. Cross the obstruction from the hepatic side, snare the wire in the IVC or right atrium and externalise it through the jugular sheath. Perform all dilatation from the jugular end over this through-and-through wire. In one series this combined route was needed in 18 of 51 cases and accounted for both haemorrhagic complications.Pearl: Through-and-through wire control converts a lesion that would not accept a catheter from either end into a stable rail for large balloons.
6. Inject through a catheter in the peripheral hepatic vein to define the exact length and location of the obstruction and to document the intrahepatic collateral network, then record the free hepatic vein pressure. These two observations are your comparators at the end of the case - in one cohort mean free hepatic vein pressure fell from 43 to 15 cmH2O after successful recanalisation.
7. Exchange for an extra-stiff wire and dilate with an 8-14 mm balloon, 40-60 mm long, sized about 2 mm above the native vein diameter and long enough to extend 10 mm beyond each end of the lesion. Inflate for about a minute and repeat until the waist disappears; several inflations are usual. Watch the oxygen saturation and the patient's respiratory pattern during and immediately after inflation, because dislodged thrombus embolises to the lungs at this moment.Pearl: Note the waist position on the first inflation - it marks the true lesion and tells you where a stent must sit if one becomes necessary.
8. Wait 15 minutes and repeat venography and pressure measurement across the treated segment. Angioplasty alone is sufficient only if residual stenosis is under 30%, the gradient across the segment is 15 cmH2O or less and the intrahepatic collaterals have disappeared. Failure of any one of these three is the trigger to stent.Pearl: Persistence of intrahepatic collaterals on the delayed run is the most sensitive of the three signs and often precedes an obvious anatomical residual stenosis.
9. Place a 10-14 mm self-expanding stent sized about 2 mm above the vein diameter, extending at least 10 mm beyond each end of the lesion, and post-dilate. Position the ostial end flush with the IVC lumen - protruding far into the cava invites thrombus and compromises the other hepatic vein ostia, while sitting short of the ostium leaves the obstructing web untreated. Confirm full expansion and residual stenosis under 30% angiographically. Standard textbook technique: segmental thrombotic obstruction is the group most likely to need a stent, membranous obstruction the group most likely to be adequately treated by dilatation alone.Pearl: Deploy from the peripheral end back towards the ostium so that any foreshortening is taken up away from the caval junction.
10. If a hepatic IVC web or stenosis with a gradient was demonstrated, dilate it with a large-diameter balloon sized to the adjacent normal cava, and stent only if there is recoil or a persistent gradient. Recheck the hepatic vein result afterwards, since relieving the caval gradient changes the outflow pressure the recanalised vein is draining against.
11. Perform completion venography of the hepatic vein and IVC and repeat the free hepatic vein pressure. Look for brisk antegrade flow into the cava, residual stenosis under 30% and complete disappearance of the intrahepatic collateral network.
12. If a transhepatic route was used, embolise the parenchymal tract with gelfoam strips delivered through the sheath as it is withdrawn. Start intraprocedural unfractionated heparin at about 50 IU/kg and remove the jugular sheath with manual compression.

Complications

• Haemoperitoneum and hepatic subcapsular haematoma
• Pulmonary embolism
• Acute re-thrombosis or stent occlusion
• Stent migration into the right atrium or IVC
• Cardiac arrhythmia during wire and catheter manipulation
• Transient hepatic congestion pain and post-procedural diuresis
• Contrast-induced nephropathy

Exam pearls

• In Budd-Chiari, percutaneous angioplasty with or without stenting is the first-line decompressive procedure for short-segment or membranous hepatic vein or IVC obstruction, with TIPS reserved for diffuse or long-segment disease and for recanalisation failure.
• Persistence of intrahepatic veno-venous collaterals after hepatic vein dilatation, not their presence beforehand, is the sign of an inadequate result and is one of the three triggers for stenting.
• Membranous obstruction is often adequately treated by balloon dilatation alone, whereas segmental thrombotic obstruction recoils and has a higher re-occlusion rate, making primary stenting the preferred strategy in that subgroup.
• A hypertrophied caudate lobe in Budd-Chiari compresses the retrohepatic IVC and can maintain a hepatic outflow gradient even after the hepatic vein has been successfully opened.
• Approximately 86-89% of patients with IVC-type or combined-type Budd-Chiari have a compensatory patent accessory hepatic vein, which can itself become the recanalisation target when the main veins are long-segment occluded.
• Anticoagulation is continued indefinitely after stenting for segmental obstruction; sub-therapeutic INR is a leading correctable cause of stent occlusion.

Viva questions

You open the right hepatic vein beautifully but the free hepatic vein pressure barely falls. What have you missed and what do you do?

An unrelieved obstruction downstream - most often a hepatic IVC web or extrinsic compression by a hypertrophied caudate lobe, giving combined-type disease. Pull back a pressure trace through the hepatic IVC and treat the caval lesion, because a recanalised vein draining into a hypertensive cava will re-thrombose.

Why is recanalising a single hepatic vein usually sufficient, and what does that let you do at the planning stage?

Intrahepatic veno-venous collaterals redistribute drainage from the whole parenchyma once one outflow channel is restored, which is why a single vein sufficed in the large majority of technically successful cases in published series. It means you select the single vein with the shortest occlusion and best calibre rather than attempting multiple veins.

Your patient desaturates during balloon inflation. What is happening and what is your immediate sequence?

Thrombus dislodged from the occluded segment has embolised to the pulmonary arteries. Stop dilatation, give oxygen and support the circulation at the table, continue heparin unless bleeding, and obtain CT pulmonary angiography once stable; subsegmental emboli in an anticoagulated patient are managed conservatively.

Justify the 15-minute delayed venogram. What are you deciding on the basis of it?

It detects elastic recoil that is invisible on the immediate run. Three findings mandate a stent rather than angioplasty alone: residual stenosis over 30%, a gradient over 15 cmH2O across the segment, or persistence of intrahepatic collaterals. Skipping it produces early symptomatic re-occlusion, classically in membranous lesions.

You cannot engage the hepatic vein ostium from the jugular route. Take me through your escalation and its price.

Escalate from angled hydrophilic wire with catheter support, to stiff wire, to the Rosch-Uchida needle, to the stiff back end of the wire advanced 3 mm at a time under road-map, and finally to ultrasound-guided transhepatic puncture with snaring of the wire into the jugular sheath. The price of the transhepatic route is capsular breach: haemorrhagic complications in reported series occurred exclusively in that group, which is why dilatation is still performed from the jugular side.

This patient has occlusion of all three main hepatic veins. Is there any endovascular target left before you commit to TIPS?

Yes - an obstructed but compensatory accessory or inferior right hepatic vein of 5 mm or more, if its occluded segment is shorter than that of any main vein. Roughly 86-89% of IVC-type and combined-type patients have a patent compensatory accessory vein, so it should be looked for on cavography and cross-sectional imaging before abandoning recanalisation.

Why is stent position at the hepatic vein ostium so unforgiving?

The ostia lie within 1-2 cm of the right atrium. A stent short of the ostium leaves the obstructing web untreated; one protruding far into the cava becomes a nidus for thrombus and can compromise the other hepatic vein ostia and any future TIPS; and an undersized device at that mobile junction can migrate into the right atrium.

Your patient is symptom-free with a patent vein at 6 months but returns at 10 months with ascites. Doppler shows retrograde flow. What is your line of management?

This is re-obstruction, the dominant late event given a 5-year primary patency around 58%. Check anticoagulation adequacy and the underlying thrombophilia treatment, then proceed to venography with a view to repeat angioplasty, additional stenting or thrombolysis; secondary patency remains around 75% at 5 years with such reintervention. Convert to TIPS or DIPS if the segment cannot be salvaged.

References