Clinical efficacy of the combination of transjugular intrahepatic portosystemic shunt and catheter-directed thrombolysis in the treatment of acute portal vein thrombosis accompanied by Budd-Chiari syndrome with extensive occlusion of hepatic veins

Abstract

Objective To evaluate the clinical efficacy of combination of transjugular intrahepatic portosystemic shunt (TIPS) and catheter-directed thrombolysis (CDT) in the treatment of acute portal vein thrombosis (PVT) accompanied by Budd-Chiari syndrome (BCS) with extensive occlusion of the hepatic veins. Methods From March 2013 to December 2015, nine patients of acute PVT accompanied by BCS with extensive occlusion of the hepatic veins were collected, and the patients were treated by the combination of TIPS and CDT. The clinical symptoms, liver function and portal vein hemodynamics of patients were observed. After operation, portal vein and shunt patency was followed up by Doppler ultrasound. The patients were followed up seven days, one, three, six months, and every six months after the operation. Paired sample t test was performed for statistically analysis. Results The study enrolled nine patients, six male and three female, with an average age of (41.6±10.9) years old. Operation was successfully performed in eight patients, and of whom three were completed under the assist of perctaneous transhepatic approach. After operation, the blood flow of portal vein was unobstructed and clinical symptoms of portal vein hypertension were obviously improved. There was no significant difference in portal vein diameter between pre-operation ((13.6±2.1) cm) and seven days ((12.5±1.7) cm), one month ((12.1±2.9) cm), three months ((12.9±3.2) cm), six months ((11.6±1.8) cm) after operation (all P>0.05). And the portal vein velocity after operation were (79.3±14.6), (84.4±17.3), (87.3±21.4) and (80.1±12.6) cm/s, respectively, which were higher than that before operation ((9.8±3.1) cm/s), and the differences were statistically significant (t=28.169, 34.713, 36.519, 30.314, all P<0.01). The maximum cross sectional area ratios of the thrombus to the lumen after operation were (17.1±6.9)%, (19.1±6.2)%, (16.2±5.5)% and (16.7±5.1)%, respectively, which were lower than that before operation ((78.2±14.5)%), and the differences were statistically significant (t=26.182, 23.931, 29.371, 27.471, all P<0.01). At the seventh day after operation, the pressure of portal vein decreased from (42.2±8.9) cmH2O (1 cmH2O=0.098 kPa) to (19.6±4.2) cmH2O (t=17.410, P<0.01). At seven days, one month, three months and six months after operation, albumin levels ((30.7±3.9), (30.9±4.2), (29.9±3.1) and (33.1±4.7) g/L) were all higher than that before operation ((26.5±4.8) g/L), and the differences were statistically significant (t=4.785, 4.874, 2.874, 5.402, all P<0.05). The levels of transaminase after operation (32.9±21.6), (39.5±22.4), (24.8±19.8), (37.1±26.9) U/L) were all lower than that before operation ((99.6±31.7) U/L), and the differences were statistically significant (t=27.624, 24.913, 33.671 and 25.019, all P<0.01). During eight to 17 months follow-up, TIPS stent shunt stenosis was found in one case at three months after operation and the blood flow recovered after treatment of balloon dilation. The shunt and blood flow of portal vein of the other seven cases were clear. None of the eight patients had the symptoms of hepatic encephalopathy and pulmonary embolism. Operation was not successfully performed in one case, and 29 days later the patient died of hepatic and renal failure. Conclusion The combination of TIPS and CDT is safe and effective in the treatment of acute PVT accompanied by BCS with extensive occlusion of the hepatic veins, which maintain the blood flow of portal vein clear during short-and medium-term follow-up. Key words: Budd-Chiari syndrome; Portal vein thrombosis; Portasystemic shunt, transjugular intrahepatic