Successful local thrombolytic therapy in subacute budd-chiari syndrome: Case report and review

Abstract

Introduction: Management of Budd-Chiari syndrome (BCS) includes different interventions and surgical procedures. There is limited data regarding catheterdirected thrombolysis when treating this condition but it appears to be helpful in the case illustrated below. Case report: A 29 year-old woman was referred to our center with one month history of right upper abdominal pain, progressive abdominal distension and intermittent fever not associated with rigors. There was no history of oral contraceptive use. She had mild right upper quadrant tenderness and abdominal distention with moderate elevation of liver enzymes. Her serology was negative for viral hepatitis, autoimmune or cholestatic liver disease. Computed tomography (CT) angiogram of the abdomen showed a large amount of ascites with extensive thrombosis of the inferior vena cava (IVC) involving the hepatic and left renal veins. There was also complete occlusion of the left common iliac vein confirmed by venogram. An infusion catheter was placed through the thrombosed segment of the IVC and right hepatic artery. Thrombolytic therapy was started with the injection of 5 mg of recombinant tissue plasminogen activator (t-PA) as a loading dose followed by 0.3 mg per hour. Enoxaparin and oral warfarin were started simultaneously and once the target INR was reached, enoxaparin was stopped and warfarin continued indefinitely. Ascites was well controlled with diuretics and large-volume paracentesis. A follow up venogram showed partial recanalization of IVC and hepatic veins. A repeat CT scan after 14 weeks showed complete resolution of the thrombus. After 28 months, she is asymptomatic with normal liver function tests and total resolution of the ascites. Conclusions: The data on local thrombolysis is limited and the agents and doses are not uniform among reported cases. This case report shows that it can be considered in acute BCS with partial obstruction, followed by angioplasty or TIPS if unsuccessful.