IVC Obstruction Research Articles

Malignant obstruction of the inferior vena cava: clinical experience with the self-expanding Sinus-XL stent system

PurposeTo evaluate the technical and clinical outcome of Sinus-XL stent placement in patients with malignant obstruction syndrome of the inferior vena cava.MethodsBetween October 2010 and January 2021, 21 patients with different malignant primary disease causing inferior vena cava obstruction were treated with Sinus-XL stent implantation. Procedural data, technical and clinical outcome parameters were retrospectively analyzed.ResultsTechnical success was 100%. Analysis of available manometry data revealed a significant reduction of the mean translesional pressure gradient following the procedure (p = 0.008). Reintervention rate was 4.8% (1/21). The available follow-up imaging studies showed primary and primary-assisted stent patency rates of 93% (13/14) and 100% (14/14), respectively. Major complications did not occur. The clinical success regarding lower extremity edema was 82.4% (14/17) for the first and 85.7% (18/21) for the last follow-up. Longer lengths of IVC obstruction were associated with reduced clinical improvement after the procedure (p = 0.025). Improvement of intraprocedural manometry results and lower extremity edema revealed only minor correlation. Ascites and anasarca were not significantly positively affected by the procedure.ConclusionSinus-XL stent placement in patients with malignant inferior vena cava obstruction showed high technical success and low complication rates. Regarding the clinical outcome, significant symptom improvement could be achieved in lower extremity edema, whereas ascites and anasarca lacked satisfying symptom relief. Based on our results, this procedure should be considered as a suitable therapy in a palliative care setting for patients with advanced malignant disease.

S2566 Idiopathic Membranous Hepatic IVC Obstruction: A Search for Viable Options

S2566 Idiopathic Membranous Hepatic IVC Obstruction: A Search for Viable Options

Endovascular Treatment (Stenting) of Total IVC Obstruction with Collaterals in Young Adult with Crohn’s Disease Maharishi Markandeshwar (Deemed to Be University)

We present a case of clinically extensive bilateral DVTs associated with chronic total inferior vena cava thrombosis with underlying crohn’s disease and who is on steroid therapy. Young patients presenting with symptoms of DVT should be investigated not only to establish any thrombophilic pre-disposition but to ascertain the proximal extent of thrombus which may itself influence treatment. Treatment options in the case of IVC thrombus without anatomical variance include anticoagulation, mechanical thrombectomy, systemic thrombolytic therapy, transcatheter regional thrombolysis, and angioplasty

Treatment of malignant inferior vena cava obstruction with Gianturco-Rosch-Z stents: a single center 13-year experience

Rationale and objectivesMalignant obstruction of the IVC can cause severe morbidity and impairment of quality of life in end-stage oncology patients. However, medical literature regarding minimally-invasive palliation using large diameter percutaneous stents, particularly the Gianturco-Rosch-Z (GRZ) stent is limited. Materials & methodsA retrospective review from January 2004 to February 2017, revealed 17 subjects with malignant obstruction of the IVC who were treated with a total of 34 GRZ stents. Pre- and post-stent pressure gradients were measured in 10. Available data regarding clinical presentation and follow-up were recorded. ResultsTechnical success for stent deployment was 100%. A median of 2 stents (range 1 to 5) were deployed per patient, with median stent diameter 20 mm (range 15 to 30 mm). The median pre-treatment pressure gradient of 17.5 mmHg (range 9–31 mmHg) decreased to a median of 4.5 mmHg (range 0–21 mmHg, p < .0004) after stent placement. One subject developed recurrent stent occlusion due to disease progression requiring additional intervention, for a primary patency rate of 94%. Lower extremity edema improved or resolved in 58% of those for whom follow-up data was recorded. Median survival after treatment was only 28 days (range 5 to 607 days). There were no procedural complications. ConclusionEndovascular treatment of malignant IVC obstruction can be safely performed with GRZ stents. Although overall survival is poor, this technique can effectively palliate lower extremity edema symptoms.

Percutaneous treatment of IVC obstruction due to post-resection hepatic torsion associated with IVC thrombosis

BackgroundMigration of the left hepatic lobe into the potential space following right lobe resection can result in torsion and hepatic venous outflow obstruction with compromised venous return from the IVC. If untreated, significant morbidity and mortality can develop.Case presentationWe report a case of a 29-year-old female with Lynch syndrome who underwent right lobe resection for a metastatic hepatic tumor. There was subsequent migration of the liver remnant, torsion of the IVC, and impaired hepatic outflow, successfully treated with thrombectomy and stenting.ConclusionFollowing right hepatectomy, hepatic venous outflow obstruction should be consdered in the setting of hepatorenal failure and hemodynamic instability. Endovascular stenting is a viable treatment option.

Is Hepatovenocaval Syndrome a Different Entity from Budd-Chiari Syndrome in Children?

To differentiate between clinical and demographic spectrum, and outcome in hepatovenocaval syndrome (HVCS) and Budd-Chiari syndrome (BCS). Descriptive study. Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Children Hospital, Lahore, from January 2014 to January 2017. All children less than 18 years of age, presenting with ascites and visible veins over abdomen, flanks and back were enrolled in the study. Real time Doppler Ultrasonogram was performed in all children for documentation of intra- hepatic part of IVC obstruction along with or without hepatic venous obstruction. Children meeting inclusion criteria underwent liver profile, coagulation profile, diagnostic paracentesis for SAAG gradient, and Gadolinium enhanced multiphasic MR scan. Liver biopsy and venography was performed in selected patients. A total of 92 children presented with ascites, among them 58 children met our inclusion criteria. Intrahepatic IVC obliteration, i.e. HVCS, found in 67% (n=39) and hepatic venous outflow obstruction, i.e. BCS was found in 33% (n=19) children. Children with BCS were older than HVCS with mean age of 9.5 ±2.58 versus 4.12 ±0.977 years. HVCS group had 14 boys and 24 girls with a ratio of 1:1.8, while BCS had a ratio of 1:0.9 with 10 boys and 9 girls. No etiological factor was found for HVCS, while most of patients with BCS had a procoagulant disorder. Caudate lobe hypertrophy was a consistent feature in BCS, while IVC obstruction was found in HVCS persistently. Orthotopic liver transplant was needed in three cases (7.6%) of HVCS and four (20.96%) of BCS cases. Antibiotic therapy has a good role in HVCS, while anticoagulation and diuretics had good result in BCS. Hepatovenocaval syndrome (HVCS) mostly affected younger children, especially girls. BCS usually affected older age groups with pro-coagulant disorders who responded to anticoagulation and diuretic. Further studies are needed to compare both conditions.

Endovascular Intervention in Budd-Chiari Syndrome

Background and Aim: Outcomes of endovascular intervention in Budd-Chiari syndrome (BCS) have been reported with varied results. Clinical outcomes of endovascular interventions in BCS and role of various prognostic scores were critically evaluated in this study. Methods: This study retrospectively analysed consecutive patients of BCS who underwent endovascular intervention between Jan 2007 to December 2016 at our center. Technical, clinical successes and complications were documented. The role of the prognostic scores such as Child-Turcotte-Pugh (CTP), model for end stage liver disease (MELD), Rotterdam index and original Clichy score in predicting mortality, clinical success and need for re-interventions were also assessed. Results: A total of 100 patients were analysed with mean age 32.34 (±11.38) years and 59 were males. The median follow up was 16 (range 1–101) months. Fifteen (15%) patients had combined IVC and HV obstruction; HV obstruction in 41 and IVC obstruction in 44 patients. Following interventions were done–IVC angioplasty alone (n = 12), IVC angioplasty with stenting (n = 38), HV angioplasty with stenting (n = 31), combined HV and IVC stent (n = 2) and DIPS (n = 15). Overall technical success was 98/100(98%) and clinical success was 85%. Immediate complications were noted 8% patients. The 1-year, 2-year, 3-year and 5-year stent patency rates were 92%, 84.8%, 74.9% and 74.8% respectively. Re-interventions were required in 15 patients. Overall mortality was 6%. Apart from MELD >14, none of the other prognostic score could predict mortality, clinical success and need for re-interventions. Conclusion: Endovascular interventions play an important role in the management of BCS, in properly selected patients, even if prognostic score are unfavourable. The authors have none to declare.

Endovascular treatment of Budd-Chiari syndrome: Single center experience.

Percutaneous radiologic interventions are increasingly being used in management of Budd-Chiari syndrome (BCS). Minimal invasive approach has resulted in excellent long-term outcomes. We evaluated the treatment efficacy and safety of radiological intervention in patients with BCS. Between January 2008 and June 2014, 190 patients with BCS underwent endovascular procedures (hepatic vein, collateral vein or inferior vena cava [IVC] plasty with or without stenting, or transjugular intrahepatic portosystemic shunting [TIPSS]). Clinical features, biochemical profile, and stent patency were monitored pre-procedure and post-procedure, and for a median duration of 42 (12-88) months. Of 190 patients (mean [SD] age = 26.9 [11.5] years; 102 men), imaging revealed hepatic vein obstruction in 147 patients, IVC obstruction in 40 patients, and concomitant hepatic vein and IVC obstruction in three patients. At presentation, the radiological interventions included hepatic vein plasty/stenting in 38 patients, collateral vein stenting in three patients, IVC plasty/stenting in 40 patients, both IVC and hepatic vein stenting in three patients, and TIPSS in 106 patients. Response was seen in 153 patients (80.5%). Repeat interventions were required in 19 patients (10.0%). Complications were noted in nine patients (4.7%). Our study demonstrates that venous recanalization and TIPSS for BCS are safe and efficacious.

Ultrasonographic Study of Ascites with Clinicopathological Correlation

=50ml). Ultrasound performs better than CT in localizing asceitic fluid in relation to peritoneal spaces becauses it allows instant visualization in different planes. Ultrasound is also less hazardous in relation to CT. it involves minial patient‟s preparation and additionally is the least expensive of available imaging tests It can also be performed in very sick non ambulatory patients at beside. Diagnosis often requires fine needle percutaneous aspiration associated with cytopathological study. US guided fine needle aspiration is a simple and easy, cost effevtive and a useful procedure for obtaining ascitic fluid samples. Aetiophysiological Classification of Ascites A. Ascites not associated with peritoneal disease 1. Portal hypertension : A. Cirrhosis B. Hepatic congestion - C. C. F - Constrictive pericarditis - IVC obstruction - Hepatic vein obstruction (Budd-Chiari syndrome) C. Portal vein occlusion

Behcet's disease in Budd-Chiari syndrome.

BackgroundBehcet’s disease (BD) is a well-known cause of Budd-Chiari syndrome (BCS). Data are lacking on the presentation and outcome of BCS related to BD.MethodsWe investigated the relationship between BD and BCS in 14 patients with both diseases and compared the results to 92 BCS patients without BD.ResultsMale gender (p = 0.003), North African origin (P = 0.007) and inferior vena cava obstruction (P < 0.0001) were more frequent in patients with BD and BCS than in those with BCS alone and the plasma C-reactive protein level was higher (p = 0.003). Two of the patients with the combined diseases underwent recanalization of the vena cava and the hepatic veins, none received transjugular intrahepatic portosystemic shunts (TIPS), one received a surgical shunt and one underwent liver transplantation. TIPS were less frequent in patients with BD and BCS than in those with BCS alone (P = 0.019). Eighty six per cent of patients with BCS and BD received corticosteroids and immunosuppressive therapy. The 5-year transplantation-free survival rate was 63% in patients with BCS alone and 91% in those without BD (P = 0.11). In our series and in the literature, a high number of patients [12 (61.5%) and 11 (64.7%) respectively] treated with anticoagulation and corticosteroids and/or immunosuppressants did not require invasive treatment.ConclusionThis study shows a higher frequency of IVC obstruction in patients with BCS and BD. Medical treatment with anticoagulation and immunosuppressive agents may improve the symptoms of BCS. Therefore early management with immunosuppressive and anticoagulation therapy appears to be the treatment of choice in patients with BCS and BD.

Behcet¿s disease in Budd-Chiari syndrome

Behcet’s disease (BD) is a well-known cause of Budd-Chiari syndrome (BCS). Data are lacking on the presentation and outcome of BCS related to BD. We investigated the relationship between BD and BCS in 14 patients with both diseases and compared the results to 92 BCS patients without BD. Male gender (p = 0.003), North African origin (P = 0.007) and inferior vena cava obstruction (P < 0.0001) were more frequent in patients with BD and BCS than in those with BCS alone and the plasma C-reactive protein level was higher (p = 0.003). Two of the patients with the combined diseases underwent recanalization of the vena cava and the hepatic veins, none received transjugular intrahepatic portosystemic shunts (TIPS), one received a surgical shunt and one underwent liver transplantation. TIPS were less frequent in patients with BD and BCS than in those with BCS alone (P = 0.019). Eighty six per cent of patients with BCS and BD received corticosteroids and immunosuppressive therapy. The 5-year transplantation-free survival rate was 63% in patients with BCS alone and 91% in those without BD (P = 0.11). In our series and in the literature, a high number of patients [12 (61.5%) and 11 (64.7%) respectively] treated with anticoagulation and corticosteroids and/or immunosuppressants did not require invasive treatment. This study shows a higher frequency of IVC obstruction in patients with BCS and BD. Medical treatment with anticoagulation and immunosuppressive agents may improve the symptoms of BCS. Therefore early management with immunosuppressive and anticoagulation therapy appears to be the treatment of choice in patients with BCS and BD.

Global Hepatic Uptake of (99m)Tc-MAA During VQ Scintigraphy Secondary to Synchronous Superior and Inferior Vena Caval Obstruction: a Demonstration of Trans-Portal Venous Collateral Pathways.

A 38-year-old woman underwent lung scintigraphy. Injection of technetium-99m macroaggregated albumin (99mTc-MAA) via the left antecubital fossa revealed global hepatic uptake (Fig. 1). Review of contemporary computed tomography (CT) imaging demonstrated synchronous superior and inferior vena cava (SVC and IVC) obstruction, with formation of systemic-portal venous collateral pathways (Fig. 2). Systemic-portal venous collateralisation can in rare circumstances lead to focal hepatic uptake of 99mTc-MAA during lung scintigraphy. This case of global hepatic uptake, secondary to synchronous SVC and IVC obstruction, demonstrates the trans-portal venous collateral pathways leading to this unusual imaging outcome (Fig. 3). Fig. 1 A 38-year-old woman, at risk of venous thromboembolic disease secondary to Factor V Leiden disorder, was referred for lung scintigraphy (a, ventilation scan posterior view). Perfusion scanning (b, left posterior oblique view) revealed global hepatic uptake ... Fig. 2 Three-dimensional CT reconstruction demonstrating left-sided systemic-portal collateral venous pathways (arrowheads retroperitoneal venous collaterals, white arrow dilated inferior mesenteric vein, black arrow haemorrhoidal plexus). Review of contemporary ... Fig. 3 Diagram of proposed systemic-portal venous collateral pathways. The first pathway involves two grossly dilated retroperitoneal veins which ascend to anastomose with a left renal/splenic venous confluence (more commonly recognised in hepatofugal flow in ...

Anterior Mediastinal Mass : A Rare Presentation of Tuberculosis

We report a case of a 10 year old male child, who presented to us with complaints of progressive abdominal distension since 9 months and exertional breathlessness since 4 months. There was history of mild jaundice noticed by a doctor, however no other history suggestive of liver, cardiac or renal disease. He had received antitubercular therapy for complaints of cough 1 year ago for 3 months. There was no history of TB contact. General examination revealed mild icterus and prominent, distended neck and upper limb veins. Jugular venous pressure was raised with an absent hepatojugular reflux. Systemic examination showed massive ascites and a firm hepatomegaly. Cardiovascular examination revealed pericardial knock. Differential diagnoses were constrictive Pericarditis of tubercular etiology, Budd Chiari syndrome and a mediastinal mass causing IVC and SVC obstruction. Investigations revealed an anterior mediastinal mass on cardiac MRI(FIG) adherent to the pericardium causing extrinsic compression of the right atrium, most probably a germ cell tumour. Tumour markers were negative. A CT-guided biopsy of the mass was inconclusive, hence an open excision biopsy was done, which on gross appearance was suggestive of tuberculosis.

Establishment and evaluation of implanted inferior vena cava tumor thrombus model in New Zealand white rabbits

Objective To establish an animal model of implanted inferior vena cava tumor thrombus (IVCTT) and examine its growth with MDCT and 3D-MPR. Methods Tumor cell line VX2 was inoculated subcutaneously into rabbit to develop the primary tumor, which was then cut into small strips. Purse-string suture was performed on the anterior wall of IVC after the laparotomy in eighteen New Zealand white rabbits.The tumor strip was injected into IVC through the purse and suspensory fixed on the inner wall of IVC. The general conditions,body weight,and the survival time were monitored after operations.MDCT examinations were performed with plain scan,arterial phase,portal phase and venous phase enhancement every week for all animals and 3D-MPR were acquired.The volumes of IVCTT were calculated.IVC,IVCTT and metastasis were examined with gross and histological pathology. Results The IVCTT was confirmed by MDCT and 3D-MPR images.Collateral varicose veins caused by IVC obstruction and metastasis were also shown in images.IVCTT and metastasis were confirmed by pathological method. The success rate of IVCTT was 100 ％. The mean survival time of operated animals was (49.5±4.4) days. Conclusions Injecting and suspensory fixing VX2 tumor strip into IVC is a reliable method to establish the IVCTT animal model. MDCT and 3D-MPR are valuable methods to monitor the growth and metastasis of IVCTT in animal models. The model of implanted IVCTT of rabbits provides a useful tool for the research of treatment of IVCTT. Key words: Cell line,VX2; Models,animal; Vena cava,inferior; Neoplastic cells,circulating; Tomography,spiral computed

Incidence of and Risk Factors for Iliocaval Venous Obstruction in Patients with Chronic Venous Leg Ulcers

Iliocaval venous obstruction (ICVO) can be a significant contributor to venous hypertension in patients with advanced disease. Percutaneous stenting has been reported to correct ICVO, resulting in improvement in pain, swelling, and other venous symptoms. The incidence of ICVO in patients with CEAP clinical class 5 and 6 disease has not been reported. In this study, we reviewed a series of patients with healed or active venous leg ulcers to determine the incidence of ICVO and the risk factors related to its occurrence. Patients with CEAP clinical class 5 and 6 venous insufficiency underwent routine evaluation with duplex ultrasound imaging to identify the presence of venous reflux in the deep and superficial systems. Computed tomography (CT) or magnetic resonance (MR) venography was performed in all patients. Each study was evaluated by two separate examiners to determine the percentage of obstruction in the iliocaval outflow tract. Demographics and risk factors related to venous disease were collected and examined for their association with the presence of ICVO. We retrospectively reviewed 78 CEAP clinical class 5 and 6 patients (53.4% men; average age, 59.3 years) evaluated with a CT or MR venogram. The ulcer affected the left lower extremity in 46%, and 50% reported a history of deep vein thrombosis (DVT). Duplex ultrasound imaging identified deep venous reflux (DVR) only in 13% of ulcerated limbs, superficial venous reflux (SVR) only in 38%, and combined DVR and SVR in 49%. The incidence of iliac and IVC obstruction is listed in the Table. Overall, 37% of imaging studies demonstrated ICVO of at least 50%. Risk factors that were associated with a significantly higher incidence of >80% narrowing of the iliocaval outflow tract included a history of DVT (P = .005) and reflux in the deep venous system (P = .002). No limb with SVR alone was found to have ICVO > 80%. Although high-grade ICVO occurred more frequently in women and in patients with left leg ulcers, the frequency was not statistically significance.TableIncidence of iliocaval stenosis in all cases and in limbs with prior deep vein thrombosis (DVT) or deep venous reflux (DVR)Iliocaval stenosisTotal cases, %DVT history, %DVR, %100%8.817.218.380% to 99%1420.721.550% to 79%1413.812.330% to 49%5.33.45.110% to 29%17.513.811.8<10%42.13130.8 Open table in a new tab ICVO is a frequent and under-appreciated contributor to venous hypertension in patients with venous leg ulcers. Patients with a history of DVT or duplex-diagnosed DVR have a higher incidence of outflow obstruction and should be routinely studied with CT or MR venography to allow correction in this high-risk group of patients.

Multidetector CT Appearance of Retained Fibrin Sheath

neal clots were evacuated. The patient tolerated the procedure well and the postoperative period was uneventful. The patient again refused further treatment and alternative options of a different type of filter and requested discharge against medical advice. The patient was prescribed 5 mg warfarin as anticoagulation therapy to protect against recurrent pulmonary embolism. Incidental reports of filter complications are particularly important in patients being considered for prophylactic IVC filter insertion. Retroperitoneal hemorrhage from migration of an IVC filter and fatal rupture of the IVC are extremely rare. The incidence of IVC filter migration ranges from 0.3% to 6%, with rare migration of the filter to the heart or lung (0.1%– 1.25%) (1). Fatal retroperitoneal hemorrhage resulting from IVC perforation is one of the most serious complications noted after TrapEase IVC filter placement in the setting of anticoagulation and thrombolytic therapy for treatment of pulmonary embolism (2). Other filter-related complications are filter migration, insertion site thrombosis, filter fracture, vessel wall perforation, strut erosion through the IVC wall, recurrent pulmonary embolism, IVC obstruction, and lower-extremity venous insufficiency (3). Filter occlusion may be caused by trapping of a clot from deep vein thrombosis or formation of clot as a result of the presence of the filter itself, and it is very difficult to determine the exact cause. However, its reported incidence varies widely from 0% to 28% (4). Filter migration is associated with potentially fatal consequences. The risks include migration to locations such as the heart or pulmonary artery. IVC rupture and retroperitoneal hemorrhage caused by IVC filter migration may occur, and further investigation is needed to determine predisposing causes to this complication.

Balloon Dilatation of Inferior Vena Cava in Post Hepatic Trnasplant Venous Outflow Obstruction

Liver transplantation is an established mode of treatment of end stage liver disease. One of the major causes of post-operative complications is vascular anastomotic stenosis which include hepatic vein, inferior venacava or portal vein stenosis. Incidence of vascular complications is reported to be higher in living donor versus cadaveric liver transplants. We encountered a patient with hepatic venous outflow tract obstruction, where hepatic vein had been previously stented, but the patient continued to have symptoms due to additional IVC obstruction. The patient required double balloon dilatation of the IVC simultaneously from internal jugular vein and inferior venacava.

Peliosis hepatis causing inferior vena cava compression in a 3-year-old child

Peliosis hepatis is a rare benign condition characterized by oval or irregular, multiple blood-filled spaces within the liver parenchyma. It is most commonly seen in adults and may be idiopathic, but has various associations including malignancy, infection and drugs. The imaging findings are often non-specific and the condition may be mistaken for multiple abscesses, metastases or vascular malformations. Peliosis hepatis is an especially rare condition in children and to our knowledge only six cases have been described in the literature. Our case describes and illustrates peliosis in a 3-year-old girl and is the first described in any age group to cause complete IVC obstruction. The patient subsequently made a full recovery.

Carcinoma of the prostate presenting as IVC obstruction

Carcinoma of the prostate presenting as IVC obstruction

Management of idiopathic obstruction of the hepatic and suprahepatic inferior vena cava with a self-expanding metallic stent.

Ten patients (median age 36 yr, 5 male) with idiopathic IVC obstruction underwent balloon angioplasty followed by placement of a self-expanding stent due to unfavourable lesion characteristics. Six had total occlusion, 5 had restenosis (including 2 with total occlusion), and 1 had a suboptimal result after initial dilatation. Median minimum IVC diameter increased from 0 to 14.5 mm, and the median gradient across the lesion decreased from 16.5 to 1 mmHg. Follow-up venography (median interval 69 d) in six patients revealed no restenosis with further enlargement at the lesion site (median 4.5 mm) and abolition of gradients. Follow-up ultrasound in nine patients revealed no restenosis in the IVC. One patient died 6 mo after the procedure with acute Budd-Chiari syndrome due to hepatic vein occlusion. Autopsy revealed a widely patent stent with hepatic vein thrombus. Stent implantation is useful in the management of IVC obstruction with prior restenosis, total occlusion, or suboptimal result of balloon angioplasty.