A 51-year-old female with a past medical history of fibromyalgia, iron deficiency anemia, hypertension, and obesity presented to an outside hospital for evaluation of protruding veins on her abdomen and chronic blood loss anemia. Endoscopy revealed grade 1 esophageal varices and liver biopsy was consistent with Budd Chiari syndrome (BCS). Inferior vena cava (IVC) venogram confirmed occlusion at the level of the sIVC (Fig. 1) with multiple retroperitoneal and abdominal wall collaterals draining the suprarenal IVC. IVC pressure was 23 mmHg and right atrial pressure was 12 mmHg. She had undergone unsuccessful attempts at sharp recanalization of the sIVC through transfemoral route at an outside hospital and was referred to our institution for recanalization of the sIVC for portal decompression.
Initial attempt at sharp recanalization through a transfemoral approach was pursued. A Rösch-Uchida transjugular liver access set (Cook, Inc.) was advanced and localized in the intrahepatic IVC using a curvilinear probe. Under continuous sonographic and fluoroscopic guidance, a 21-gauge Chiba needle was advanced through the cannula and used to puncture the sIVC. Subsequently, a V-14 wire was advanced through the needle into the right atrium. Cone beam CT was performed demonstrating the wire coursing through the IVC, hepatic parenchyma, and into the right atrium. Subsequently, a 4-French glide catheter was advanced over the V-14 guidewire into the right atrium. The catheter was then retracted and an over the wire tractogram was performed demonstrating contrast pooling into the pericardial space on cone beam CT (Fig. 2), consistent with a trans-pericardial course into the right atrium. This was attributed to the relative anatomy of the sIVC, which was short and in the same horizontal plane as the intrahepatic IVC (iIVC) segment. Hence to target the sIVC for sharp recanalization, the initial thought was to place a fogarty balloon in the sIVC via a percutaneous direct transhepatic approach. Under sonographic guidance, a 21-G Chiba needle was advanced through the hepatic parenchyma into the patent sIVC. The needle traversed the overlying middle hepatic vein (MHV) into the sIVC (Fig. 3). A 0.018 inch micro-guidewire was advanced into the right atrium and the needle was exchanged for a 6-French Neff set (Cook, Inc.). A 4-French glide catheter was then advanced coaxially into the right atrium and used to perform an over the wire tractogram to exclude an inadvertent trans-pericaridal course. Tractogram confirmed a non-trans-pericardial course and also showed opacification of the infrahepatic IVC from the MHV (Fig. 4A). Given this finding, attempts to snare the wire in the MHV from a transfemoral approach was performed to pursue stenting extending from the iIVC across the MHV and into the sIVC. However, instead of a straighter course, the wire and the catheter looped around the hepatic dome, to ultimately grasp the wire coursing through the MHV (Fig. 4B). Cone beam CT was performed demonstrating the wire and catheter passing through intrahepatic collaterals bridging the right hepatic vein (RHV) and MHV with complete occlusion at their confluence. Considering this complete occlusion, recanalization of the sIVC from transjugular approach was pursued. The wire which was placed through the direct percutaneous transhepatic approach into the sIVC was snared through the right jugular access and a 5 Fr Kumpe catheter was advanced over the wire into the MHV through the sIVC. Multiple attempts at crossing the occlusion between the MHV and the RHV using catheter wire combination were performed but were unsuccessful. Finally, the Kumpe catheter was exchanged for a Rösch-Uchida TIPS cannula and the 21 G-Chiba needle was used for sharp recanalization between the MHV and the RHV. A glidewire was then advanced into the infrahepatic IVC. Thereafter, angioplasty of the recanalized intrahepatic segement was performed to 10 mm. No extravasation was identified. A 14 mm x 60 mm Zilver Vascular Self-Expanding stent (Cook Inc.) was deployed across the areas of occlusion extending from the infrahepatic IVC into the MHV and into the sIVC with good flow thought the stent. There was no gradient across the IVC, post stenting. The patient demonstrated clinically improvement with decreased size of her varices, is experiencing no symptoms post-procedure, and has had no complications secondary to the endovascular procedure. Her post procedure CT 8 months later shows a patent IVC stent with interval decompression of the venous collaterals (Fig. 5).