IVC Angioplasty Alone Strategy in the Management of Combined Budd–Chiari Syndrome

Purpose: To evaluate the efficacy of an IVC-alone endovascular strategy in combined Budd-Chiari syndrome (BCS) with inferior vena cava (IVC) and hepatic vein (HV) involvement, and to determine the need for HV intervention in these cases.

Materials and Methods: Consecutive symptomatic BCS patients treated between June 2021-June 2024 were prospectively evaluated (N=120). Patterns were classified on Doppler as combined IVC and HV occlusion or HV-only occlusion with patent IVC. 68 patients had occlusion of both IVC and HVs. The remaining 52 patients had HV-only occlusions. None of the patients had IVC-only occlusion. The study population included only the combined subgroup (n=68). Short-segment IVC lesion was defined as a membranous web or focal stenosis < 2 cm; long-segment as ≥2 cm or a thrombotic cast. Collateral adequacy was defined as accessory hepatic or caudate veins ≥5-6 mm with demonstrable hepatocaval drainage on imaging. Technical success was defined as crossing the obstruction and restoring uninterrupted IVC outflow on venography. Clinical success was defined as improvement or resolution of ascites with better liver biochemistry at 6 months.

IVC balloon angioplasty (20-24 mm) was the index therapy in all 68; stents were placed only for documented restenosis on follow-up with recurrent symptoms.

Results: All 68 had IVC obstruction with ≥1 compromised HV ostium. Lesion type was membranous/short-segment in 65/68 (95.6%) and long-segment with visible thrombosis in 3/68 (4.4%). Collaterals were present in all short-segment cases. Technical success for short-segment lesions was 100% (65/65). Clinical success at 6 months was 66/68 (97.1%). No patient required HV recanalization (index or staged). Three long-segment thrombotic cases required TIPS. Restenosis occurred in 4/65 (6.2%) within 6 months (three stented, one repeat angioplasty). Procedure-related complications occurred in 2/68 (2.9%)-hemothorax and hemopericardium-both managed conservatively; one death (anticoagulation-related gastrointestinal bleed) occurred on day 10.

Conclusion: With adequate hepatocaval collaterals, IVC angioplasty alone can suffice for managing combined BCS, safely avoiding unnecessary HV interventions or TIPS.