Application Value Of Accessory Hepatic Vein Angioplasty In The Treatment Of Hepatic Vein-type And Mixed-type Budd-Chiari Syndrome

Objective To investigate safety and efficacy of accessory hepatic vein?AHV?angioplasty?balloon dilatation or stent implantation?in the treatment of hepatic vein-type and mixed-type Budd-Chiari syndrome?BCS?,and to follow-up the mid-long-term situation of survival and patency of AHV.Methods From Mar.2007 to Jul.2016,totally 60 patients with BCS treated with AHV balloon dilatation or AHV stent implantation in our institution were collected retrospectively.All patients diagnosis,including 33 patients with hepatic vein-type BCS and 27 patients with mixed-type BCS,were confirmed by clinical manifestations,color ultrasound,CT or MR,digital subtraction angiography.Totally three hepatic veins in all patients were obstructed universality or became wee,and hepatic veins were hard to be opened.AHVs were dilated but with obstruction.When the angle between AHV and distal inferior vena cava?IVC?was obtuse angle,the angioplasty approach was from femoral vein.When the angle between AHV and distal IVC was acute angle,the angioplasty approach was from vena jugularis interna.If AHV diameter was rebounded slightly,AHV pressure declined obviously,or collateral vessel disappeared or decreased after the AHV balloon dilatation,AHV stent implantation was not implemented due to the good result of dilatation.Conversely,if AHV diameter was rebounded obviously,AHV pressure declined slightly,or collateral vessel did not fade away,AHV stent implantation was implemented due to the bad result of dilatation.If patients combined with IVC stenosis or occlusion,IVC balloon dilatation or IVC stent implantation was implemented before the AHV angioplasty.After the AHV angioplasty,patients were treated with enoxaparin sodium and warfarin.The warfarin was taken for 6¹2 months.Color ultrasound,biochemistry,and blood routine were examined to evaluate pathogenic condition at 1 month after the operation.Color ultrasound was examined every 1³ months,and if necessarily,CT or MR was also performed to evaluate the AHV patency.The SPSS 16.0 soft was used to analyze data,and measurement data was expressed with mean±standard deviation.AHV pressure and laboratory indexes before and after the operation was compared by pared-samples T test.Survival curve and vascular patency curve were drawn by life-table-method and Kaplan-Meier method,respectively.Different of vascular patency rate between two groups was tested by Log-rank test.Difference was statistically significant if P<0.05.Results Among the 60 patients with BCS,there were 46 patients with hepatic veins segmental occlusion,14 patients with hepatic veins segmental occlusion and small diameter.Dilated AHV in all patients were showed,and were communicated with hepatic veins by abundant tortuous dilated intrahepatic collateral vessels.Totally 60AHVs,with diameter of 6.3 mm¹5.3 mm and mean diameter of?11.3±2.6?mm,were selected as therapeutic target vessels,including 42 AHVs with stenosis in exit and 18AHVs with membranous occlusion in exit,and 51 inferior right hepatic veins and 9hepatic caudal veins.Among the 18 patients with AHV membranous occlusion,5 cases punctured through the vena jugularis interna,5 cases punctured through the femoral vein,and 8 cases were by percutaneous transhepatic puncture.All 60 AHVs were opened successfully,including 36 cases through the vena jugularis interna and 24 cases through the femoral vein,with success rate of 100%.And obstruction of IVC in the 27patients was opened successfully during the operation,also with success rate of 100%.There were 51 patients treated with AHV balloon dilatation,and 9 patients treated with AHV stent implantation.Among the 9 patients treated with AHV stent implantation,7patients were due to AHV rebound obviously after balloon dilatation and 2 patients were due to AHV angiorrhexis after balloon dilatation.The AHV pressure in all patients decreased obviously,from the preoperative pressure?44.6±12.0?cmH₂O to postoperative pressure?26.5±5.0?cmH₂O,the difference was statistically significant?t=4.323,P<0.05?.Compared with pre-operation,symptoms and signs in all patients,including ventosity,stomachache,hydrothorax and ascite,digestive tracthemorrhage,hepatosplenomegaly,lower extrimities swelling,lower extremity pigmentation and ulcer,decreased or disappeared one month after the operation.Blood indexes of glutamic oxalacetic transaminase,glutamyltranspeptidase,alkaline phosphatase,total bilirubin,platelet count improved significantly,the differences were statistically significant?P<0.05?.Blood indexes of glutamic-pyruvic transaminase and albumin also improved,but with no significant differences?P?29?0.05?.During the 9⁷2 months follow-up,with median follow-up time of 37 months,3 patients died due to alimentary tract hemorrhage and hepatic failure at 9,34,59 months after the operation.The 1-,3-,and 5-accumulate survival rate were 98.3%,96.7%,and 95%,respectively.The 1-,3-,and 5-accumulate patency rate of AHV were 95%,70.8%,and 57.3%,respectively,and were 90.9%,62.7%,56.4%respectively in hepatic vein-type BCS,and were 100%,80.8%,60.6%respectively in mixed-type BCS.The difference of accumulate patency rate of AHV between the hepatic vein-type BCS and mixed-type BCS was not statistically significant?P?29?0.05?.Conclusion 1.The AHV angioplasty for treatment of hepatic vein-type and mixed-type BCS is safe and feasible,with high success rate of operation and definite near-term therapeutic effect.It can significantly improve the signs and symptoms of portal hypertension and IVC hypertension.2.The mid-long-term situations of survival and vascular patency after AHV angioplasty are both comparatively good.And the difference of mid-long-term AHV patency rate between hepatic vein-type BCS and mixed-type BCS is not statistically significant.