The Characteristics Analysis Of Budd-chiari Syndrome In Henan Province And Its Therapeutic Effect After Interventional Therapy

Background and Objectives This study is carried out to evaluate the types of venous involvement in Budd-Chiari Syndrome(BCS) patients in Henan Province and the relative diagnostic accuracy of the different imaging modalities. The safety, long-term patency and clinical efficacy of BCS after big balloon angioplastry are studied by comparing the clinical experience in our department of treating 446 cases of BCS patients with Inferior Vena Cave(IVC) lesions with big balloons of 30 mm in diameter with treatment of BCS patients with IVC stenosis or occlusion using small balloons of25 mm or 26 mm in diameter. The long-term patency and clinical efficacy of hepatic vein angioplasty and TIPSS treatment of 173 cases of BCS are observed in our department.Materials and Methodology1. Characteristics of BCS in Henan Province Using digital subtraction angiography(DSA) as a reference standard,color Doppler ultrasound(CDUS), computed tomography angiography(CTA), and magnetic resonance angiography(MRA) were performed on338 patients with BCS. We analyzed the course of the main and any accessory hepatic veins(HVs) and the inferior vena cava(IVC) to assess the etiology of obstructed segments and diagnostic accuracy of CDUS,CTA and MRA.2. The efficacy analysis of big balloon dilatation for inferior vena cava stenosis or occlusion From January 2007 to December 2015, a total of 730 cases of the inferior vena cava type and mixed type of BCS were enrolled, of which,446 cases were treated with angioplasty using big balloons of 30 mm in diameter, while 284 cases using small balloons of 25 mm or 26 mm in diameter. The patients' general condition, symptoms, vitals,complications, disease classification, etc. are monitored as well as the situation of perioperative complications and postoperative follow-up of efficacy and patency of the inferior vena cava treatment.3. The efficacy analysis of balloon dilatation and TIPSS for hepatic vein stenosis or occlusion From January 2007 to December 2015, a total of 173 cases of BCS were treated with balloon dilatation or Transjugular Intrahepatic Portosystemic Stent Shunt(TIPSS) treatment for hepatic vein lesions, of which 127 cases were treated with dilation, and 46 cases TIPSS. The patients' general condition on admission, symptoms, vitals, complications,disease sub-classification, etc. are analyzed, the occurrence of perioperative complications and postoperative follow-up of efficacy and treatment of hepatic veins and TIPSS shunt patency are observed in both groups.4.Medical imaging test All patients have undergone color Doppler ultrasound and / or multi-slice spiral CT scan preoperatively to confirm diagnosis and BCS classification, and to detect blood flow, diameters, lesion types and length of hepatic vein and inferior vena cava, and the existence of thrombosis.Multi-slice spiral CT scan conducts a multi-phase enhanced scan which delay the scanning time to 180 seconds, displaying a clear image of the inferior vena cava, thus avoiding possible misdiagnosis caused by excessive, slow or inadequate blood flow. MRI test obtains dynamic 3D image of veins useing 1.5T or 3.0T magnetic resonance artery enhancement scanning sequence, SE sequence scanning and 3D TOF spoiled gradient echo sequence(3D TOF FSPGR), and liver fast volume acquisition technology(LAVA) dynamic enhanced scanning. Diagnosis,analysis, and measurement of diseased vein stenosis / occlusion location are performed based on the image, and diameter, blood flow velocity are calculated.5.The balloon angioplasty for inferior vena cava Patients lie supine on DSA bed, after routine disinfection, sterile draping and local anesthesia, Seldinger technique is used for femoral vein puncture or jugular vein puncture. 5F straight catheter is inserted to the inferior vena cava and hepatic venography were performed to identify lesion location, shape, length and collateral circulation. The balloon catheter guide wire is used for rupture in patients with inferior vena cava occlusion, strengthening guidewire and the sheath of 12 F or 8mm diameter balloon catheter were introduced for dilation of blocking segment, PTA is performed with a diameter of 25 mm, 26 mm, or 30 mm balloon catheter, inferior vena retrievable stents or permanently stents is used when necessary.6.Balloon dilatation and TIPSS for hepatic vein The guide wire and catheter are inserted into the(vice) hepatic veins,and venography is performed to show the property, location, diameter and length of the lesion. If hepatic vein catheterization fails, percutaneous and transhepatic puncture is performed, thus occlusion deblocked and path created. Balloon catheters of 10 mm, 12 mm, 14 mm,16mm, 20 mm in diameter are options for dilation of stenosis/occlusion segments in(vice) hepatic vein or the inferior vena cava. After the insertion is completed,venography is perfomed again to evaluate the patency of blood flow.TIPSS: After local anesthesia, the right internal jugular vein was punctured using hard guide wire and Rupss-100 puncture kit, in most of the cases puncture is directed to portal vein through IVC. Adjust the angle of the intrahepatic puncture for successful portal vein puncture and then intrahepatic shunt is dialated using balloon catheter of 6mm or 8mm in diameter before bare stent and/ or covered stent of 8mm or 10 mm in diameter are inserted between hepatic vein and portal vein. Angiography is performed again to evaluate patency of the shunts, gastrointestinal bleeding after bleeding and gastric coronary vein thrombosis for instance.7.Statistical analysis All qualitative data are presented in percentage. Chi-square test is used for qualitative analysis variable data(SPSS, Chicago, USA). When P <0.05, the data is considered statistically significant. All data is processed using S P S S10.00 application packages. When data is normally distributed, t test and F test are applied for statistical analysis;while not normally distributed, wilcoxon rank sum test and rank sum test kw are applied, ? = 0.05 as test standard.Results1. Characteristics of BCS in Henan Province Among the 338 cases, there are 8 cases(2.4%) of isolated IVC membranous obstruction, 45 cases(13.3%) of isolated HV occlusion, and285 cases(84.3%) with both IVC membranous obstruction and HV occlusion. Comparing with DSA, CDUS, CTA have a diagnostic accuracy of 89.3% and 80.2% in detecting BCS, and MRA 83.4%.occlusion A total of 730 cases of BCS were enrolled using balloon dilatation for the inferior vena cava lesions. Among them, 446 cases are treated with large balloon dilation of 30 mm diameter, including 317 males and129 females with an average age of 47.13 ± 11.43; 284 cases are treated with small balloon dilation of less than 30mm(25mm, 26mm) diameter,includeing 186 males, and 98 females, with an average age of 46.52 ±10.22. The mixed type of BCS is the most common type in both groups,accounting for 91.9% and 94.1% in big and small balloon respectively,surgical success rates are 95.1% and 98.6%; clinical cure rate accounted for 92.0% and 87.0% respectively. The overall primary patency rate of97.6% of short-term, medium 95.4%, 92.2% of long-term in big balloon group, short-term patency of 89.8%, 87.8% of medium-term, 84.1% of long-term in small balloon group.3.The efficacy analysis of balloon dilatation and TIPSS for hepatic vein stenosis or occlusion A total of 173 cases of BCS were enrolled for treatment of hepatic vein lesions using balloon dilatation or TIPSS. Wherein 127 cases are in balloon group, including 92 cases of male and 35 female, with an average age 43.52 ± 18.03; 46 case in TIPSS group, including 31 male cases and15 female, with an average age 43.95 ± 13.19. The hepatic vein type is the most common type in both groups, accounting for 74.0% and 80.4%in balloon group and TIPSS group respectively. Intraoperative pain is the most common perioperative complications without fatal complications.Balloon group is followed-up every 49.6 ± 33.9 months, the short-term initial patency of hepatic vein in 95 cases(95.0%), medium-term patency in 94 cases(94.0%), and long-term patency in 90(90.0%); TIPSS group is followed-up every 46.2 ± 31.8 months, the short-term patency of intrahepatic shunt in 36 cases(94.7%), medium-term patency in 34 cases(89.5%), and long-term patency in 31 cases(81.6%). The long-term2.The efficacy analysis of big balloon dilatation for IVC stenosis or primary patency rate in balloon group are significantly higher than that of TIPSS group(P<0.05). For secondary patency rate, balloon group shows short-term patency in 98 cases(98.0%), medium-term patency in 96cases(96.0%), and long-term patency in 93 cases(93.0%); TIPSS group shows short-term patency of intrahepatic shunt in 37 cases(97.4%),medium-term patency in 35 cases(92.1%), and long-term patency in 32cases(84.2%). The long-term secondary patency rate in balloon group is significantly higher than that of TIPSS group(P<0.05).Conclusions1. In Henan Province, most patients with BCS have complex lesions combining IVC and HV involvement. The combination of CDUS and CTA or MRI is useful for diagnosing BCS and guiding therapy.2.The treatment of IVC disease using big balloon angioplasty with diameter of 30 mm is safe, effective, and with less surgical complications., The long-term efficacy and patency rate of big balloon angioplasty for treatment of BCS IVC disease are significantly higher than that of small balloon angioplasty group.3. The treatment of hepatic venous hepatic vein by balloon angioplasty and TIPSS is safe, effective, and postoperative patency rate of hepatic vein is significantly higher than that of venous shunt in TIPSS group. TIPSS is optional for the treatment of three hepatic veins lesions,and hepatic vein balloon angioplasty failure patients.