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Case Report

Endovascular stenting of IVC usingBrockenborough’s needle in BuddeChiarisyndrome e A case report

Pawan Poddar*, Sudarsana Gurizala, Sudarshan Rao

Department of Cardiology, Yashoda Hospital, Malakpet, Hyderabad 500 036, India

a r t i c l e i n f o

Article history:

Received 27 September 2013

Accepted 23 March 2014

Available online xxx

Keywords:

Angioplasty

Vena cava

Inferior

BuddeChiari syndrome

* Corresponding author. Flat No. 501, KrishnE-mail address: pawanpod@yahoo.com (P

Please cite this article in press as: Poddarsyndrome e A case report, Indian Heart

http://dx.doi.org/10.1016/j.ihj.2014.03.0140019-4832/Copyright ª 2014, Cardiological S

a b s t r a c t

A young female presented with BuddeChiari syndrome due to membranous obstruction of

inferior vena cava. Membrane was quite thick with complete occlusion of the IVC. She had

a previous unsuccessful attempt at endovascular stenting using conventional CTO wire

technique. She was successfully treated with balloon angioplasty and stenting after

perforation of the thick membrane with Brokenborough’s needle. At three months follow-

up she was asymptomatic with patent stent.

Copyright ª 2014, Cardiological Society of India. All rights reserved.

1. Case report

A previously healthy 41-year-old female was referred to our

center with 2 months history of abdominal pain, abdominal

distention, pedal edema and loss of appetite. There was no

history of jaundice. She was diagnosed to have hypothyroid-

ism two years back andwas on thyroid hormone replacement.

Clinical examination revealed markedly distended abdomen

with prominent superficial veins and bilateral pedal edema.

There was no jaundice and JVP was not elevated. Vitals were

stable. Laboratory examination at another hospital revealed a

total bilirubin of 1.6 mg/dl and mildly raised liver enzymes.

Ultrasound of abdomen showed moderate ascites, hepato-

megaly and complete occlusion of proximal inferior vena cava

(IVC). Endoscopy revealed oesophageal varices. Contrast

a Residency, Hill Fort Roa. Poddar).

P, et al., Endovascular stJournal (2014), http://dx.

ociety of India. All rights

enhanced computed tomography was done which revealed a

thick web in proximal IVC with complete occlusion (Fig. 1).

Patient was referred to us for PTA and stenting of IVC after a

failed attempt at another hospital. Patient was already on oral

anticoagulation for the last 6 weeks at the time of presenta-

tion at our center.

Patient was primed with 300 mg of Clopidogrel and 325 mg

of Aspirin. Venous access was obtained via 6 Fr sheaths in

right Internal Jugular Vein (IJV) and right Femoral Vein (FV).

Unfractionated heparin (5000 units) was given. Venography

was performed by simultaneous contrast injections via NIH

catheter in right IJV and pigtail catheter in right FV in two

orthogonal views. It revealed a short completely occluded

segment (thick web) in proximal IVC with post stenotic dila-

tation (Fig. 2). The thick web was punctured with a Broken-

borough’s needle. After confirming the position of

d, Nowbat Pahad, Hyderabad 500 004, India.

enting of IVC using Brockenborough’s needle in BuddeChiaridoi.org/10.1016/j.ihj.2014.03.014

reserved.

Fig. 1 e Contrast enhanced CT of the abdomen showing

complete occlusion of proximal IVC (arrows).

Fig. 3 e Dilatation of proximal IVC with 12 3 40 mm

balloon.

i n d i a n h e a r t j o u r n a l x x x ( 2 0 1 4 ) 1e32

Brokenborough’s needle by contrast injection, Mullin’s sheath

was advanced over the needle into the IVC beyond the oc-

clusion. Then a 0.03200 J-tip wirewas negotiated across theweb

and was parked in right subclavian vein via superior vena

cava. The web was first dilated with septal dilator over the

0.03200 wire and then sequentially with 6 � 15 mm and

12 � 40 mm balloons (Fig. 3). Proximal IVC was then stented

with 22 � 45 mm self-expanding wall stent. IVC venogram

Fig. 2 e IVC venogram showing a thick membrane in

proximal IVC causing complete occlusion.

Please cite this article in press as: Poddar P, et al., Endovascular ssyndrome e A case report, Indian Heart Journal (2014), http://dx.

post stenting showed good stent apposition with brisk flow

(Fig. 4). Distended superficial abdominal veins disappeared on

table itself. Patient was ambulated the following day and she

had marked reduction in abdominal girth. She was given

unfractionated heparin for 2 days and was discharged on oral

anticoagulation on 3rd post-procedure day. Patient was

asymptomatic at 3 months follow-up and venous Doppler

revealed patent IVC stent.

Fig. 4 e Venogram showing restoration of IVC patency after

deployment of 22 3 45 mm self-expanding wall stent.

tenting of IVC using Brockenborough’s needle in BuddeChiaridoi.org/10.1016/j.ihj.2014.03.014

i n d i a n h e a r t j o u r n a l x x x ( 2 0 1 4 ) 1e3 3

2. Discussion

BuddeChiari syndrome is defined as hepatic venous outflow

track obstruction at any level from small hepatic veins to right

atrium-IVC junction, regardless of the cause of obstruction.1,2

Pure IVC obstruction is more common in Asia whereas pure

hepatic vein obstruction predominates in Western countries.3

Most common cause of IVC obstruction is by membranous

web. Membranous webs were earlier thought to be of

congenital origin, but more recent evidence suggests that

membranouswebsare the sequelaeof thrombus formation.4e6

Treatment of BCS varies depending on the etiology, pre-

sentation and the level of obstruction. It includes thrombol-

ysis, surgical porto-systemic shunts, transjugular intrahepatic

porto-systemic shunt (TIPS), endovascular PTA and liver

transplantation. Endovascular angioplasty and stenting is an

importantmodality of treatment in the subset of patients with

membranous obstruction of IVC. Angioplasty alone has high

recurrence rates due to elastic recoil. Hence, stent placement

in IVC after balloon angioplasty is recommended. Angioplasty

and stenting may be technically challenging when a thick

membrane is encountered as in our case. In such cases, using

Brokenborough’s needle is a safe and effective way of

increasing the success rates of the procedure as demonstrated.

Zhang et al reported the long term effects of stent place-

ment in IVC or hepatic veins in 115 patients. In this study

96.7% of IVC stents remained patent over a mean follow-up of

49months. Absence of anticoagulants after the procedurewas

associated with higher incidence of stent occlusion.7 In

another study by Srinivas BC et al, twelve cases of hepatic vein

outflow obstruction who underwent endovascular balloon

dilatation� stentingwere followed up for upto 13 years. There

was only one case of restenosis.8 Thus, endovascular man-

agement of IVC obstruction has long term patency rates.

In BCS with membranous obstruction of IVC, PTA and

stenting should be the treatment of choice as it can be

Please cite this article in press as: Poddar P, et al., Endovascular stsyndrome e A case report, Indian Heart Journal (2014), http://dx.

accomplished with least morbidity and mortality and excel-

lent long term patency rates.

Conflicts of interest

All authors have none to declare.

r e f e r e n c e s

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2. de Franchis R. Evolving consensus in portal hypertensionreport of the Baveno IV Consensus Workshop on methodologyof diagnosis and therapy in portal hypertension. J Hepatol.2005;43:167e176.

3. Valla D. Hepatic venous outflow tract obstructionetipathogenesis: Asia versus the West. J Gastroenterol Hepatol.2004;19:S204eS211.

4. Kage M, Arakawa M, Kojiro M, Okuda K. Histopathology ofmembranous obstruction of the inferior vena cava in theBuddeChiari syndrome. Gastroenterology.1992;102:2081e2090.

5. Kew MC, Hodkinson HJ. Membranous obstruction of theinferior vena cava and its causal relation to hepatocellularcarcinoma. Liver Int. 2006;26:1e7.

6. Terabayashi H, Okuda K, Nomura F, Ohnishi K, Wong P.Transformation of inferior vena caval thrombosis tomembranous obstruction in a patient with the lupusanticoagulant. Gastroenterology. 1986;91:219e224.

7. Zhang CQ, Fu LN, Xu L, et al. Long-term effect of stentplacement in 115 patients with BuddeChiari syndrome. World JGastroenterol. 2003;9:2587e2591.

8. Srinivas BC, Dattatreya PV, Srinivasa KH, Prabhavathi,Manjunathan CN. Inferior vena cava obstruction: long-termresults of endovascular management. Indian Heart J. 2012MareApr;64:162e169.

enting of IVC using Brockenborough’s needle in BuddeChiaridoi.org/10.1016/j.ihj.2014.03.014