Modified Sharp Recanalization for Inferior Vena Cava Occlusion in Patient with Budd-Chiari Syndrome

Abstract

We report a case of Budd-Chiari syndrome successfully treated with endovascular recanalization of an inferior vena cava occlusion using a modified sharp recanalization technique. A 45-year-old man presented with hepatic dysfunction, and contrast-enhanced computed tomography revealed a 1.5 cm chronic inferior vena cava occlusion. Standard sharp recanalization using the conventional end of a guidewire failed to cross the lesion. Therefore, we reshaped the end of a 0.035-inch guidewire into a sharper form, enabling successful penetration without the use of specialized devices. This modified technique, adapted from peripheral artery interventions, may offer a safer and more cost-effective option for treating fibrotic venous occlusions. Stepwise balloon dilation was subsequently performed to minimize complications. This report highlights the potential utility of a reshaped guidewire end as a practical alternative when the conventional technique fails.

Introduction

In recent years, numerous reports have highlighted the efficacy of percutaneous transluminal angioplasty (PTA) for treating Budd-Chiari syndrome (BCS) involving occlusion of the inferior vena cava (IVC) or major hepatic veins, owing to advancements in interventional techniques and devices. However, several challenges remain, including difficulty in crossing the occluded segment, restenosis after PTA, and complications such as IVC rupture associated with the use of large-diameter balloons.

This report describes a case of successful balloon angioplasty for a segmental occlusion of the IVC in a patient with BCS, performed without IVC bleeding by using a modified sharp recanalization (SR) technique and stepwise dilation with the triple-balloon method.

Case Report

Ethics committee approval was not required for this type of study. Informed consent for participation in the study was obtained.

A 45-year-old male with hypertension and diabetes was referred due to liver dysfunction (platelet count 12.9×10³/μL, total bilirubin 1.6 mg/dL, direct bilirubin 0.4 mg/dL, albumin 4.3 g/dL, aspartate aminotransferase 36 U/L, alanine aminotransferase 41 U/L, lactate dehydrogenase 178 U/L, alkaline phosphatase 143 U/L, gamma glutamyl transpeptidase 229 U/L, prothrombin time-international normalized ratio 1.05). The Child-Pugh classification was A with a score of 5, and the albumin-bilirubin score was −2.69, indicating well-preserved liver function. Abdominal ultrasound revealed occlusion of the main hepatic veins and the hepatic IVC. Contrast-enhanced CT confirmed occlusion of the main trunks of the hepatic veins and a 1.5 cm occlusion of the hepatic IVC, along with portosystemic collaterals such as esophageal varices, dilatation of the paraumbilical vein, and mild splenomegaly (Figure 1a and b). Congestive hepatomegaly and ascites were not observed. Upper gastrointestinal endoscopy revealed esophageal varices (LmF1CbRC0), but they were not prone to bleeding. This case was diagnosed as BCS, classified as Type Ib according to the Sugiura classification [1]. Angioplasty was considered indicated to alleviate portal hypertension, as further deterioration of liver function or disease progression could potentially lead to liver failure or the development of hepatocellular carcinoma. Angioplasty for the IVC obstruction was planned as the initial treatment, with hepatic vein dilation to be considered if no clinical improvement was observed.

Figure 1.

Pre-procedural contrast-enhanced CT (a: coronal, b: sagittal). A 1.5-cm long occlusion was observed in the hepatic IVC (arrow).

IVC: inferior vena cava

The procedure began with the insertion of 6 F sheaths into the right femoral vein and right internal jugular vein, respectively, under local anesthesia. Systemic heparinization was initiated with 4,000 units of heparin, followed by 1,000 units hourly. IVC and right atrial angiography demonstrated complete occlusion of the hepatic IVC and significant development of collateral circulation through the ascending lumbar vein (Figure 2). The pressure in the hepatic IVC was elevated to 22 mmHg. A 4 F pigtail catheter was placed just above the occlusion via the right internal jugular vein as a marker. In addition to a 0.035-inch guidewire (Radifocus, Terumo, Tokyo, Japan), a 0.014-inch 12 g tip-loaded guidewire (Halberd, ASAHI INTECC, Aichi, Japan), and a 40 g tip-loaded guidewire (Astato9-40, ASAHI INTECC) were also used in an attempt to cross the occlusive lesion via the femoral vein approach. However, the occlusion was too hard to penetrate.

Figure 2.

Pre-angioplasty IVC angiography. Collateral circulation (arrows) was developed around the occluded hepatic IVC through the ascending lumbar vein, azygos vein, and hemiazygos vein.

IVC: inferior vena cava

Guidewire passage via the internal jugular vein and a conventional SR technique using a 0.035-inch guidewire end also failed, necessitating the use of a modified SR technique. Specifically, the end of a 0.035-inch stiff guidewire was cut at an angle and sharpened using nippers. The black coating approximately 2 cm from the tip was peeled off using nippers. The sharp end was curved about 10 degrees using mosquito forceps. (Figure 3). A pigtail catheter was placed just below the occlusion as a fluoroscopic landmark, and under fluoroscopic guidance, the lesion was carefully penetrated using the modified sharp guidewire, while confirming the tip position from multiple working angles (Figure 4a). The modified sharp guidewire successfully crossed the occlusion, but the angiographic catheter could not follow. A 7 Fr snare catheter was then inserted via the femoral vein to capture the guidewire tip. Using the applied tension, the catheter was advanced across the lesion. The guidewire was then exchanged for a standard 0.035-inch guidewire, establishing a pull-through. Stepwise dilation of the IVC occlusion was performed using 6 mm, 8 mm, and 10 mm balloons (Mustang, Boston Scientific; Marlborough, MA, USA), each inflated at 10 atm for 60 seconds with careful monitoring for abdominal pain. To reduce the cost of large-diameter balloons, the double-balloon and triple-balloon methods were then applied. After the 6 F sheath in the right femoral vein was replaced with a 12 F sheath, both 10 mm and 8 mm balloons were inserted from the right femoral vein and simultaneously dilated, and the remaining 6 mm balloon was inserted from the right internal jugular vein and simultaneously dilated (each at 10 atm for 60 seconds) (Figure 4b). Post-dilation IVC angiography showed improved blood flow and disappearance of collateral circulation, with a reduction in hepatic IVC pressure to 15 mmHg (Figure 4c). The procedure was completed without complications such as abdominal pain or vascular injury.

Figure 3.

Modified guidewire end. The head of a 0.035-inch stiff guidewire was cut at an angle, stripped of its coating, and bent (arrow).

Figure 4.

a: Successful downward passage through the IVC segmental occlusion by sharp recanalization. b: Triple-balloon dilation. An 8 mm and 10 mm balloon were inserted via a 12 F sheath in the right femoral vein, and a 6 mm balloon was inserted via a 6 F sheath in the right internal jugular vein. c: Post-angioplasty IVC angiography. The IVC was patent (arrow), and the collateral pathways disappeared.

IVC: inferior vena cava

The patient was started on direct oral anticoagulant (Edoxaban 60 mg) the day after the procedure, and had a favorable course, being discharged on the third postoperative day. Postoperative contrast-enhanced CT showed improvement in the hepatic IVC stenosis and enhancement of the main hepatic vein, with a reduction in the visualization of collateral circulation (Figure 5).

Figure 5.

Post-procedural contrast-enhanced CT (sagittal view). The hepatic IVC was patent (arrow), and contrast enhancement was good.

IVC: inferior vena cava

Discussion

SR is an alternative technique for recanalizing chronic central venous occlusions. Since the initial reports by Gupta et al. [2] in 1998, who used an 18 G beveled hollow-core puncture needle, and Murphy et al. [3] in 1999, who used a 20 G Chiba needle, various devices have been reported, including the Rosch-Uchida needle by Goo et al. [4] and the radiofrequency guidewire by Guimaraes et al. [5].

A recent large series demonstrated a technical success rate of 90.2% and a major or moderate complication rate of 3.2%, supporting the safety and feasibility of SR [6]. In that series, most procedures employed septal puncture needles, while only 12% utilized the end of a guidewire. Although most SR devices involve needles, the use of a guidewire end remains relatively uncommon. Nonetheless, using a guidewire end offers several advantages: it eliminates the need for specialized equipment, is cost-effective, shortens preparation time, and requires no specific training. Furthermore, since the guidewire end is relatively blunter than a needle, it may reduce the risk of venous injury [7]; however, its lower penetration force can lead to a reduced technical success rate.

In the present case, the lesion was severely fibrotic and resistant, and SR using the guidewire end was unsuccessful. Therefore, we employed a modified SR technique in which the guidewire end was reshaped to be more ‘sharp.' This technique has previously been reported as an alternative approach for crossing chronic total occlusions of the superficial femoral artery [8]. We considered this combined penetration-and-drilling technique, which has proven effective in long chronic arterial occlusions in peripheral artery disease, to be suitable for fibrotic IVC occlusions. Compared with the conventional guidewire end, it is expected to penetrate fibrotic lesions more effectively while potentially posing a lower risk of injury to the IVC wall than a J-shaped needle. Importantly, a major advantage of this technique is that it does not require specialized or costly equipment, making it feasible even in resource-limited healthcare settings. Additionally, since it is based on techniques commonly used in endovascular therapy for peripheral artery disease, no additional device-specific training is required for experienced operators.

In patients with BCS, the IVC is known to be highly elastic, which often results in high rates of restenosis and recoil after PTA with small-diameter balloons. As a result, large-diameter balloons have become more commonly used in recent years [9].

According to a retrospective cohort study of 119 BCS patients with IVC occlusion, large-diameter balloon angioplasty (≥24 mm) demonstrated superior clinical response and patency compared with small-diameter balloon angioplasty (≤20 mm) [10]. However, IVC rupture, a potentially fatal complication, occurred in 0.81% of cases, all of which involved large-diameter balloons [9]. Moreover, large-diameter balloon angioplasty was associated with a higher incidence of abdominal pain compared to small-diameter balloons [10].

To minimize such risks, we focused on selecting appropriate balloon sizes and avoiding dilation that provokes abdominal pain. A stepwise dilation strategy, starting with small balloons and gradually increasing in size, was considered optimal. In this case, after using 3 balloon catheters, we adopted double- and triple-balloon techniques to continue the stepwise dilation, aiming to reduce the cost associated with using a fourth or fifth balloon. Balloon dilation using 3 or 4 balloons simultaneously was first reported by Yamada et al. [11] in 1983. According to Gaylord et al. [12], an ellipse formed using 6 mm, 8 mm, and 10 mm balloons measures approximately 19 × 16 mm. Although the triple-balloon technique with differing balloon sizes results in a shape closer to an arcuate triangle than a true ellipse, it contributed to reducing the need for balloons larger than 12 mm in diameter.

Conclusions

The modified SR technique may serve as a viable option for IVC occlusions that cannot be crossed using a conventional guidewire end. Given the risk of venous hemorrhage associated with SR, a stepwise balloon dilation strategy is recommended to minimize bleeding risk, and the triple-balloon technique may help reduce costs during this process.

Author Contributions

SK and YK designed the study. SK collected the data. SK, YK, AN, SA, TN, DK performed the procedure for this case. YK and DU aided in interpreting the results and worked on the manuscript. SK wrote the manuscript with support from YK and DU. All authors discussed and approved the final manuscript.

Conflicts of Interest

There are no conflicts of interest.

Informed Consent

The patient provided written informed consent for the publication of this case report and associated images.

Clinical Registration Number, If Applicable

None