In Reply to: Re: 597 10 -- Fine needle TIPS for Budd-Chiari Syndrome posted by MICHAEL J HALLISEY on July 12, 1997 at 21:52:40:
I do not agree with Dr. Hallisey that TIPS was unneccessary. I do not think we are able to know this in this case. If there were indeed a focal, membranous type lesion within several hepatic veins, suffiecient to cause a full-blown Budd Chiari syndrome, then angioplasty and stenting of these lesions alone may have reolved the patient's symptoms. Indeed, the heaptic venogram will be telling, and we will attempt to have this 'added' to the images, if we can obtain the images from Dr. Oleaga. This hepatic vein membranous type of Budd Chiari is, in my experience, a relatively rare finding, compared to the hepatic vein and venular thrombosis that typically occurs with B-C related to polycythemia vera, etc.
In the latter cases, TIPS is a very important tool. This is perhaps the best place for TIPS because we have the ability to reverse a destructive congestive hepatopathy due to post hepatic obstruction. The underlying liver destruction may end and liver function improve as hepaticytes regenrate--unlike cirrhotics where we are treating severe complications while attempting not to cause acellerated liver failure and encephalopathy. If indeed this case is one of hepatic vein thrombosis and diffuse hepatic venoo-occlusive-type disease, then TIPS was a very appropriate treatment.
With regards to the role of transhepatic venography, the JVIR article by Wilson and Ring describes the importance adjunctive value of transhepatic venography in outlining and identifying the nature of the hepatic vein disease in patients with B-C syndrome. The role of this in this cases remains unclear until we have seen Dr. Oleaga's hepatic venograms.
Finally, it's important to emphasize how difficult these B-C TIPS cases can be--one of the points of this case. Just yesterday I was striving to make a new record for the 'longest' TIPS possible--a good part of the day, creating one in a B-C patient. Ultimately I had to use the gunsight approach to make a transcaval to left portal TIPS because there essentially no usable hepatic veins.