Recurrent acute Budd–Chiari syndrome after right hepatectomy: US color-Doppler vascular pattern and left hepatic vein stenting for treatment

After extended right hepatectomy remnant liver can be affected by outflow obstruction due to torsion of the inferior vena cava or kinking of the left hepatic vein. Remnant liver fixation is therefore suggested to avoid postoperative acute Budd–Chiari syndrome. Despite remnant liver reposition during surgery, a 76-years-old woman developed complete outflow obstruction. This clinical situation, due to left hepatic vein kinking, was suspected by US examination and confirmed by CT scan that showed a pathological intrahepatic vascular pattern. Patient required urgent relaparotomy and the liver was replaced in normal position. However, recurrence of outflow obstruction occurred and it was ultimately treated by inferior vena cava angiogram with left hepatic vein stenting.     

节段性狭窄闭塞布-加综合征的介入治疗

目的　探讨布 加综合征 (BCS)下腔静脉节段性狭窄、闭塞合并肝静脉阻塞的介入治疗。方法　 2 8例节段性狭窄、节段闭塞患者 ,多数合并 1～ 3支肝静脉闭塞 ,无合并下腔静脉血栓形成。应用球囊导管或房间隔穿刺针行下腔静脉开通术 ,下腔静脉开通后用 2 .0～ 2 .3cm球囊扩张后放入金属内支架。术后抗凝治疗 2年。结果　 2 7例患者成功进行了经皮穿刺球囊破膜扩张 ,即经皮腔内血管成形术 (PTA)和血管内支架植入治疗。闭塞肝静脉多数扩张下腔静脉后同时开通。患者肝、脾缩小 ,腹水吸收。 1例穿破下腔静脉急诊手术止血。随访 2～ 36个月未见复发及消化道出血。结论　下腔静脉狭窄者注意有肝静脉闭塞 ;下腔静脉闭塞破膜后 ,2 0例肝静脉闭塞者 19例随之开放 ,无需特殊处理 ;安放支架时注意保护肝静脉入口。     

微创时代下腔静脉开放手术的治疗机遇

因下腔静脉在解剖学及组织学方面的特性,治疗上具有特殊性。本文通过回顾既往文献报道,对下腔静脉综合征、平滑肌肉瘤及布加综合征等下腔静脉疾病外科治疗方式的进展进行论述。下腔静脉综合征为下腔静脉部分或完全阻塞所致的临床症候群,较常见且病因多样,占位性病变中下腔静脉平滑肌肉瘤发病罕见,根治性切除是目前唯一有效的治疗手段,其中下腔静脉及肾静脉的处理为手术难点。布加综合征表现为肝后性门脉高压,外科治疗包括手术治疗及介入治疗。     

布-加综合征肝脏病理学与肝静脉和下腔静脉阻塞类型的相关性研究

目的:探讨布-加综合征肝脏病理学改变与肝静脉、下腔静脉病变的关系。方法:27例布-加综合征患者术前行彩超检查,术中常规行下腔静脉造影和选择性肝静脉造影或经皮肝穿刺肝静脉造影了解肝静脉、下腔静脉阻塞情况;影像引导下经皮肝穿刺组织活检了解肝脏病理学变化。根据病变累及血管分为肝静脉型、下腔静脉型、肝静脉和下腔静脉混合型;根据血管阻塞程度将其分为狭窄型和完全闭塞型。将肝脏病理学改变与肝静脉、下腔静脉阻塞情况进行相关性分析。结果:25例穿刺组织达满意组织学诊断要求,其中肝静脉阻塞型11例,下腔静脉阻塞型4例,肝静脉和下腔静脉混合阻塞型10例;狭窄型7例,完全闭塞型18例。肝纤维化程度与血管阻塞程度密切相关;肝血窦扩张和肝细胞变性与血管阻塞程度无关,肝脏病变与阻塞部位无相关性。结论:肝静脉和下腔静脉阻塞对肝脏的损害程度是一致的,血管阻塞程度较阻塞部位对肝脏损害的影响更大。     

Hepatocellular carcinoma with invasion into right cardiac cavities: report of a case and literature review.

Hepatocellular carcinoma is a tumor that rarely invades the inferior vena cava and right heart. We describe the case of a 63-year-old man with jaundice and a history of cryptogenic hepatic cirrhosis with diagnosis of hepatocellular carcinoma. He was referred to the echocardiography laboratory for sudden dyspnea and suggestion of pulmonary thromboembolism. Echocardiographic study reported a mass in the right atrium proceeding from the inferior vena cava.     

Ovarian cancer manifested as exertional hypotension due to obstruction of the inferior vena cava

We have reported a case of inferior vena cava obstruction caused by recurrent ovarian carcinoma. This case is noteworthy first because it shows that physical findings in inferior vena cava obstruction may be minimal. Secondly, we believe ours is the first reported case of exertional hypotension caused by obstruction of the inferior vena cava. Finally, ovarian cancer has rarely been reported as a cause of inferior vena cava obstruction.     

Diagnosis of Budd-Chiari syndrome: three-dimensional dynamic contrast enhanced magnetic resonance angiography

Objective

To investigate the characteristics and diagnostic value of three-dimensional contrast-enhanced magnetic resonance angiography (3D CE-MRA) in the diagnosis of Budd?CChiari syndrome (BCS).

Methods

One hundred thirty-three BCS patients underwent 3D CE-MRA, 64 patients had primary BCS, and 69 had secondary BCS.

Results

Fifty five cases (41.4%) showed a segmental stenosis of the inferior vena cava, 9 cases (6.8%) a membranous obstruction of the inferior vena cava, 5 cases (3.8%) an unobstructed inferior vena cava and hepatic veno-occlusive condition, 16 cases (12.0%) an inferior vena cava stenosis and hepatic veno-occlusive disease, and 48 cases (36.1%) an intraluminal filling defect in the inferior vena cava. In 52 cases (39.1%), collateral blood vessels were formed, with deep, medium, and shallow portal veins and intrahepatic collateral veins in 88 groups. Among these, 41 (46.6%) had deep venous collateral channels, 24 (27.3%) had medium venous collateral channels, 9 (10.2%) had superficial venous collateral channels, 5 (5.7%) had portal vein collateral channels, and 9 (10.2%) had intrahepatic venous collateral channels.

Conclusion

3D CE-MRA is important in the clinical diagnosis and treatment planning of BCS and displays hepatic veins, the inferior vena cava system, and collateral vessels.     

磁共振血管成像评价肝移植术后血管形态：11例分析

背景:多数学者认为超声发现血栓形成和血管狭窄的灵敏度比较高,但对血管吻合口的直接显示较困难,磁共振血管造影对血管解剖的显示及并发症的诊断优于多普勒超声。目的:观察磁共振血管造影对肝移植术后血管形态的显示及其对并发症的评估。设计:观察对比实验。单位:南方医科大学附属南方医院影像中心。对象:选择2004-01/2006-12于南方医科大学附属南方医院影像中心收治的11例男性原位肝移植术后患者。年龄40～58岁,平均49岁。术前临床诊断为原发性肝癌2例,重症肝硬化9例,均经病理组织学检测证实,其中9例行原位经典式肝移植,2例行背驮式原位肝移植术。所有患者均对检测项目知情同意。方法:对11例原位肝移植术后患者均用磁共振快速自选回波序列及快速小角度激发梯度回波序列常规扫描、钆喷替酸葡甲胺动态增强3D磁共振血管造影检查,在MRA成像后,迅速采用与平扫FLASH T1WI抑脂序列完全相同参数行轴面和冠状面扫描。根据ECST法计算血管直径狭窄率S(S=[(D-d)/D]×100%),d为最狭窄处内径,D为该处正常管径。判断狭窄的程度:直径狭窄率S在0～30%为正常范围;31%～50%为轻度狭窄;51%～85%为中度狭窄;86%～100%为重度狭窄。分析各序列图像特点。同时行多普勒超声检查。主要观察指标:①磁共振血管造影观察肝移植术后血管形态及对并发症的评估结果。②多普勒超声检查结果。结果:纳入患者11例全部进入结果分析。①磁共振血管造影:显示3例肝动脉、门静脉和下腔静脉吻合口通畅,其中1例供体门静脉管径略小于受体门静脉,1例肝移植术后早期MRT2WI图像见到门静脉周围高信号,持续3周后消失。其余8例中,2例肝动脉过长迂曲,2例肝动脉供体端瘤样轻度扩张,2例门静脉轻度狭窄,位于吻合口,且门静脉供体段与受体段的管径不相等,门静脉肝内分支均正常,2例肝静脉末梢分支杵状扩张,而其下腔静脉未见异常。1例下腔静脉血栓,磁共振血管造影表现为高信号血管腔内椭圆形低无信号区。2例肝静脉末梢分支杵状扩张患者半年后肝静脉末梢分支扩张程度降低,但仍有轻度扩张,下腔静脉血栓治疗1月后复查血栓消失。②多普勒超声检测:1例肝动脉过长迂曲合并肝动脉供体端瘤样轻度扩张诊断为肝动脉过长迂曲,例门静脉轻度狭窄1例诊断为正常,1例诊断为可疑狭窄。未发现肝静脉末梢分支杵状扩张。其余诊断与磁共振血管造影相符。结论:磁共振血管造影可清楚显示肝移植术后血管解剖并准确、快速诊断肝移植术后出现的血管并发症。     

Intrahepatic portosystemic venous shunt via the right adrenal vein: treatment with vascular plug

A 65-year-old man with hepatocellular carcinoma (HCC) due to alcohol-related liver cirrhosis had undergone transarterial chemoembolization 11 times. However, treatment for HCC was difficult to continue, due to episodic hepatic encephalopathy. He was referred to our hospital for treatment of hepatic encephalopathy, showing a Child-Pugh score of 8 despite medical therapy. Abdominal computed tomography revealed intrahepatic portosystemic venous shunt comprising two shunt tracts from the right posterior portal vein to the inferior vena cava via the right adrenal vein. The larger tract was occluded using an Amplatzer Vascular Plug (AVP) II, and the smaller tract was occluded using an original AVP. The postembolization course was uneventful. Hepatic encephalopathy improved after shunt occlusion and no recurrence had occurred as of one year after the procedure.     

预先腹内控制下腔静脉防治肝切除术中肝静脉及下腔静脉损伤大出血

作者对7例半肝以上肝切除术及2例ⅦⅧ肝段切除应用止血带在腹腔内围绕肝下肾上及膈下肝上之下腔静脉,同时用橡皮管控制肝门血管,而暂不阻断,以预防术中可能发生的肝静脉或/和下腔静脉损伤大出血,其中2例还同时控制膈下腹腔动脉以上的腹主动脉。9例中7例无意外,2例术中发生肝中静脉损伤大出血,经止血带迅速控制,修补裂口,抢救成功。本文对肝叶切除术中误伤肝静脉或/和下腔静脉的原因和预防处理方法进行了讨论,认为在病变接近或累及第二肝门或下腔静脉的肝叶肝段切除,以及在半肝或三叶切除术中常规控制下腔静脉和肝门是一个简而有效的防治肝静脉或/和下腔静脉损伤大出血的好方法。     

Color Doppler imaging of inferior vena cava: identification of tumor thrombus.

Color-coded Doppler sonography (CCDS) was used for the examination of tumor thrombus (n = 7) and benign thrombosis (n = 6) of the inferior vena cava. Tumor thrombus was due to hepatocellular carcinoma in two cases and to renal cell carcinoma in five cases. Whereas no specific information about the nature of thrombus formation could be gained by gray scale sonography, a typical patchy vascularization pattern was noted within tumor thrombi in six of seven cases using CCDS. This ws due to marked neovascularization within the tumor thrombi, confirmed by histologic examination in all cases. In one patient no vascularization within the tumor thrombus could be observed by CCDS because the thrombus was relatively small. In patients with bland thrombosis, either no vascularization of the thrombus was seen (n = 5) or linear recanalization of the thrombus occurred (n = 1). Therefore, it might be possible to differentiate tumor from nontumor thrombus in the inferior vena cava by using CCDS. Further studies are needed to confirm this preliminary hypothesis.     

Classification of hepatic venous outflow obstruction: ambiguous terminology of the Budd-Chiari syndrome

Severe hepatic venous outflow obstruction and its manifestations often are recorded under the label "Budd-Chiari syndrome." Unfortunately, this label is ambiguous; it does not clearly identify the site of the lesion (hepatic veins versus inferior vena cava), its morphologic features (thrombotic versus nonthrombotic), or its cause. In the literature, implied or expressed definitions vary. Use of a standardized topographic and pathogenetic classification of hepatic venous outflow obstruction would enable investigators to group patients with comparable conditions, as required for therapeutic trials, prognostic evaluations, and studies of pathogenetic pathways. Review of our own cases revealed that hepatic venous outflow obstruction involving large hepatic veins is usually thrombotic and that isolated obstruction of the inferior vena cava or of small hepatic veins is usually nonthrombotic. Application of such a classification seems feasible and may yield useful results.     

Sonographic appearance of lipoma of the inferior vena cava.

Lipomas of the major central veins are rare, and their sonographic features have rarely been reported. We report a case in which a lipoma of the inferior vena cava (IVC) was incidentally identified during liver sonography in a 68-year-old man. Sonography of the upper abdomen revealed coarsening of the liver echotexture, with a relatively small liver and atrophy of the right hepatic lobe. A 2-cm hypoechoic hepatic nodule was visualized in segment IV. Sonography also showed a 2.2- x 1.8-cm, highly echogenic, homogeneous nodule in the hepatic segment of the IVC at its junction with the right atrium. The lumen of the IVC was partially occluded. The CT and MRI appearances of the IVC lesion were consistent with a lipoma, which was not treated because there was no clinical evidence of obstruction. Histopathologic analysis following a sonographically guided biopsy of the liver nodule revealed hepatocellular carcinoma, which was treated by percutaneous ethanol injection.     

肝癌并下腔静脉癌栓行肝动脉造影及栓塞的临床意义

目的探讨肝动脉造影及栓塞对肝癌合并下腔静脉癌栓的诊疗价值。方法回顾分析20例肝癌并下腔静脉癌栓的重复肝动脉造影和栓塞的影像学表现及介入治疗意义。结果l0例均在肝动脉造影及栓塞前后显示下腔静脉癌栓血管,16例在栓塞后l一3月内造影显示下腔静脉癌栓的供应血管增多,癌栓增大,其中4例累及心房。4N下腔静脉癌栓血管不显影。栓塞后癌栓内均见碘油沉积．部分癌栓缩小。结论原发性肝癌之下腔静脉癌栓由肝动脉主要供血．造影有较好的诊断价值。栓塞对癌栓有一定的治疗作用,不排除有促进癌栓生长的可能。治疗上宜采用综合治疗。     

Numerical simulation of hemodynamics in membranous obstruction of the suprahepatic inferior vena cava based on a subject-specific Budd-Chiari syndrome model

BackgroundThis study was performed to determine the hemodynamic changes of Budd-Chiari syndrome when the inferior vena vein membrane is developing.MethodsA patient-specific Budd-Chiari syndrome vascular model was reconstructed based on magnetic resonance images using Mimics software and different degrees (16%, 37%, and 54%) of idealized membrane were built based on the Budd-Chiari syndrome vascular model using Geomagic software. Three membrane obstruction Budd-Chiari syndrome vascular models were established successfully and fluent software was used to simulate hemodynamic parameters, including blood velocity and wall shear stress.FindingsThe simulation results showed that there is low velocity and a low wall shear stress region at the junction of the inferior vena cava and the branches of the hepatic veins, and swirl may occur in this area. As the membrane develops, the size of the low velocity and low wall shear stress regions enlarged and the wall shear stress was increased at the membrane region. There was a significant difference in the mean values of wall shear stress between the different obstruction membrane models (P < 0.05).InterpretationHemodynamic parameters play an important role in vascular disease and there may be a correlation between inferior vena cava wall shear force changes and the slow development process of the inferior vena cava membrane.     

肾癌伴下腔静脉癌栓的手术治疗

目的探讨手术治疗肾癌伴下腔静脉癌栓的效果。方法回顾性分析2004年10月至2006年3月共5例肾癌伴下腔静脉癌栓患者的临床资料,男3例,女2例,平均49.8岁。5例均为右侧,肾静脉型(Ⅰ型)1例,肝下型(Ⅱ型)2例,肝内型(Ⅲ型)2例。均行肾癌根治性切除加下腔静脉切开取栓术。结果1例因癌栓脱落引起肺栓塞术中死亡外,余4例手术顺利。1例癌栓侵犯腔静脉壁,术后局部复发和肺部转移,17个月死亡。其余3例分别随访7个月、9个月、23个月,均未发现肿瘤复发和远处转移。结论对于未发现有远处转移的肾癌下腔静脉癌栓,肾癌根治性切除加下腔静脉切开取栓术是积极有效的治疗方法。     

A new method for the measurement of intrahepatic shunts

After transhepatic portal pressure determination, 96 patients were assessed for the presence of intrahepatic shunts by injection of microspheres (25 +/- 5 micron diameter) into the portal vein using RISA-131I as an indicator of dilution. Multiple portal vein injections in each patient allowed blood sampling from the hepatic vein (site 1) and from two inferior vena cava sampling sites (site 2, at the junction of the hepatic vein orifice with the inferior vena cava, and site 3, 2 to 3 cm closer to or within the right atrium). Intrahepatic shunting was calculated from each site: hepatic vein in 57 patients and inferior vena cava, site 2 in 43 patients and site 3 in 77 patients. At least one valid IHS calculation was available in 92 of the patients. Intrahepatic shunting calculated from sequential portal vein injections with sampling from the hepatic vein was highly correlated (r = 0.98, p less than 0.0001, slope = 1.0), with a mean difference of 1.9% +/- 1.9%. There was no significant difference by t test comparison of the mean IHS calculated from sites 1, 2, and 3. The IHShv was correlated with the IHSivc (site 2) (r = 0.79, p less than 0.0001, slope = 1.0) and IHSivc (site 3) (r = 0.82, p less than 0.0001, slope = 2.1). Occasional marked discrepancies were noted between IHS calculated from site 1 or site 2 compared with site 3, and the site 3 calculation was always greater. A shunt index in all patients included shunts calculated from the hepatic vein in 57 patients plus shunt calculation from the inferior vena cava in the remaining patients (site 2 in 26 patients and site 3 in nine). A control group with minimal chronic liver disease (10 patients) had a portal pressure (greater than IVC) of 4.1 +/- 1.4 mm Hg and shunt index of 0.5% +/- 0.6%. The 82 patients with portal hypertension or chronic liver disease had a higher portal pressure, 13.8 +/- 4.6 mm Hg, and a significantly greater shunt index, 13.7% +/- 24.5% (p less than 0.0001) compared with controls. The frequency distribution of IHS in patients with chronic liver disease demonstrated less than 2% IHS in 49% of patients and less than 5% IHS in 63%. The validity of our methods and the implications of the infrequent demonstration of a large IHS are discussed.     

恶性肿瘤患者下腔静脉滤器的应用研究

目的研究下腔静脉滤器在恶性肿瘤患者中的应用,探讨其在预防肺栓塞发生中的作用。方法回顾性分析1998年至2004年,经病理学或细胞学确诊为恶性肿瘤,并于治疗前存在血栓栓塞性疾病的37例患者,安放下腔静脉滤器后肺栓塞的发生情况。结果下腔静脉滤器全部安全置入下腔静脉内,随访1～36个月,滤器无移位,无肺栓塞发生。结论对恶性肿瘤合并血栓栓塞性疾病的患者放置下腔静脉滤器,能安全有效地预防肺栓塞的发生。     

多层螺旋CT血管成像评价肝移植受者移植前后血管结构

背景:多层螺旋CT具有先进的扫描技术和强大的图像后处理功能,其亚秒级的扫描速度及各向同性的成像功能,在血管成像上有很多优势.目的:探讨多层螺旋CT血管成像技术对肝移植受者移植前后血管结构评价的应用价值.设计、时间及地点:回顾性分析,以肝移植受者肝脏血管为观察对象,自身对照观察,于2003-10/2006-12在中山大学附属第五医院放射科完成.对象:选择拟行原位肝移植患者27例,年龄31～67岁,男17例,女10例.方法:轴位螺旋扫描范围为膈顶上方2 cm至双肾下极以下.电压120 kV,动脉期准直0.75 mm,平扫、门脉期、肝静脉期准直1.5 cm;使用非离子型对比剂优维显,注射速度为3 mL/s,三期增强扫描延迟时间分别为20～25 s,50～55 s,75～80 s.重建增强的薄层图像序列,动脉期层厚1 mm,间隔0.7 mm;门脉期、肝静脉期层厚2 mm,间隔1 mm.将图像序列传入后处理工作站,以MIP、VR等方式显示腹腔干系、门脉系、肝静脉及下腔静脉血管的三维结构.主要观察指标:肝移植前后患者血管三维结构.结果:移植前所有患者腹腔干系均得到良好显示,21例肝动脉走形正常,6例患者肝动脉变异,其中门静脉海绵样变2例,门脉多发血栓1例,因不适宜手术此3例未进行肝移植.24例患者第二肝门及下腔静脉肝内段血管结构显示清楚,肝右静脉单独汇入下腔静脉、肝左静脉和肝中静脉先汇合后再注入下腔静脉18例,肝有静脉、肝中静脉及肝左静脉分别单独汇入下腔静脉6例,下腔静脉肝后段狭窄2例.17例肝移植后CT血管成像发现肝动脉吻合口部狭窄2例,门脉高压侧支迂曲缓解10例,另7例患者因检查费用问题选择B超检查.结论:多层螺旋CT血管成像能够清晰显示肝移植患者移植前后血管结构,对适宜手术的病例筛选、指导手术方案及移植后血管结构的评价具有重要意义.     

Foramen ovale: an ultrasonographic study of its relation to the inferior vena cava, ductus venosus and hepatic veins.

According to the literature, oxygenated blood from the ductus venosus and hepatic veins may either enter the right atrium before flowing through the foramen ovale to the left atrium, or flow directly from the ductus venosus and the hepatic veins to the foramen ovale, bypassing the right atrium. To address this problem, 103 normal fetuses were examined by two-dimensional imaging, M-mode and color Doppler at an average gestational age of 27 weeks (range, 15-40 weeks). The position of the ventricular septum and foramen ovale, and the angle and flow direction of the inferior vena cava, ductus venosus and hepatic veins were recorded. Two pathways for blood were described: a left ductus venosus-foramen ovale pathway that delivers blood directly to the foramen ovale circumventing the right atrium, and a right inferior vena cava-right atrium pathway that delivers blood into the right atrium through the right portion of the proximal inferior vena cava at an angle of 13 degrees to the long axis of the spine. The left and medial hepatic veins enter the left ductus venosus-foramen ovale pathway, and the right hepatic vein enters the right inferior vena cava-right atrium pathway. This supports the hypothesis that oxygenated blood from the ductus venosus and left hepatic veins flows directly through the foramen ovale to the left atrium avoiding extensive mixture in the inferior vena cava and an intermediate entrance to the right atrium.