Clinical and Diagnostic Profile and Management of Inferior Vena Cava Obstruction- A Descriptive Study at a Tertiary Care Centre, Hyderabad

Abstract

Introduction: Obstruction to hepatic venous outflow is a rare disease with a potentially fatal outcome, if not recognised and managed promptly. The level of obstruction can vary, anywhere from the small hepatic venules to the entry point of the Inferior Vena Cava (IVC) into the right atrium. The original patients that Budd-Chiari described had acute hepatic vein thrombosis but this syndrome now encompasses various hepatic venous outflow blocks, of which a membrane in the IVC is the most common anatomical form of obstruction. Pure IVC obstruction is commonly seen among Asians. Aim: To study the clinical and diagnostic profile of patients presenting with IVC obstruction and to evaluate the treatment efficacy and safety of percutaneous transluminal angioplasty. Materials and Methods: For this prospective, descriptive study, from November 2015 to August 2019, a total of 21 patients were admitted with obstruction of hepatic venous flow. Most of the patients were young adults. Clinical features, aetiologies and coagulation profiles were studied. Ascites, pain abdomen and pedal oedema were common presentations. Diagnosis was established by clinical examination and was confirmed by ultrasound-doppler study, computed tomography and conventional angiography. Statistical analysis was done by using statistical package for social sciences IBM SPSS statistics for Windows, version 20.0. The data were expressed as percentages of study population while, continuous data were expressed as mean±standard deviation. Results: The mean age of the population was 24.7±2.9 years, with a female preponderance. (male: female=1:2). IVC angiography was done in 15 patients. Seven of the 15 patients had diffuse narrowing of IVC. Eight patients had focal or segmental narrowing of IVC, among them seven patients underwent Percutaneous Transluminal Angioplasty (PTA) with stenting. The venous access was obtained from femoral vein. The stenoses were crossed with either guide wire or Brocken brough needle with Mullins sheath. Three patients did not need predilatation. In four patients, obstructed IVC was dilated with Inoue balloon and then self-expanding stents were placed. Success was achieved in all cases, with significant drop in the pressure gradients from 20±5 mmHg before procedure to 3±2 mmHg immediately after the procedure. After PTA, all seven patients had either total relief or decrease of symptoms and clinical signs of hepatic venous obstruction. No major complications were observed and no repeat interventions were required. The mean postprocedural follow-up was six months that showed good outcomes with good stent patency. Conclusion: Chronic obstruction of IVC presents with abdominal pain, progressive ascites and portal hypertension in young adults, with mild abnormality of liver function tests. The IVC obstruction can be due to an obstructive membrane or segmental stenosis or diffuse narrowing of IVC. PTA with stenting can be done safely and it effectively relieves the symptoms and venous congestion and can be considered as the first decompressive procedure in patients with IVC stenosis.

Keywords

• brockenbrough needle
• hepatic vein
• inoue balloon
• percutaneous transluminal angioplasty
• stenting