Comparison of direct intrahepatic portosystemic shunt and other major radiological interventions in patients with Budd-Chiari syndrome.

Introduction: Radiological interventions in Budd-Chiari syndrome (BCS) include anatomical recanalization of the hepatic vein (HV), inferior vena cava (IVC) angioplasty and stenting. In case of technical difficulty and anatomical non-feasibility, an ultrasound-guided direct intrahepatic portosystemic shunt (DIPSS) is created. We aimed at evaluating the outcome of patients managed with DIPSS and comparing it with anatomical recanalization.

Methods: We retrieved the data of patients with BCS managed at our institution between 2011 and 2021. Safety, efficacy and long-term outcomes were assessed and compared between radiological interventions.

Results: Total 236 patients with BCS underwent radiological intervention in the study period. As many as 96 patients were excluded and 140 patients were included in the final analysis. The majority were males (F:M = 54:86). The median age at the time of diagnosis was 30 years (interquartile range: 25-37 years). The median follow-up period was 58 (14-72) months. On imaging, 53% (74) patients had combined HV and IVC block followed by isolated HV block in 54 patients (38.5%) and isolated IVC block in 12 patients (8.5%). As many as 32 patients were managed by DIPSS. Among others, 56 patients underwent IVC angioplasty with HV stenting and 30 required HV angioplasty and stenting. DIPSS had a comparable technical success rate (100% vs. 98.2% vs. 96%, respectively p > 0.5). However, the median stent patency was higher in the DIPSS group (72 [48-96] months) compared to IVC angioplasty and HV stenting (46 [36-60] months; p = 0.02) and HV angioplasty-stenting (42 [30-48] months; p = 0.04) groups. They had similar re-thrombosis rates (28%, 34% and 21%, respectively; p > 0.05). Overall complications were rare (3.5%) and no patient in the DIPSS group had adverse events.

Conclusion: DIPSS is a safe and effective salvage procedure with an excellent long-term outcome in patients with BCS. It has a longer median stent patency compared to the anatomical recanalization group.