Interventional Shigeru Furui, MD #{149} Satoshi Sawada, MD #{149} Toshiyuki Irie, MD #{149} Kohzoh Teiyu Yamauchi, MD #{149} Syoichi Kusano, MD #{149} Kenji Ibukuro, MD Hironobu Nakamura, MD #{149} Eiichi Takenaka, MD, PhD
Hepatic Treatment Expandable
O
of the
BSTRUCTION
cava by hepatic ing
edema
in the
yet there treatment pathic is one
lower
has been for this
(1,2)
surgical
yenta
body,
and
and
hepatic syn-
IVC
can be treated
methods
(2-5)
transbuminal
as
no corrective condition. Idio-
obstruction of the cause of Budd-Chiani
drome ous
inferior
(IVC) due to compression tumors can cause debibitat-
by
or percutane-
angioplasty
(PTA)
mm
developed
12.5-F night
Teflon femoral
cuban
for vascular
use
(8-13).
and
Some
nonvas-
of them
offer
venting
PTA
reocclusion
for the
treatment
obstruction.
This
experience able metallic with
of the
IVC
describes
with Gianturco stents in nine
hepatic
IVC
MATERIALS
years)
after
of idiopathic
article
our
expandpatients
obstruction.
AND
METHODS
Since February 1989, nine patients with hepatic IVC obstruction underwent placement of Gianturco expandable metallic stents at the National Defense Medical College Hospital in Saitama, Mitsui Memorial Hospital in Tokyo, and Kitazato University East Hospital in Kanagawa, Japan.
the stents
steel
wire.
from Each
0.018-inch
stent
was
East
sui
neoplasms, grafts and interventional
Liver cavae,
secondary, 761.33 #{149} Venae prostheses, 982.1299 #{149} Venae cavae, procedure, 982.1299 #{149} Venae cavae, stenosis or obstruction, 982.759, 982.789
25 mm
1990; 176:665-670
Kanagawa, Hospital,
Japan
Tokyo
(5K.);
(K.I.);
and
Mitthe
Research Institute for Microbial Diseases, Osaka University, Osaka, Japan (H.N.). Received January 3, 1990; revision requested February 15; revision received April 2; accepted April 9.
Address C
reprint
RSNA,
See Radiology
Hospital,
Memorial
in this
also
issue.
requests editorial
transverse
performed
through
sheath vein
showed
diameter
IVC immediPlacement
introduced following
IVC
reports women
a 12.0the
of or
via the method
(8,14). (aged 52-74
obstructions
80-140
mm long that were due to compression by large hepatic tumors (metastatic tumor, n = 4; hepatocellulan carcinoma, n 2) (Table). The patients had recently developed clinical symptoms and signs including severe edema of the lower extremities and abdominal walls (n = 6), marked swelling of the scrotum (n 2), and renal dysfunction (n = 2). Contrast material-enhanced computed tomography (CT) and ultrasonography did not show intraluminal thrombi at or around the obstruction in any
of the
six
patients.
We
placed
four
to
six stents in tandem without performing balloon dilation through a Teflon sheath that
had
been
passed
through
struction Three
over a guide wine. men (aged 42-50 years)
iopathic
obstruction
had (n
the
ob-
with
developed 2; 25 and
ideither 30
recurrent obstruction mm long, 8 and 3 months after PTA, respectively) or severe stenosis (n 1; 30 mm long, 21 months after PTA) (patient 7 was included in a previous report of lasen-assisted PTA [7]). We placed single or tandem stents after repeat dilation of the lesions with use of Gruentzig balloon catheters. Stents were placed immediately after repeat dilation in patients 8 and 9 and 3 months after repeat dilation in patient 7.
to S.F. Abbreviations:
1990 the
the
portion of the the obstruction.
described in previous Four men and two
hope in correcting IVC obstruction due to hepatic tumors and in pre-
sity
#{149}
than
was
Departments of Radiology, NaMedical College, 3-2 Namiki, Saitama 359, Japan (S.F., TI., KM., T.Y., E.T.); Tottori University School of Medicine, Tottori, Japan (5.5.); Kitazato Univen-
761 .32
greater
stents
I From the tional Defense Tokorozawa,
neoplasms,
long, with a diameter of 20-28 mm, and had five or six bends. We used single stents or multiple (two to six) stents in tandem connected by 0.018-inch stainless steel struts that allowed a 1-2-mm gap between stents (Fig 1). To prevent slippage and migration, we attached one barb of 0.018-inch stainless steel wire at each end of single stents (14) and at each end of the tail stent of multiple stents in tandem. We placed stents with diameters 2-5 of the patent ately below
stainless
Liver
MD
(6,7); however, reocclusion often occurs. In recent years, several types of metallic endoprostheses have been
We made
terms:
Makita,
Inferior Vena Cava Obstruction: of Two Types with Gianturco Metallic Stents’
Gianturco expandable metallic stents were used for treating six patients with inferior vena cava (IVC) obstruction due to compression by large hepatic tumors and three patients with idiopathic obstruction of the hepatic IVC and Budd-Chiari syndrome who showed reocclusion or stenosis 3-21 months after previously performed percutaneous transluminal angioplasty (PTA). In all six patients with compression by hepatic tumors, stents dilated the IVC and debilitating edema of the lower body disappeared. In the three patients with idiopathic obstruction, stents were placed after repeat dilation of the lesions and Budd-Chiari sydrome did not recur during a follow-up period of 7-10 months. In two of the three, cavograms obtained 8 months after placement showed the channels to be open with minimal intimal thickening. Gianturco expandable metallic stents can correct IVC obstruction due to compression by hepatic tumors and are useful in preventing reocclusion of the IVC after PTA for the treatment of idiopathic obstruction. The authors recommend using tandem stents connected by at least two struts.
Index
Radiology
by
Wright
(pp
620-621)
inferior luminal
vena cava, angioplasty.
AP
anteropostenior, PTA
percutaneous
IVC trans-
665
a.
b.
Figure
2. Case
1.
d.
C.
Compression
by hepatic
tumors.
(a) Inferior
vena
(b)
cavogram
shows
ob-
lateral (c) inferior vena cavograms obtained after placement of six stents in tandem show good blood flow through the IVC lumen, which is well dilated in both the transverse and AP directions. The upper two stents (arrow) have separated from the lower four and have partially lodged in the right atrium. (d) Five weeks later, three stents in tandem were placed striding the separated struction
stents.
Figure
1.
by
struts.
two
tached
Four
stents in tandem Two barbs (arrows)
of
the
upper
Examination
part
after
of the
IVC.
Anteropostenior
the procedure
shows
(AP)
the fully
dilated
and
IVC.
connected are at-
to the tail stent.
After the procedure went anticoagulant of hepanin2
lowed
patients undertherapy: 5,000 IU/d
(intravenously)
by 150 mg/d
chloride3,
300
mg/d
for
2 days
of ticlopidine
fol-
hydro-
of dipynidamole4,
and 60 mg/d of aspirin5 (orally) for 1 month. In patients 8 and 9, thrombolytic therapy with 180,000 IU/d of urokinase6 (intravenously)
was
also
administered
for
2 days. In these two patients, stents were placed immediately after repeat dilation of idiopathic obstruction (6,7).
a.
b.
Figure
3. Case
2.
Compression
c.
by hepatic
vogram shows obstruction of the cavograms obtained after placement the elliptically dilated IVC lumen
tumors.
(a) Digital
subtraction
inferior
vena
upper
part of the IVC. AP (b) and lateral (c) inferior of four stents in tandem show good blood flow with marked regression of collateral circulation.
ca-
vena through
RESULTS Placement
of Stents
in
Giantunco expandable stents were successfully site of the lesion in all Placement was performed
2
Novo
I
Panaldine;
eral
Hepanin;
Pensantin; Republic
Novo, Daiichi
Dr. Karl of Germany.
JP Aspirin; Urokinase
Yoshida Injection;
Japan.
666
.
Radiology
metallic placed at the nine patients. one time
Bagsvaerd, Seiyaku. Thomae,
Denmark.
Tokyo. Biberach,
Pharmaceutical, Green
Cross,
Fed-
Tokyo. Osaka,
seven
patients
patients 1 and 8.
In patient connected placed,
and
two
1, six stents
by single but a single
times
in
in tandem
struts were strut became
dis-
connected and the upper two stents separated from the lower four (Fig 2). Five weeks later, three stents in tandem were placed striding the upper and lower stents. In patient 8, upon placement, a single stent slipped upward from the site of the lesion and partially lodged
in the right atrium. An additional single stent was placed covering the lower part of the lesion, but still the central pant of the lesion had not been covered by the stents. At that time, we delayed placement of anothen stent for fear that the procedure might move the upper stent further into the night atrium. Four weeks baten, two stents in tandem were placed striding the two previously placed stents.
Follow-up
abdominal
radiographs
September
1990
Summary
of Placement
of Gianturco
Expandable
Metallic
Stents
in Nine
Cases Diameter*
Patient/
Length of Lesion (mm)
Age (y)/ Sex
Type
of Hepatic
IVC Obstruction
Type of Stents
1 /67/M
Compression
by HM from
100
6 in tandem
2/61/M
Compression Compression Compression
by HM from colonic cancer by HM from gallbladder cancer by hepatocellular carcinoma
130 140 130
4 in tandem 5 in tandem 5 in tandem
Compression
by HM from colonic by hepatocellular
110 80
4 in tandem 4 in tandem
7/50/M
Compression Idiopathic
8/42/M 9/45/M
Idiopathic Idiopathic
3/71/F 4/74/M 5/66/F 6/52/M
Note.-HM *
=
Transverse
hepatic diameter
gastric
cancer
cancer carcinoma
obstruction (BCS), stenosis after PTA obstruction (BCS), reocclusion after PTA obstruction(BCS), reocclusion after PTA metastases,
BCS
Budd-Chiari
=
X anteropostenior
of
Lesion Placement
and 3 in tandem
X 2
30
1 single
25 30
2 single stents and 2 in tandem 3 in tandem X 2
after (mm)
Follow-up Period
18 X 22
5 mo (died)
6 X 22 22 X 13 26 x 8
3 wk (died) 2 mo (died) 3 mo (died)
21 x 18 8 X 30 15 x 18 13 X 12 12 x 16
2 mo (alive) 2 mo (alive) 10 mo (alive) 10 mo
(alive)
7 mo (alive)
syndrome.
diameter.
I
Figure 4. Case 7. Idiopathic (a) Cavogram (lateral view)
obstruction.
obtained
21
months after PTA shows stenosis of the hepatic IVC, which is 30 mm long and 6 mm in minimum AP diameter. (b) Cavogram ob-
tamed shows has
after placement of a single stent that the AP diameter of the channel
been
widened
to 18 mm.
(c) Follow-up
cavogram obtained 4 months after placement shows the channel to be patent. Around the posterior edge of the stent, intimal thickening of about 2 mm (arrow) is visible. (d) At 8-month follow-up examination the channel is patent, and there has been no
change
a.
b.
d.
.
in intimal
thickening
(arrow).
tically toms
(Fig 3). In all patients, sympdisappeared within several days
after
treatment.
In no patient
did
symptoms stents was
recur, and collapse not seen at nadiologic
amination of 3 weeks placement
during follow-up periods to 5 months after initial of stents. Two patients are
still
four
alive;
died
une, intestinal bleeding, within 5 months after topsy
performed
of the ex-
of hepatic
fail-
or cachexia treatment. Au-
in patients
2 and
3,
who died at 3 and 7 weeks after treatment, respectively, showed that the IVC and the hepatic veins bridged by the stents were patent and that the stents brous
were partially proliferation.
In the a.
b.
Figure
5. Case 8. Idiopathic obstruction. (a) Digital subtraction angiogram months after the initial placement of stents shows patency of the portion of vein bridged by the stents. (b) Inferior vena cavogram obtained at the same blood flow through the hepatic IVC. Defect (arrow) indicates inflow of the vein.
obtained 8 the right hepatic time shows good right hepatic
three
no delayed in any of the
Effect
migration nine cases.
of the
In the
six patients due
rior
cavograms
vena
Volume
176
with
to hepatic
#{149} Number
procedure
showed
good
flow
through
the
dilated
mens,
which
were
6-26
blood
IVC mm
IVC tumors,
obtained 3
obinfe-
after
the obstructions disappeared pletely (Fig 2). In the other
tients,
the
lumens
were
luin trans-
verse diameter and 8-30 mm diameter (Table). In patients
of Treatment
struction
the
in AP 1 and 5, cornfour pa-
dilated
ellip-
with
by
fi-
idiopath-
ic obstruction, inferior vena cavograms obtained after placement of stents showed good blood flow through the channels, which were 12-15 and 12-18 mm in transverse and AP diameter, respectively (Table). In none of the three patients did
Budd-Chiani showed stents
patients
covered
syndrome
recur
during
the follow-up period of 7-10 months. Patients 7 and 8 underwent followup inferior vena cavography at 8 months after placement. Examination
showed
the
channels
to be well
but some intimal thickening curred (Fig 4). In patient of the right hepatic vein the stents was confirmed
open,
had oc8, patency bridged by by injection
Radiology
#{149} 667
of contrast material into the vessel (Fig 5). Patient 9 underwent radionuclide angiognaphy, which showed good blood flow through the channel at 6 months after placement.
the
hepatic
IVC.
canalized
with
There were no complications except for pneumothonax, which was observed in patient 8. The patient complained of chest pain on the night stents.
of the second placement The chest radiograph
a moderate side that
was
intercostal
pneumothorax on the treated by inserting
drainage
CT performed small both
bullae lungs
of the
of showed
tube
1 week in the as well
later
for
left an
upper lobes as disappearance
was
Case 1.-A 67-year-old man developed severe edema of the abdominal walls and legs and marked swelling of the scrotum. Three months earlier the patient had undergone subtotal gastrectomy for scinrhous carcinoma of the stomach. He had received intnaarterial infusion chemotherapy for liver metastases three times. The patient was treated with an implantable delivery
system
that
was
con-
nected to a catheter inserted in the proper hepatic artery through the left subcbavian artery. Inferior vena cavography showed a 10-cm-bong obstruction
of the
upper
abdominal
IVC
(Fig 2a). CT showed the IVC to be compressed by large tumors in the medial segment of the left hepatic lobe. Six stents in tandem were placed at the site of the obstruction. Inferior vena cavograms obtained after the procedure showed that the IVC was dilated
to 18 X 22 mm
in transverse
and AP diameters; however, the upper two stents had separated from the lower four and had partially lodged in the right atrium (Fig 2b, 2c). Edema of the lower body disappeared completely after 5 days, and the patient recovered the ability to walk. Five weeks later, three stents in tandem were placed striding the uppen and bower stents for the purpose of preventing delayed migration of the upper stents (Fig 2d). The patient died of cachexia 5 months after the initial placement of the stents. toms did not recur before that Case 7.-A 50-year-old man 11-year history of Budd-Chiani
drome. mm-long 668
He underwent segmental
#{149} Radiology
three
balloon
placed
later
at the
a single
site
Inferior placement
stent
vena cavograshowed the
Symptime. had an syn-
PTA for a 25obstruction of
phy
performed
4 months
after
di-
place-
ment showed that the channel was well open, but around some parts of the stent intimal thickening of about 2 mm was visible tion at 8 months
showed the
the
intimab
(Fig after
4c). Examinaplacement
channel
to be patent,
thickening
appeared
same (Fig 4d). Budd-Chiani did not recur during the period Case
4-year drome.
In June
PTA
and the
syndrome follow-up
45-year-old man of Budd-Chiani 1988,
he
for a 20-mm-long
struction
of
struction
was
the
a
underwent
hepatic
IVC.
The
canalized
with
a stiff
and
scintigraphy netium-99m-labeled
Six months
radionuclide
pulmonary with
injection of techmacnoaggregat-
DISCUSSION Giantunco
expandable
metallic force that
stents have expansile termined by the size
(8,15). system, by the
When they tunica
of the
is de-
wire,
the
in the stents
placed in the venous are gradually covered intima and inconporat-
ed into the enal weeks tency of the date, these symptomatic of the vena
vascular wall within 5evwithout impairing the paside branches (8,14). To stents have been used for stenosis or obstruction cava, the bile ducts, and
tracheobnonchial
trees
(14,16-18).
The results have demonstrated the usefulness of these stents in reopening narrowed lumens and maintainalthough been limited.
the
effect
has
We have used Gianturco expandabbe metallic stents in patients with two types of hepatic IVC obstruction. The
obob-
an-
perfusion
ed albumin from the dorsal venous arch of the foot. Examination showed good blood flow through the channeb. Budd-Chiani syndrome did not recur during the follow-up period of 7 months.
ing patency, sometimes
had syn-
segmental
health.
underwent
giography
the
of 10 months.
9.-A history
in good he
number and angle of bends wine, and the length of the
of the previous
ameter of the channel to be 15 X 18 mm (Fig 4b). The patient was discharged in good health 1 month baten. Follow-up inferior vena cavogra-
Reports
drug
months
obstruction. phy after
pneumothonax.
Case
laser
was widened to diameter by si-
inflating
charged later,
catheters. Follow-up inferior vena cavography performed 13 months after PTA showed the channel to be patent. However, examination at 21 months showed a stenosis 30 mm long and 6 X 6 mm in minimum transverse and AP diameters (Fig 4a). The stenosis was subsequently dilated to 12 X 13 mm with balloon catheters. Three
of
was
(Nd:YAG)
(7), and the channel 12 mm in transverse
5 days.
showed
obstruction
urn-aluminum-garnet
multaneously
Complications
The
a neodymiurn-yttni-
hepatic
IVC
runs
in a deep
groove on the posterior surface of the liver. It is connected to the liver by the
principal
and
accessory
hepatic
guide wire, and the channel was dibated to 10 mm in transverse diarneten by simultaneously inflating three balloon catheters. Three months baten, the patient developed recurrent Budd-Chiari syndrome, and examina-
veins. Hepatic tumors can compress the IVC from various directions. They can cause obstruction of the IvC with or without displacing the vessel from its original site. Such ob-
tion patic
ma of the lower half of the body. Symptoms may improve with devebopment of collateral circulation but do not disappear entirely in many
showed IVC.
neocclusion He underwent
on September Chiari
of the hePTA again
20; however,
syndrome
Budd2 months
recurred
later. Repeat PTA and stent placement were performed on May 25, 1989. The recurrent obstruction, 30 mm long, was canalized with a guide wine and balloon dilated to 7 mm in transverse diameter. We placed three stents in tandem but missed the uppen pant of the lesion, as we were concerned about lodging the cephalic stent in the right atrium. We then placed an additional three stents in tandem. Inferior vena cavography performed after placement showed that the diameter of the channel had increased
weeks
to 12 X 16 mm.
later,
the
patient
Three
was
dis-
structions
cases.
usually
Surgical
bead
treatment
are
not
time
and
always
ence, open
quite
for
the
corrected.
treating the of the tumors
IVC
obstruction In our
immediately
after
of the balloons. Gianturco able metallic stents seem to this
In our
study,
tu-
is
expeni-
PTA with balloon catheters the IVC lumen, but occlusion
reoccurs
lution
exten-
arterial infusion or chernoembolization
is often indicated mors, but shrinkage
takes
mdi-
as the hepattype of IVC ob-
generally
sive. Hepatic chemotherapy
ede-
is not
cated for this condition, ic tumors causing this struction
to severe
can
deflation
expandto offer a so-
problem.
all of the
IVC
September
ob1990
structions
due
to compression
by
he-
patic tumors remained well dilated after placement of the stents. In two of the six patients, examination after placement showed complete disappearance of the obstructions. In the other four patients, the obstructions were dilated elliptically, but there was good blood flow through the lumen. These results suggest that the expansile force of the stents can counterbalance the pressure of hepatic tumors. The fact that hepatic tumors generally compress the IVC walls eccentrically and the fact that the posterior wall of the hepatic IVC is normally
not
and is therefore hepatic tumors cessful dilation tions
as well
covered
by
the
liver
not compressed by can explain the sucof the IVC obstrucas the
elliptical
dilation
seen in four cases. Idiopathic obstruction of the hepatic IVC is one of the most common causes of Budd-Chiani syndrome (1,2). Idiopathic obstruction is divided into two types-membranous and segmental-based on angiognaphic appearances. At histologic examination, the former obstruction is seen as a fibrotic membranous web (1-3). The batter can be due to the following conditions: a membranous web associated with mural thrombus, fibrous thickening of the caval intima with or without mural thrombus, and obliteration of the IVC by onganization of the thrombus (2,3,19). Idiopathic obstruction has been treated by several surgical methods that require extracorporeal circulation (2-5). Recently, PTA with a stiff guide wire or laser for canalization and balloon catheters
for
dilation
has
become
more widely used pathic obstruction dure is less invasive
for correcting idio(6,7). This procethan surgery.
Reocciusion
occurs
often
after
treat-
ment. Although there is little histologic evidence, neocclusion after PTA is most likely due to fibrous narrowing of the dilated area and formation of mural thrombi. To our knowledge, neocclusion occurs more often in cases of segmental obstruction. We have performed PTA in five cases of segmental obstruction and three cases of membranous obstruction. Three of the five segmentab cases showed reocclusion within 1 year aften treatment, while none of the three membranous cases showed reoccbusion during the follow-up penods of 2-6 years. Yamada et al (20) reported eight cases of segmental obstruction treated by means of PTA. Four showed reocclusion within 1 Volume
176
#{149} Number
3
year after treatment. Reoccbusion has been treated by repeated PTA, but frequent PTA is cleanly a heavy bunden on the patient. Our results with the use of Gianturco expandable metallic stents in cases of idiopathic obstruction are limited but promising. In all three patients, examinations performed 68 months channels
Chiari ing
after to be
placement patent,
syndrome the
did
follow-up
showed Budd-
and
not
recur
periods
the
dun-
of mural
by
the
development
of retrievable
and
of 7-10
months. In two cases, neocclusion had occurred at 3 and 8 months after PTA. These results suggest that the stents keep the channel open by countering the development of fibrous narrowing. Preservation of blood flow would prevent the formation
We placed single stents with anchor barbs in two patients with idiopathic obstruction, as the target areas were about one stent length. Slippage occurred during placement in one case. To prevent this slippage, we now place stents only in tandem, as the cephalic stent will act as anchor during placement. Oifficulty in placing tandem stents at the optimal location as in patient 9 may be solved
thrombi.
relocatable stents. We believe that the pneumothonax seen in patient 8 was unrelated to the placement of the stents, as it occurred on the left side, away from the IVC, and CT showed small bullae in both lungs.
In our due
six cases
of IVC
to compression
obstruction
by
hepatic
tu-
Endovascubar use of metallic stents for both arteries and veins can cause marked intimab thickening (hyperplasia) that leads to buminab narrowing (10-12,21-24). Thus, bong-term patency depends on the degree of in-
mors, radiobogic examination penformed before placement of stents did not show intraluminal thrombi that might cause pulmonary embo-
timal
mend ment
thickening.
In our
series,
minor
intimal thickening was visible at fobbow-up inferior vena cavography performed in patients 7 and 8. In patient
7, the
thickening
crease
during
months
after
the
did
not
period
in-
from
placement.
The
4 to 8 intimal
lism
at the
sive
thnombi
stents
tion.
Lausanne,
Swit-
the
stents
is particularly
important,
as blockage of the hepatic venous outflow can cause Budd-Chiani syndnome. In our series, none of the patients showed recurrent or newly developed Budd-Chiari syndrome after placement of the stents, and patency of the hepatic veins was confirmed at angiognaphy in patient 8 and at autopsy in patients 2 and 4. The main difficulties in placing Giantunco
expandable
metallic
If mas-
present,
we
them (16).
at this
also
time
useful
sion
of the
the
treatment
recom-
before
place-
suggest
that
in preventing
hepatic
IVC
they
reocclu-
after
of idiopathic
PTA
for
obstruc-
U
Acknowledgments:
We thank
for his aid in preparing daharu Kojima for his
the manuscript photographic
E. T. Martin and work.
Ta-
References 1.
2.
3.
4.
stents
included separation of tandem stents in one patient and slippage of a single stent partially into the night atniurn in one patient. To solve the probbern of separation of tandem stents, we connected stents with two or more struts instead of only one as had been done previously.
dissolving of stents
results
are
(Medinvent,
of placement.
are
We conclude that Giantunco expandable metallic stents are useful in correcting IVC obstruction due to compression by hepatic tumors. Our
thickening seen in our two cases was less prominent than that which has been reported with the use of Wallzerland) for peripheral veins (23,24). This may be due to the open structune of Gianturco expandable metalbic stents as well as the correct fitting of stents to the vascular diameter, which avoids excessive expansile force (21). In treatment of hepatic IVC obstructions with metallic stents, patency of the hepatic veins bridged by
time
Mitchell
MC,
Boitnott
JK,
Kaufman
5,
Cameron JL, Maddrey WC. Budd-Chiani syndrome: etiology, diagnosis and management. Medicine 1982; 61:199-218. Hirooka M, Kimuna C. Membranous obstruction of the hepatic portion of the inferior vena cava: surgical correction and etiological study. Arch Surg 1970; 100:656-663. Yamamoto
5, Yokoyama
Y, Takeshige
K,
Iwatsuki S. Budd-Chiani syndrome with obstruction of the inferior vena cava. Gastroenterology 1968; 54:1070-1084. Nakao K, Adachi S, Kawashima V. Okamoto E, Manabe H. A radical operation for the Budd-Chiani syndrome associated with obstruction of the inferior vena cava: a report of six patients. J Cardiovasc Surg 1984; 25:216-221.
5.
Senning
6.
section of the liver as treatment Budd-Chiani syndrome. World J 1983; 7:632-640. Yamada R, Sato M, Kawabata M, suka H, Nakamuna K, Kobayashi mental obstruction of the hepatic vena cava treated by transluminal
A.
Transcaval
posterocranial
plasty.
Radiology
7.
Furui
5, Yamauchi
1983;
re-
of the Sung NakatN. Seginferior anglo-
149:91-96.
T, Ohtomo
K, Tsuchiya
Radiology
#{149} 669
K, Makita K, Takenaka E. Hepatic infenior vena cava obstructions: clinical results of treatment with percutaneous transluminal laser-assisted angioplasty. Radiology 1988; 166:673-677. 8.
Wright
KC,
Wallace
Carrasco CH, endovasculan uation.
9.
D, Zollikofer A.
156:69-72.
CL,
Lagiaden
Radiological
luminally
10.
1 985;
follow-up
inserted
vascular
ses: an experimental ing spirals. Radiology Dotter CT, Buschmann nitinol
11.
coil
stent
grafting:
14.
C,
G Jr.
Wright
KC,
Wallace 5, Giantunco C. expanded stent for small gy 1987; 162:276-278.
F, et al. endovasculan
experimental
study.
Use of pros-
19. 20.
Radiology
164:709-714.
Charnsangavej C, Canrasco CH, Wallace S. et al. Stenosis of the vena cava: preliminary assessment of treatment with expandable metallic stents. Radiology 1986;
21.
16.
re-
Channsangavej
17.
C,
balloonRadiolo-
BC, Wallace stents.
5, Giantunco of the
Invest
C.
Elas-
self-expanding Radiol
1988;
23:370-
18.
Putnam JS, Uchida BT, Antonovic R, R#{246}sch J. Superior vena cava syndrome associated with massive thrombosis: treatment with expandable wine stents. Radiology 1988; 167:727-728. Irving JD, Adam A, Dick R, Dondelingen RF, Lundenquist A, Roche A. Giantunco expandable metallic billiany stents: results of a European clinical trial. Radiology 1989; 172:321-326. Wallace MJ, Charnsangavej C, Ogawa K, et al. Tracheobronchial tree: expandable metallic stents used in experimental and clinical
applications.
Radiology
Parker RGF. Occlusion vein in man. Medicine Yamada R, Tsuji T, Sato tnansluminal angioplasty tems. Kokyu to Junkan [Japanese] Duprat C Jr. Wright KC,
22.
23.
of the hepatic 1959; 38:369-402. M. Percutaneous in venous sys1986; 34:945-950.
Charnsangavej C, Self-expanding metallic stents for small vessels: an experimental evaluation. Radiology 1987; 162:469-472.
Wallace
376.
expandable preliminary
Falone metallic
endopnosthe-
Flexible vessels.
an
J, Joffre
Peul
tic characteristics
of tnans-
pont. Radiology 1983; 147:259-260. Palmaz JC, Sibbitt RR, Reuten SR. Tb FO, Rice WJ. Expandable intraluminal graft: a preliminary study. Radiology 1985; Duprat
self-expanding
161:295-298.
15.
F, Sen-
156:73-77. 12.
H,
a new 1987;
study using expand1984; 152:659-663. RW, McKinney
MK, R#{246}sch J. Transluminal
Rousseau thesis:
Giantunco C. Percutaneous stents: an experimental eval-
Radiology
Maass ning
5, Charnsangavej
13.
Gunther
5, Gianturco
RW,
Vonwerk
C.
D,
Borndorf
K, Pe-
ters I, El-Din A, Messmer B. Iliac and femoral artery stenoses and occlusions: treatment with intravascular stents. Radiology 1989; 172:725-730. Zollikofer CL, Largiaden I, Bruhmann WF, Ulhschmid GK, Marty AH. Endovascular stenting of veins and grafts: preliminary clinical experience. Radiology 1988; 167:707-712.
24.
Gunther RW, Vorwerk D, Bohndorf K, et at. Venous stenoses in dialysis shunts: treatment with self-expanding metallic stents. Radiology 1989; 170:401-405.
1986;
158:309-312.
670
#{149} Radiology
September
1990
Hepatic Treatment Expandable
O
of the
BSTRUCTION
cava by hepatic ing
edema
in the
yet there treatment pathic is one
lower
has been for this
(1,2)
surgical
yenta
body,
and
and
hepatic syn-
IVC
can be treated
methods
(2-5)
transbuminal
as
no corrective condition. Idio-
obstruction of the cause of Budd-Chiani
drome ous
inferior
(IVC) due to compression tumors can cause debibitat-
by
or percutane-
angioplasty
(PTA)
mm
developed
12.5-F night
Teflon femoral
cuban
for vascular
use
(8-13).
and
Some
nonvas-
of them
offer
venting
PTA
reocclusion
for the
treatment
obstruction.
This
experience able metallic with
of the
IVC
describes
with Gianturco stents in nine
hepatic
IVC
MATERIALS
years)
after
of idiopathic
article
our
expandpatients
obstruction.
AND
METHODS
Since February 1989, nine patients with hepatic IVC obstruction underwent placement of Gianturco expandable metallic stents at the National Defense Medical College Hospital in Saitama, Mitsui Memorial Hospital in Tokyo, and Kitazato University East Hospital in Kanagawa, Japan.
the stents
steel
wire.
from Each
0.018-inch
stent
was
East
sui
neoplasms, grafts and interventional
Liver cavae,
secondary, 761.33 #{149} Venae prostheses, 982.1299 #{149} Venae cavae, procedure, 982.1299 #{149} Venae cavae, stenosis or obstruction, 982.759, 982.789
25 mm
1990; 176:665-670
Kanagawa, Hospital,
Japan
Tokyo
(5K.);
(K.I.);
and
Mitthe
Research Institute for Microbial Diseases, Osaka University, Osaka, Japan (H.N.). Received January 3, 1990; revision requested February 15; revision received April 2; accepted April 9.
Address C
reprint
RSNA,
See Radiology
Hospital,
Memorial
in this
also
issue.
requests editorial
transverse
performed
through
sheath vein
showed
diameter
IVC immediPlacement
introduced following
IVC
reports women
a 12.0the
of or
via the method
(8,14). (aged 52-74
obstructions
80-140
mm long that were due to compression by large hepatic tumors (metastatic tumor, n = 4; hepatocellulan carcinoma, n 2) (Table). The patients had recently developed clinical symptoms and signs including severe edema of the lower extremities and abdominal walls (n = 6), marked swelling of the scrotum (n 2), and renal dysfunction (n = 2). Contrast material-enhanced computed tomography (CT) and ultrasonography did not show intraluminal thrombi at or around the obstruction in any
of the
six
patients.
We
placed
four
to
six stents in tandem without performing balloon dilation through a Teflon sheath that
had
been
passed
through
struction Three
over a guide wine. men (aged 42-50 years)
iopathic
obstruction
had (n
the
ob-
with
developed 2; 25 and
ideither 30
recurrent obstruction mm long, 8 and 3 months after PTA, respectively) or severe stenosis (n 1; 30 mm long, 21 months after PTA) (patient 7 was included in a previous report of lasen-assisted PTA [7]). We placed single or tandem stents after repeat dilation of the lesions with use of Gruentzig balloon catheters. Stents were placed immediately after repeat dilation in patients 8 and 9 and 3 months after repeat dilation in patient 7.
to S.F. Abbreviations:
1990 the
the
portion of the the obstruction.
described in previous Four men and two
hope in correcting IVC obstruction due to hepatic tumors and in pre-
sity
#{149}
than
was
Departments of Radiology, NaMedical College, 3-2 Namiki, Saitama 359, Japan (S.F., TI., KM., T.Y., E.T.); Tottori University School of Medicine, Tottori, Japan (5.5.); Kitazato Univen-
761 .32
greater
stents
I From the tional Defense Tokorozawa,
neoplasms,
long, with a diameter of 20-28 mm, and had five or six bends. We used single stents or multiple (two to six) stents in tandem connected by 0.018-inch stainless steel struts that allowed a 1-2-mm gap between stents (Fig 1). To prevent slippage and migration, we attached one barb of 0.018-inch stainless steel wire at each end of single stents (14) and at each end of the tail stent of multiple stents in tandem. We placed stents with diameters 2-5 of the patent ately below
stainless
Liver
MD
(6,7); however, reocclusion often occurs. In recent years, several types of metallic endoprostheses have been
We made
terms:
Makita,
Inferior Vena Cava Obstruction: of Two Types with Gianturco Metallic Stents’
Gianturco expandable metallic stents were used for treating six patients with inferior vena cava (IVC) obstruction due to compression by large hepatic tumors and three patients with idiopathic obstruction of the hepatic IVC and Budd-Chiari syndrome who showed reocclusion or stenosis 3-21 months after previously performed percutaneous transluminal angioplasty (PTA). In all six patients with compression by hepatic tumors, stents dilated the IVC and debilitating edema of the lower body disappeared. In the three patients with idiopathic obstruction, stents were placed after repeat dilation of the lesions and Budd-Chiari sydrome did not recur during a follow-up period of 7-10 months. In two of the three, cavograms obtained 8 months after placement showed the channels to be open with minimal intimal thickening. Gianturco expandable metallic stents can correct IVC obstruction due to compression by hepatic tumors and are useful in preventing reocclusion of the IVC after PTA for the treatment of idiopathic obstruction. The authors recommend using tandem stents connected by at least two struts.
Index
Radiology
by
Wright
(pp
620-621)
inferior luminal
vena cava, angioplasty.
AP
anteropostenior, PTA
percutaneous
IVC trans-
665
a.
b.
Figure
2. Case
1.
d.
C.
Compression
by hepatic
tumors.
(a) Inferior
vena
(b)
cavogram
shows
ob-
lateral (c) inferior vena cavograms obtained after placement of six stents in tandem show good blood flow through the IVC lumen, which is well dilated in both the transverse and AP directions. The upper two stents (arrow) have separated from the lower four and have partially lodged in the right atrium. (d) Five weeks later, three stents in tandem were placed striding the separated struction
stents.
Figure
1.
by
struts.
two
tached
Four
stents in tandem Two barbs (arrows)
of
the
upper
Examination
part
after
of the
IVC.
Anteropostenior
the procedure
shows
(AP)
the fully
dilated
and
IVC.
connected are at-
to the tail stent.
After the procedure went anticoagulant of hepanin2
lowed
patients undertherapy: 5,000 IU/d
(intravenously)
by 150 mg/d
chloride3,
300
mg/d
for
2 days
of ticlopidine
fol-
hydro-
of dipynidamole4,
and 60 mg/d of aspirin5 (orally) for 1 month. In patients 8 and 9, thrombolytic therapy with 180,000 IU/d of urokinase6 (intravenously)
was
also
administered
for
2 days. In these two patients, stents were placed immediately after repeat dilation of idiopathic obstruction (6,7).
a.
b.
Figure
3. Case
2.
Compression
c.
by hepatic
vogram shows obstruction of the cavograms obtained after placement the elliptically dilated IVC lumen
tumors.
(a) Digital
subtraction
inferior
vena
upper
part of the IVC. AP (b) and lateral (c) inferior of four stents in tandem show good blood flow with marked regression of collateral circulation.
ca-
vena through
RESULTS Placement
of Stents
in
Giantunco expandable stents were successfully site of the lesion in all Placement was performed
2
Novo
I
Panaldine;
eral
Hepanin;
Pensantin; Republic
Novo, Daiichi
Dr. Karl of Germany.
JP Aspirin; Urokinase
Yoshida Injection;
Japan.
666
.
Radiology
metallic placed at the nine patients. one time
Bagsvaerd, Seiyaku. Thomae,
Denmark.
Tokyo. Biberach,
Pharmaceutical, Green
Cross,
Fed-
Tokyo. Osaka,
seven
patients
patients 1 and 8.
In patient connected placed,
and
two
1, six stents
by single but a single
times
in
in tandem
struts were strut became
dis-
connected and the upper two stents separated from the lower four (Fig 2). Five weeks later, three stents in tandem were placed striding the upper and lower stents. In patient 8, upon placement, a single stent slipped upward from the site of the lesion and partially lodged
in the right atrium. An additional single stent was placed covering the lower part of the lesion, but still the central pant of the lesion had not been covered by the stents. At that time, we delayed placement of anothen stent for fear that the procedure might move the upper stent further into the night atrium. Four weeks baten, two stents in tandem were placed striding the two previously placed stents.
Follow-up
abdominal
radiographs
September
1990
Summary
of Placement
of Gianturco
Expandable
Metallic
Stents
in Nine
Cases Diameter*
Patient/
Length of Lesion (mm)
Age (y)/ Sex
Type
of Hepatic
IVC Obstruction
Type of Stents
1 /67/M
Compression
by HM from
100
6 in tandem
2/61/M
Compression Compression Compression
by HM from colonic cancer by HM from gallbladder cancer by hepatocellular carcinoma
130 140 130
4 in tandem 5 in tandem 5 in tandem
Compression
by HM from colonic by hepatocellular
110 80
4 in tandem 4 in tandem
7/50/M
Compression Idiopathic
8/42/M 9/45/M
Idiopathic Idiopathic
3/71/F 4/74/M 5/66/F 6/52/M
Note.-HM *
=
Transverse
hepatic diameter
gastric
cancer
cancer carcinoma
obstruction (BCS), stenosis after PTA obstruction (BCS), reocclusion after PTA obstruction(BCS), reocclusion after PTA metastases,
BCS
Budd-Chiari
=
X anteropostenior
of
Lesion Placement
and 3 in tandem
X 2
30
1 single
25 30
2 single stents and 2 in tandem 3 in tandem X 2
after (mm)
Follow-up Period
18 X 22
5 mo (died)
6 X 22 22 X 13 26 x 8
3 wk (died) 2 mo (died) 3 mo (died)
21 x 18 8 X 30 15 x 18 13 X 12 12 x 16
2 mo (alive) 2 mo (alive) 10 mo (alive) 10 mo
(alive)
7 mo (alive)
syndrome.
diameter.
I
Figure 4. Case 7. Idiopathic (a) Cavogram (lateral view)
obstruction.
obtained
21
months after PTA shows stenosis of the hepatic IVC, which is 30 mm long and 6 mm in minimum AP diameter. (b) Cavogram ob-
tamed shows has
after placement of a single stent that the AP diameter of the channel
been
widened
to 18 mm.
(c) Follow-up
cavogram obtained 4 months after placement shows the channel to be patent. Around the posterior edge of the stent, intimal thickening of about 2 mm (arrow) is visible. (d) At 8-month follow-up examination the channel is patent, and there has been no
change
a.
b.
d.
.
in intimal
thickening
(arrow).
tically toms
(Fig 3). In all patients, sympdisappeared within several days
after
treatment.
In no patient
did
symptoms stents was
recur, and collapse not seen at nadiologic
amination of 3 weeks placement
during follow-up periods to 5 months after initial of stents. Two patients are
still
four
alive;
died
une, intestinal bleeding, within 5 months after topsy
performed
of the ex-
of hepatic
fail-
or cachexia treatment. Au-
in patients
2 and
3,
who died at 3 and 7 weeks after treatment, respectively, showed that the IVC and the hepatic veins bridged by the stents were patent and that the stents brous
were partially proliferation.
In the a.
b.
Figure
5. Case 8. Idiopathic obstruction. (a) Digital subtraction angiogram months after the initial placement of stents shows patency of the portion of vein bridged by the stents. (b) Inferior vena cavogram obtained at the same blood flow through the hepatic IVC. Defect (arrow) indicates inflow of the vein.
obtained 8 the right hepatic time shows good right hepatic
three
no delayed in any of the
Effect
migration nine cases.
of the
In the
six patients due
rior
cavograms
vena
Volume
176
with
to hepatic
#{149} Number
procedure
showed
good
flow
through
the
dilated
mens,
which
were
6-26
blood
IVC mm
IVC tumors,
obtained 3
obinfe-
after
the obstructions disappeared pletely (Fig 2). In the other
tients,
the
lumens
were
luin trans-
verse diameter and 8-30 mm diameter (Table). In patients
of Treatment
struction
the
in AP 1 and 5, cornfour pa-
dilated
ellip-
with
by
fi-
idiopath-
ic obstruction, inferior vena cavograms obtained after placement of stents showed good blood flow through the channels, which were 12-15 and 12-18 mm in transverse and AP diameter, respectively (Table). In none of the three patients did
Budd-Chiani showed stents
patients
covered
syndrome
recur
during
the follow-up period of 7-10 months. Patients 7 and 8 underwent followup inferior vena cavography at 8 months after placement. Examination
showed
the
channels
to be well
but some intimal thickening curred (Fig 4). In patient of the right hepatic vein the stents was confirmed
open,
had oc8, patency bridged by by injection
Radiology
#{149} 667
of contrast material into the vessel (Fig 5). Patient 9 underwent radionuclide angiognaphy, which showed good blood flow through the channel at 6 months after placement.
the
hepatic
IVC.
canalized
with
There were no complications except for pneumothonax, which was observed in patient 8. The patient complained of chest pain on the night stents.
of the second placement The chest radiograph
a moderate side that
was
intercostal
pneumothorax on the treated by inserting
drainage
CT performed small both
bullae lungs
of the
of showed
tube
1 week in the as well
later
for
left an
upper lobes as disappearance
was
Case 1.-A 67-year-old man developed severe edema of the abdominal walls and legs and marked swelling of the scrotum. Three months earlier the patient had undergone subtotal gastrectomy for scinrhous carcinoma of the stomach. He had received intnaarterial infusion chemotherapy for liver metastases three times. The patient was treated with an implantable delivery
system
that
was
con-
nected to a catheter inserted in the proper hepatic artery through the left subcbavian artery. Inferior vena cavography showed a 10-cm-bong obstruction
of the
upper
abdominal
IVC
(Fig 2a). CT showed the IVC to be compressed by large tumors in the medial segment of the left hepatic lobe. Six stents in tandem were placed at the site of the obstruction. Inferior vena cavograms obtained after the procedure showed that the IVC was dilated
to 18 X 22 mm
in transverse
and AP diameters; however, the upper two stents had separated from the lower four and had partially lodged in the right atrium (Fig 2b, 2c). Edema of the lower body disappeared completely after 5 days, and the patient recovered the ability to walk. Five weeks later, three stents in tandem were placed striding the uppen and bower stents for the purpose of preventing delayed migration of the upper stents (Fig 2d). The patient died of cachexia 5 months after the initial placement of the stents. toms did not recur before that Case 7.-A 50-year-old man 11-year history of Budd-Chiani
drome. mm-long 668
He underwent segmental
#{149} Radiology
three
balloon
placed
later
at the
a single
site
Inferior placement
stent
vena cavograshowed the
Symptime. had an syn-
PTA for a 25obstruction of
phy
performed
4 months
after
di-
place-
ment showed that the channel was well open, but around some parts of the stent intimal thickening of about 2 mm was visible tion at 8 months
showed the
the
intimab
(Fig after
4c). Examinaplacement
channel
to be patent,
thickening
appeared
same (Fig 4d). Budd-Chiani did not recur during the period Case
4-year drome.
In June
PTA
and the
syndrome follow-up
45-year-old man of Budd-Chiani 1988,
he
for a 20-mm-long
struction
of
struction
was
the
a
underwent
hepatic
IVC.
The
canalized
with
a stiff
and
scintigraphy netium-99m-labeled
Six months
radionuclide
pulmonary with
injection of techmacnoaggregat-
DISCUSSION Giantunco
expandable
metallic force that
stents have expansile termined by the size
(8,15). system, by the
When they tunica
of the
is de-
wire,
the
in the stents
placed in the venous are gradually covered intima and inconporat-
ed into the enal weeks tency of the date, these symptomatic of the vena
vascular wall within 5evwithout impairing the paside branches (8,14). To stents have been used for stenosis or obstruction cava, the bile ducts, and
tracheobnonchial
trees
(14,16-18).
The results have demonstrated the usefulness of these stents in reopening narrowed lumens and maintainalthough been limited.
the
effect
has
We have used Gianturco expandabbe metallic stents in patients with two types of hepatic IVC obstruction. The
obob-
an-
perfusion
ed albumin from the dorsal venous arch of the foot. Examination showed good blood flow through the channeb. Budd-Chiani syndrome did not recur during the follow-up period of 7 months.
ing patency, sometimes
had syn-
segmental
health.
underwent
giography
the
of 10 months.
9.-A history
in good he
number and angle of bends wine, and the length of the
of the previous
ameter of the channel to be 15 X 18 mm (Fig 4b). The patient was discharged in good health 1 month baten. Follow-up inferior vena cavogra-
Reports
drug
months
obstruction. phy after
pneumothonax.
Case
laser
was widened to diameter by si-
inflating
charged later,
catheters. Follow-up inferior vena cavography performed 13 months after PTA showed the channel to be patent. However, examination at 21 months showed a stenosis 30 mm long and 6 X 6 mm in minimum transverse and AP diameters (Fig 4a). The stenosis was subsequently dilated to 12 X 13 mm with balloon catheters. Three
of
was
(Nd:YAG)
(7), and the channel 12 mm in transverse
5 days.
showed
obstruction
urn-aluminum-garnet
multaneously
Complications
The
a neodymiurn-yttni-
hepatic
IVC
runs
in a deep
groove on the posterior surface of the liver. It is connected to the liver by the
principal
and
accessory
hepatic
guide wire, and the channel was dibated to 10 mm in transverse diarneten by simultaneously inflating three balloon catheters. Three months baten, the patient developed recurrent Budd-Chiari syndrome, and examina-
veins. Hepatic tumors can compress the IVC from various directions. They can cause obstruction of the IvC with or without displacing the vessel from its original site. Such ob-
tion patic
ma of the lower half of the body. Symptoms may improve with devebopment of collateral circulation but do not disappear entirely in many
showed IVC.
neocclusion He underwent
on September Chiari
of the hePTA again
20; however,
syndrome
Budd2 months
recurred
later. Repeat PTA and stent placement were performed on May 25, 1989. The recurrent obstruction, 30 mm long, was canalized with a guide wine and balloon dilated to 7 mm in transverse diameter. We placed three stents in tandem but missed the uppen pant of the lesion, as we were concerned about lodging the cephalic stent in the right atrium. We then placed an additional three stents in tandem. Inferior vena cavography performed after placement showed that the diameter of the channel had increased
weeks
to 12 X 16 mm.
later,
the
patient
Three
was
dis-
structions
cases.
usually
Surgical
bead
treatment
are
not
time
and
always
ence, open
quite
for
the
corrected.
treating the of the tumors
IVC
obstruction In our
immediately
after
of the balloons. Gianturco able metallic stents seem to this
In our
study,
tu-
is
expeni-
PTA with balloon catheters the IVC lumen, but occlusion
reoccurs
lution
exten-
arterial infusion or chernoembolization
is often indicated mors, but shrinkage
takes
mdi-
as the hepattype of IVC ob-
generally
sive. Hepatic chemotherapy
ede-
is not
cated for this condition, ic tumors causing this struction
to severe
can
deflation
expandto offer a so-
problem.
all of the
IVC
September
ob1990
structions
due
to compression
by
he-
patic tumors remained well dilated after placement of the stents. In two of the six patients, examination after placement showed complete disappearance of the obstructions. In the other four patients, the obstructions were dilated elliptically, but there was good blood flow through the lumen. These results suggest that the expansile force of the stents can counterbalance the pressure of hepatic tumors. The fact that hepatic tumors generally compress the IVC walls eccentrically and the fact that the posterior wall of the hepatic IVC is normally
not
and is therefore hepatic tumors cessful dilation tions
as well
covered
by
the
liver
not compressed by can explain the sucof the IVC obstrucas the
elliptical
dilation
seen in four cases. Idiopathic obstruction of the hepatic IVC is one of the most common causes of Budd-Chiani syndrome (1,2). Idiopathic obstruction is divided into two types-membranous and segmental-based on angiognaphic appearances. At histologic examination, the former obstruction is seen as a fibrotic membranous web (1-3). The batter can be due to the following conditions: a membranous web associated with mural thrombus, fibrous thickening of the caval intima with or without mural thrombus, and obliteration of the IVC by onganization of the thrombus (2,3,19). Idiopathic obstruction has been treated by several surgical methods that require extracorporeal circulation (2-5). Recently, PTA with a stiff guide wire or laser for canalization and balloon catheters
for
dilation
has
become
more widely used pathic obstruction dure is less invasive
for correcting idio(6,7). This procethan surgery.
Reocciusion
occurs
often
after
treat-
ment. Although there is little histologic evidence, neocclusion after PTA is most likely due to fibrous narrowing of the dilated area and formation of mural thrombi. To our knowledge, neocclusion occurs more often in cases of segmental obstruction. We have performed PTA in five cases of segmental obstruction and three cases of membranous obstruction. Three of the five segmentab cases showed reocclusion within 1 year aften treatment, while none of the three membranous cases showed reoccbusion during the follow-up penods of 2-6 years. Yamada et al (20) reported eight cases of segmental obstruction treated by means of PTA. Four showed reocclusion within 1 Volume
176
#{149} Number
3
year after treatment. Reoccbusion has been treated by repeated PTA, but frequent PTA is cleanly a heavy bunden on the patient. Our results with the use of Gianturco expandable metallic stents in cases of idiopathic obstruction are limited but promising. In all three patients, examinations performed 68 months channels
Chiari ing
after to be
placement patent,
syndrome the
did
follow-up
showed Budd-
and
not
recur
periods
the
dun-
of mural
by
the
development
of retrievable
and
of 7-10
months. In two cases, neocclusion had occurred at 3 and 8 months after PTA. These results suggest that the stents keep the channel open by countering the development of fibrous narrowing. Preservation of blood flow would prevent the formation
We placed single stents with anchor barbs in two patients with idiopathic obstruction, as the target areas were about one stent length. Slippage occurred during placement in one case. To prevent this slippage, we now place stents only in tandem, as the cephalic stent will act as anchor during placement. Oifficulty in placing tandem stents at the optimal location as in patient 9 may be solved
thrombi.
relocatable stents. We believe that the pneumothonax seen in patient 8 was unrelated to the placement of the stents, as it occurred on the left side, away from the IVC, and CT showed small bullae in both lungs.
In our due
six cases
of IVC
to compression
obstruction
by
hepatic
tu-
Endovascubar use of metallic stents for both arteries and veins can cause marked intimab thickening (hyperplasia) that leads to buminab narrowing (10-12,21-24). Thus, bong-term patency depends on the degree of in-
mors, radiobogic examination penformed before placement of stents did not show intraluminal thrombi that might cause pulmonary embo-
timal
mend ment
thickening.
In our
series,
minor
intimal thickening was visible at fobbow-up inferior vena cavography performed in patients 7 and 8. In patient
7, the
thickening
crease
during
months
after
the
did
not
period
in-
from
placement.
The
4 to 8 intimal
lism
at the
sive
thnombi
stents
tion.
Lausanne,
Swit-
the
stents
is particularly
important,
as blockage of the hepatic venous outflow can cause Budd-Chiani syndnome. In our series, none of the patients showed recurrent or newly developed Budd-Chiari syndrome after placement of the stents, and patency of the hepatic veins was confirmed at angiognaphy in patient 8 and at autopsy in patients 2 and 4. The main difficulties in placing Giantunco
expandable
metallic
If mas-
present,
we
them (16).
at this
also
time
useful
sion
of the
the
treatment
recom-
before
place-
suggest
that
in preventing
hepatic
IVC
they
reocclu-
after
of idiopathic
PTA
for
obstruc-
U
Acknowledgments:
We thank
for his aid in preparing daharu Kojima for his
the manuscript photographic
E. T. Martin and work.
Ta-
References 1.
2.
3.
4.
stents
included separation of tandem stents in one patient and slippage of a single stent partially into the night atniurn in one patient. To solve the probbern of separation of tandem stents, we connected stents with two or more struts instead of only one as had been done previously.
dissolving of stents
results
are
(Medinvent,
of placement.
are
We conclude that Giantunco expandable metallic stents are useful in correcting IVC obstruction due to compression by hepatic tumors. Our
thickening seen in our two cases was less prominent than that which has been reported with the use of Wallzerland) for peripheral veins (23,24). This may be due to the open structune of Gianturco expandable metalbic stents as well as the correct fitting of stents to the vascular diameter, which avoids excessive expansile force (21). In treatment of hepatic IVC obstructions with metallic stents, patency of the hepatic veins bridged by
time
Mitchell
MC,
Boitnott
JK,
Kaufman
5,
Cameron JL, Maddrey WC. Budd-Chiani syndrome: etiology, diagnosis and management. Medicine 1982; 61:199-218. Hirooka M, Kimuna C. Membranous obstruction of the hepatic portion of the inferior vena cava: surgical correction and etiological study. Arch Surg 1970; 100:656-663. Yamamoto
5, Yokoyama
Y, Takeshige
K,
Iwatsuki S. Budd-Chiani syndrome with obstruction of the inferior vena cava. Gastroenterology 1968; 54:1070-1084. Nakao K, Adachi S, Kawashima V. Okamoto E, Manabe H. A radical operation for the Budd-Chiani syndrome associated with obstruction of the inferior vena cava: a report of six patients. J Cardiovasc Surg 1984; 25:216-221.
5.
Senning
6.
section of the liver as treatment Budd-Chiani syndrome. World J 1983; 7:632-640. Yamada R, Sato M, Kawabata M, suka H, Nakamuna K, Kobayashi mental obstruction of the hepatic vena cava treated by transluminal
A.
Transcaval
posterocranial
plasty.
Radiology
7.
Furui
5, Yamauchi
1983;
re-
of the Sung NakatN. Seginferior anglo-
149:91-96.
T, Ohtomo
K, Tsuchiya
Radiology
#{149} 669
K, Makita K, Takenaka E. Hepatic infenior vena cava obstructions: clinical results of treatment with percutaneous transluminal laser-assisted angioplasty. Radiology 1988; 166:673-677. 8.
Wright
KC,
Wallace
Carrasco CH, endovasculan uation.
9.
D, Zollikofer A.
156:69-72.
CL,
Lagiaden
Radiological
luminally
10.
1 985;
follow-up
inserted
vascular
ses: an experimental ing spirals. Radiology Dotter CT, Buschmann nitinol
11.
coil
stent
grafting:
14.
C,
G Jr.
Wright
KC,
Wallace 5, Giantunco C. expanded stent for small gy 1987; 162:276-278.
F, et al. endovasculan
experimental
study.
Use of pros-
19. 20.
Radiology
164:709-714.
Charnsangavej C, Canrasco CH, Wallace S. et al. Stenosis of the vena cava: preliminary assessment of treatment with expandable metallic stents. Radiology 1986;
21.
16.
re-
Channsangavej
17.
C,
balloonRadiolo-
BC, Wallace stents.
5, Giantunco of the
Invest
C.
Elas-
self-expanding Radiol
1988;
23:370-
18.
Putnam JS, Uchida BT, Antonovic R, R#{246}sch J. Superior vena cava syndrome associated with massive thrombosis: treatment with expandable wine stents. Radiology 1988; 167:727-728. Irving JD, Adam A, Dick R, Dondelingen RF, Lundenquist A, Roche A. Giantunco expandable metallic billiany stents: results of a European clinical trial. Radiology 1989; 172:321-326. Wallace MJ, Charnsangavej C, Ogawa K, et al. Tracheobronchial tree: expandable metallic stents used in experimental and clinical
applications.
Radiology
Parker RGF. Occlusion vein in man. Medicine Yamada R, Tsuji T, Sato tnansluminal angioplasty tems. Kokyu to Junkan [Japanese] Duprat C Jr. Wright KC,
22.
23.
of the hepatic 1959; 38:369-402. M. Percutaneous in venous sys1986; 34:945-950.
Charnsangavej C, Self-expanding metallic stents for small vessels: an experimental evaluation. Radiology 1987; 162:469-472.
Wallace
376.
expandable preliminary
Falone metallic
endopnosthe-
Flexible vessels.
an
J, Joffre
Peul
tic characteristics
of tnans-
pont. Radiology 1983; 147:259-260. Palmaz JC, Sibbitt RR, Reuten SR. Tb FO, Rice WJ. Expandable intraluminal graft: a preliminary study. Radiology 1985; Duprat
self-expanding
161:295-298.
15.
F, Sen-
156:73-77. 12.
H,
a new 1987;
study using expand1984; 152:659-663. RW, McKinney
MK, R#{246}sch J. Transluminal
Rousseau thesis:
Giantunco C. Percutaneous stents: an experimental eval-
Radiology
Maass ning
5, Charnsangavej
13.
Gunther
5, Gianturco
RW,
Vonwerk
C.
D,
Borndorf
K, Pe-
ters I, El-Din A, Messmer B. Iliac and femoral artery stenoses and occlusions: treatment with intravascular stents. Radiology 1989; 172:725-730. Zollikofer CL, Largiaden I, Bruhmann WF, Ulhschmid GK, Marty AH. Endovascular stenting of veins and grafts: preliminary clinical experience. Radiology 1988; 167:707-712.
24.
Gunther RW, Vorwerk D, Bohndorf K, et at. Venous stenoses in dialysis shunts: treatment with self-expanding metallic stents. Radiology 1989; 170:401-405.
1986;
158:309-312.
670
#{149} Radiology
September
1990
