IVC kinking and stenosis

[Maria Corina Plaz Torres]

Dear colleagues,

We would like to know your opinion in the case of this patient:

– 49 y old female
– Liver disease: Budd Chiari sd –> TIPS October 2007 –> TIPS dilatation October 2008 –> TIPS extension in May 2009 and further extension in 2013 –> 2015 IVC stenosis with related symptoms: oedema and abdominal distension–> January 2015 combined IVC dilatation and TIPS dilatation which were repeated every 4/6 months thereafter (last in May 2018) as symptoms recurred four weeks later.
– Myeloproliferative disease (JAK2 V617F allele)

Treatment: Warfarin, Aspirin, Hydroxicarbamide.

At imaging there is a supra-hepatic IVC stenosis. When balloons are in place, the IVC untwists, there is a decrease in pressures. Clinically, after each dilatation the patient looses 4 kg and abdominal distension disappears.
After each dilatation, the IVC re-stenoses because of the twisting action as opposed to recurrent endothelial hyperplasia. The last attempt has been with larger Atlas balloons in the IVC but still the stenosis and symptoms recurred 4 weeks later.
We think IVC stenting would not be recommended as stent placement would be critical with high risk of migration but we would like to have an opinion from you and to know what you have done if you had similar cases.
Would you recommend an IVC stenting?

Thank you very much,

Dr Plaz Torres Maria C. and Dr. David Patch

• This topic was modified 6 months ago by Ved Prakash Singh Bohra.
• This topic was modified 6 months ago by Ved Prakash Singh Bohra.

[Markus Peck-Radosavljevic]

I am not sure about the ”twisting“ but we had similar cases of IVC-stenosis and were able to treat them successfully with stenting.
So, I personally would stent this patient.

Kind regards,

Markus Peck

Prof. Dr. Markus Peck-Radosavljevic, M.D.

Chair, Dept. Internal Medicine & Gastroenterology (IMuG)
Hepatology, Endocrinology, Rheumatology and Nephrology
with Centralized Emergency Department (ZAE)

Klinikum Klagenfurt am Wörthersee
Feschnigstrasse 11
9020 Klagenfurt
Austria

Ph: +43 463 538 31103 (Ms. Werkl)
Fax: +43 463 538 31109

On Twitter: @MarkusPeck1

[Juan Carlos Garcia-Pagan]

I completely agree about stenting,
best

[David Patch]

the stenosis is between the tips and the right atrium-it is a maximum of 2cm. Any stent will then end up with the free end in the atrium, plus could also impinge on the TIPS stent. I have an inherent worry about metal stents in benign disease anyway tho there are short large diameter stents available. PLus, she is relatively young, and I am also concerned about complicating the transplant issue with an embedded IVC stent in say 5 years time….
Its not easy!(not sure if there is a way we can share some of the images-the NHS firewall is relatively robust, unlike our politicians!

[Fabio Piscaglia]

I share David’s concerns about future transplant possibilities and I wonder whether it could already be the time to consider candidacy if there is not effective alternative. It is also strange how often the TIPS needed to be revised, is there any possible explanation?

[David Patch]

the problem with transplant is that she “only” has abdominal distension and probable gut oedema. She has no ascites etc-and well preserved liver function.
re frequent recurrence-I can only imagine that when we dilate, the IVC “un-twists” a bit, and after dilatation it gradually returns back to predilatation state.

[Juan G Abraldes]

Agree I would not place an stent that has to enter the atrium. Agree with Fabio that the best long term solution would be a transplant, even if the only hard indication is the inability to keep the IVC open

[Author]

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