Introduction: Management of Budd-Chiari syndrome (BCS) includes different interventions and surgical
procedures. There is limited data regarding catheterdirected thrombolysis when treating
this condition but it appears to be helpful in the case illustrated below. Case report: A 29 year-old woman was referred to our center with one month history of right upper
abdominal pain, progressive abdominal distension and intermittent fever not associated
with rigors. There was no history of oral contraceptive use. She had mild right upper
quadrant tenderness and abdominal distention with moderate elevation of liver enzymes.
Her serology was negative for viral hepatitis, autoimmune or cholestatic liver disease.
Computed tomography (CT) angiogram of the abdomen showed a large amount of ascites
with extensive thrombosis of the inferior vena cava (IVC) involving the hepatic and
left renal veins. There was also complete occlusion of the left common iliac vein
confirmed by venogram. An infusion catheter was placed through the thrombosed segment
of the IVC and right hepatic artery. Thrombolytic therapy was started with the injection
of 5 mg of recombinant tissue plasminogen activator (t-PA) as a loading dose followed
by 0.3 mg per hour. Enoxaparin and oral warfarin were started simultaneously and once
the target INR was reached, enoxaparin was stopped and warfarin continued indefinitely.
Ascites was well controlled with diuretics and large-volume paracentesis. A follow
up venogram showed partial recanalization of IVC and hepatic veins. A repeat CT scan
after 14 weeks showed complete resolution of the thrombus. After 28 months, she is
asymptomatic with normal liver function tests and total resolution of the ascites.
Conclusions: The data on local thrombolysis is limited and the agents and doses are not uniform
among reported cases. This case report shows that it can be considered in acute BCS
with partial obstruction, followed by angioplasty or TIPS if unsuccessful.
Key-words:
Subacute Budd-Chiari Syndrome - Thrombolysis - Liver - Venous disease
