Simultaneous IVC/SVC Endovascular Sharp Recanalization in A Patient with Budd-Chiari Syndrome, Systemic Lupus Erythematosus and Antiphospholipid Syndrome, A Case Report

Abstract: Background: Budd‐Chiari syndrome (BCS) is a rare life-threatening condition and is caused by an obstruction to the hepatic venous outflow. We herein report a case of BCS complicated with inferior vena cava (IVC) and superior vena cava (SVC) stenosis that was managed by a simultaneous IVC/SVC sharp recanalization. Case presentation: A forty-year-old lady came to the clinic complaining of distended abdomen. She is a known case of antiphospholipid syndrome and systemic lupus erythematosus. Triphasic liver computed tomography showed a heterogeneous liver with nutmeg appearance and attenuation of hepatic veins with caudate hypertrophy. There was a severe dilatation of the azygos and hemiazygos veins with multiple posterior mediastinal and retrocrural tortuous collaterals recanalizing the IVC distally. Contrast enhanced CT of the chest showed a chronic complete occlusion of the left brachiocephalic vein with enlargement of the left superior intercostal vein, hemiazygos, and azygos veins. SVC was patent with multiple calcific foci of the wall likely related to chronic thrombosis. Through the right femoral access, inferior venacavogram was obtained, which showed suprahepatic IVC complete occlusion. Then, an upper venous access was obtained through the right internal jugular vein.  Followed by a venogram which showed a complete occlusion at the right brachiocephalic vein with extensive collaterals were noted. Sharp recanalization from the jugular access of the brachiocephalic vein/SVC was performed targeting the balloon within the SVC that was advanced from the azygos vein, which followed by placing a covered stent graft. Then Multiple balloon angioplasties were made at the level of suprahepatic IVC followed by placing a non-covered stent. Conclusion: It was a Successful recanalization for the completely occluded suprahepatic IVC and placement of IVC stent, and a Successful recanalization for the completely occluded right brachiocephalic vein and placement of a stent.