Accessory hepatic vein recanalization for Budd-Chiari syndrome: a systematic review and meta-analysis.

BACKGROUND: Budd-Chiari syndrome (BCS) results when the outflow of the hepatic vein (HV) is obstructed. BCS patients exhibiting an accessory HV (AHV) that is dilated but obstructed can achieve significant alleviation of liver congestion after undergoing AHV recanalization. This meta-analysis was developed to explore the clinical efficacy of AHV recanalization in patients with BCS. MATERIALS AND METHODS: PubMed, Embase, and Wanfang databases were searched for relevant studies published as of November 2022, and RevMan 5.3 and Stata 12.0 were used for pooled endpoint analyses. RESULTS: Twelve total studies were identified for analysis. Pooled primary clinical success, re-stenosis, 1- and 5-year primary patency, 1- and 5-year secondary patency, 1-year overall survival (OS), and 5-year OS rates of patients in these studies following AHV recanalization were 96%, 17%, 91%, 75%, 98%, 91%, 97%, and 96%, respectively. Patients also exhibited a significant reduction in AHV pressure after recanalization relative to preoperative levels (P < 0.00001). Endpoints exhibiting significant heterogeneity among these studies included, AHV pressure (I2 = 95%), 1-year primary patency (I2 = 51.2%), and 5-year primary patency (I2 = 62.4%). Relative to HV recanalization, AHV recanalization was related to a lower rate of re-stenosis (P = 0.002) and longer primary patency (P < 0.00001), but was not associated with any improvements in clinical success (P = 0.88) or OS (P = 0.29) relative to HV recanalization. CONCLUSIONS: The present meta-analysis highlights AHV recanalization as an effective means of achieving positive long-term outcomes in patients affected by BCS, potentially achieving better long-term results than those associated with HV recanalization.

Percutaneous recanalization in hepatic vein-type Budd-Chiari syndrome: hepatic or accessory hepatic vein.

PURPOSE: This study was designed to assess the clinical efficiency and long-term outcomes of hepatic vein (HV) and accessory hepatic vein (AHV) recanalization in patients with HV-type Budd-Chiari syndrome (BCS). MATERIAL AND METHODS: A total of 27 patients with HV-type BCS underwent AHV recanalization and 94 patients had HV recanalization at our center from January 2012 to December 2019. The treatment effectiveness and long-term outcomes were compared. RESULTS: Technical success was accomplished in all patients, without any procedure-related complications. The clinical success rates were 96.3% (26/27) and 95.7% (90/94) (p = 1.000). In the AHV and HV groups, re-obstruction was observed in 5 and 36 patients, respectively (p = 0.056). The median primary durations of AHV and HV patency were 64 and 49 months, respectively (p = 0.036), while the median secondary durations of AHV and HV patency were 70 and 64 months, respectively (p = 0.134). The median overall survival after AHV and HV recanalization was 73 and 78 months, respectively (p = 0.263). CONCLUSIONS: Our findings suggest that AHV could be employed as a replacement for HV, as a hepatic drainage vein, in HV-type BCS patients.

A Hepatectomy Based on a Hybrid Concept of Portal Perfusion of Anterior Segment and Venous Drainage Area of Superior Right Hepatic Vein.

BACKGROUND: Right hepatic vein sometimes could not be a reliable landmark between the anterior and posterior segment. The aim of this study was to clarify the portal perfusion area of the anterior segment and to propose a less invasive hepatectomy based on both the portal perfusion and the hepatic venous drainage. METHODS: Three-dimensional computerized tomography images of 66 patients were constructed. A case, in which the perfusion area of the anterior segment crossed over superior right hepatic vein (SRHV), was called as SRHV-inclusion. It was defined as inclusion of more than 1 cm of the proximal site of SRHV surrounded by the portal perfusion area of the anterior segment. RESULTS: SRHV-inclusion was observed in 26%. The cases with large inferior right hepatic vein (IRHV) had more frequent SRHV-inclusion (47%). The elderly patient with hepatic disorder, who had hepatocellular carcinoma near the root of the SRHV, underwent a less invasive hepatectomy (anterior segment + SRHV drainage area) resulting in the preservation of the IRHV. CONCLUSIONS: The perfusion area of the anterior segment crossed over SRHV in one fourth of patients in the study. Our proposed less invasive hepatectomy based on a hybrid concept might be an alternative operative procedure other than right hepatectomy.

Comparative anatomo-radiological study of intrahepatic venous vascularization in the Spain.

BACKGROUND: Anatomic variations in the hepatic venous system are the least understood aspect of hepatic anatomy. The variations are diverse, and data are lacking with respect to the population of Spain and methods of detection. The objective was to examine morphological patterns of variations in hepatic venous vascularization using cadaveric dissections vs. radiological imaging, and to analyze the findings with respect to Spain and to published studies. METHODS: Thirty-one livers were anatomically dissected and analyzed for their hepatic venous anatomy and then compared to the venous anatomy of livers examined in 216 CT scans from 119 men and 97 women, ranging between 27 and 89 years of age. Statistical analysis was done using the Chi squared and Fisher homogeneity tests. RESULTS: The hepatic portal vein showed morphological variations in cadavers vs. CT of 67.3% vs. 67.6% (p-I), 29% vs. 12.2% (p-II), 0% vs. 14.6% (p-III), 0% vs. 14.6% (p-IV), 3.2% vs. 0.5% (p-V) and 6.5% vs. 1.9% (p-VI), respectively in cadavers vs. CT. Hepatic vein pattern variation were found in 64.5% vs. 50.7% (h-I), 32.2% vs. 31.5% (h-II), 0% vs. 2.3% (h-III), 0% vs. 4.7% (h-IV), respectively in dissections vs. CT). In Accessory Hepatic Veins the frequency in pattern variation was 64.5% vs. 18.8% (a-2.1), 29.0% vs. 8.0% (a-2.2), 58.1% vs. 11.3% (a-2.3), 9.7% vs. 0.9% (a-2.4), 67.7% vs. 16.9% (a-2.5), 9.7% vs. 4.2% (a-2.6) and 0% vs. 0.5% (a-2.7), respectively, in cadavers vs. CT. CT showed in 27.2% no accessory hepatic veins. Sex was not a factor influencing patterns of variation. CONCLUSION: Anatomical variants of the hepatic portal vein, the hepatic vein and accessory hepatic veins are very diverse and show greater variability in the specimens compared to those detected with radiological images, finding a wider spectrum of variations as it allows the clinician to have a more precise definition of the vasculature. A higher precision in the definition of anatomical variations is warranted for surgical planning in liver resection and transplantation.

Accessory hepatic vein recanalization for hepatic vein-type Budd-Chiari syndrome.

PURPOSE: To explore the clinical efficacy and long-term outcomes of accessory hepatic vein (AHV) recanalization as a means of treating hepatic vein (HV)-type Budd-Chiari syndrome (BCS). METHODS: Between January 2011 and December 2018, a total of 46 symptomatic HV-type BCS patients were treated by AHV recanalization in our hospital. The technical and clinical success of this treatment, as well as associated long-term patient prognosis was assessed herein. RESULTS: The AHV recanalization approach was technically successful in 100% of patients, without any instances of complications associated with the operation. This procedure was 95.7% (44/46) clinically successful and resultant. AHV re-obstruction occurred in 12 patients. The cumulative primary one-, two-, and five-year patency rates were 77.3%, 71.7%, and 71.7%, respectively. The secondary cumulative one-, two-, and five-year patency rates were 97.7, 87.1, and 87.1%, respectively. The five-year patency rates did not differ significantly between patients treated with balloons and stents (p = .674). Based on Cox-regression analysis, younger age was an independent predictor of re-obstruction (p = .005). The cumulative one-, two-, and five-year survival rates were 97.7, 92.2, and 92.2%, respectively. CONCLUSIONS: AHV recanalization is a safe and effective treatment for HV-type BCS.

Endovascular treatment for hepatic vein-type Budd-Chiari syndrome: effectiveness and long-term outcome.

PURPOSE: To determine the clinical effectiveness and long-term outcomes of endovascular treatment for hepatic vein (HV)-type Budd-Chiari syndrome (BCS). MATERIALS AND METHODS: From June 2011 to August 2016, 68 consecutive patients with symptomatic HV-type BCS underwent endovascular treatment in our center. Data on the baseline characteristics, technical success, clinical success, and long-term outcomes were collected and analyzed retrospectively. RESULTS: The technical success rate of endovascular treatment was 100%. Fifty patients underwent HV recanalization, and 18 underwent accessory HV (AHV) recanalization. The clinical success rate was 95.6% (65/68). During a mean follow-up period of 29.4 ± 13.6 months, 19 patients experienced re-obstruction of either the HV (n = 18) or the AHV (n = 1). The cumulative 1-, 2-, and 5-year primary patency rates were 80.0, 72.8, and 67.9%, respectively. The cumulative 1-, 2-, and 5-year secondary patency rates were 93.8, 90.3, and 82.9%, respectively. Univariate and multivariate analyses revealed that the independent predictor of a prolonged primary patency duration was recanalization of the AHV. Five patients died 1-28 months (median, 15 months) after treatment. The cumulative 1-, 2-, and 5-year survival rates were 96.9, 93.4, and 91.2%, respectively. There was no significant difference in survival between the HV and AHV recanalization groups. CONCLUSION: Endovascular treatment is effective for patients with HV-type BCS. It can result in excellent long-term patency and survival rates. If it is applicable, AHV recanalization should be considered prior to treatment in order to achieve a longer patency.

Variant Anatomy of the Hepatic Vasculature: Importance in Hepatobiliary Resections.

A variant anatomy of the hepatic vasculature has a clinically significant role in hepatobiliary transplantation, resection, tumour embolisation as well as in extrahepatic abdominal surgeries involving the stomach, pancreas or gall bladder. During routine cadaveric dissection, we observed a case of unusually small calibre hepatic artery proper. An accessory hepatic artery was seen emerging from the superior mesenteric artery to the right hepatic lobe along with an accessory hepatic vein from the right hepatic lobe that drained directly into the inferior vena cava. Such accessory hepatic vessels complicate and necessitate an alteration of surgical methodology during resection of hepatic lobes. Preoperative knowledge of variant hepatic vasculature is crucial for minimising the iatrogenic injury and facilitating successful abdominal surgeries.

Predicting the presence of an accessory hepatic vein using abdominal computed tomography / Predicción de la presencia de una vena hepática accesoria mediante tomografía computarizada abdominal

The incidence of detection of accessory hepatic vein (AHV) using MRI or CT has been reported. However, previous studies had a small sample size or only reported on the incidence of hepatic vein variants. To the best of our knowledge, there has been no previous report evaluating the factors predictive of the presence of an AHV. To evaluate the incidence and morphology of the accessory hepatic vein (AHV) using multidetector row computed tomography (MDCT) and to investigate the factors which may be helpful in predicting the presence of an AHV. We enrolled 360 patients who underwent abdominal MDCT. We investigated whether the AHV was present and evaluated the frequency of AHVs greater than 5 mm in diameter. We classified the morphology of the AHV entering the inferior vena cava (IVC). We also examined the factors that predicted the presence of an AHV by comparing the diameter of the middle hepatic vein (MHV) and the right hepatic vein (RHV). We identified an AHV in 164 of the 360 patients (45.6 %). Among the 164 AHVs, 56.7 % were larger than 5 mm in diameter. The most common morphologies of the inferior RHV were a single main trunk (58.5 %), followed by two main trunks with a V-shape (19.5 %) and two trunks entering the IVC separately (17.0 %). The possibility that an AHV will be present was significantly higher when the diameter of the RHV was smaller than that of the MHV. MDCT can provide important information regarding AHV incidence and morphology. The possibility of an AHV being present was significantly higher when the diameter of the RHV was smaller than that of the MHV.

Se ha informado de la incidencia de la detección de la vena hepática accesoria (VHA) mediante RM o TC. Sin embargo, estudios previos tenían un tamaño muestral pequeño o solo informaban sobre la incidencia de variantes de las venas hepáticas. Hasta donde sabemos, no ha habido ningún informe previo que evalúe los factores predictivos de la presencia de una VHA. El objetivo del estudio fue evaluar la incidencia y morfología de la vena hepática accesoria (VHA) mediante tomografía computarizada multidetector (TCMD) e investigar los factores que pueden ser útiles para predecir la presencia de un VHA. Se evaluaron 360 pacientes que se sometieron a TCMD abdominal. Se investigó si la VHA estaba presente y se evaluó la frecuencia de VHA mayores de 5 mm de diámetro. Se clasificó la morfología del VHA que drenaba en la vena cava inferior (VCI). Además, se examinaron los factores que predijeron la presencia de una VHA mediante la comparación del diámetro de la vena hepática media (VHM) y la vena hepática derecha (VHD). Se identificó un VHA en 164 de los 360 pacientes (45,6%). Entre las 164 VHA, el 56,7% tenía más de 5 mm de diámetro. Las morfologías más frecuentes del VHD inferior fueron un tronco principal único (58,5%), seguido por dos troncos principales con forma de V (19,5%) y dos troncos que drenaban en la VCI por separado (17,0%). La posibilidad de que una VHA esté presente fue significativamente mayor cuando el diámetro de la VHD era menor que la de la VHM. La MDCT puede proporcionar información importante sobre la incidencia de la VHA y su morfología. La posibilidad de que un VHA estuviera presente era significativamente mayor cuando el diámetro del VHD era menor que la VHM.

Comparison of 3.0T MRI with 3D LAVA sequence and digital subtraction angiography for the assessment of accessory hepatic veins in Budd-Chiari syndrome.

PURPOSE: To compare 3D liver acceleration volume acquisition (LAVA) and digital subtraction angiography (DSA) for evaluating the presence of accessory hepatic veins (AHV) in Budd-Chiari syndrome (BCS). MATERIALS AND METHODS: This was a retrospective study in 228 patients with BCS who underwent 3.0T magnetic resonance imaging (MRI) with the 3D LAVA sequence. Two reviewers noted AHV: openings located in the inferior vena cava (IVC), caliber, and the angle of entering into the IVC. MRI results were compared to DSA. Kappa statistics were calculated to quantify intrareader variability in detecting AHVs. RESULTS: On MRI, 63 patients demonstrated no AHV on LAVA images, 70 had one AHV, 62 had two AHVs, 26 patients had three AHVs, six patients had four AHVs, and one patient had five AHVs (P < 0.05 vs. DSA). The mean caliber of the AHVs was 8.3 ± 4.0 mm compared to 9.9 ± 3.2 for DSA (P < 0.001). Among the 301 AHVs, there were 140 with acute angles (46.5%), 71 with right angles (23.6%), and 90 with obtuse angles (29.8%). The prevalence of AHVs on DSA was 54.8% (125/228), while MRI demonstrated 301 AHVs in 165 patients, for a prevalence of 72.4% (165/228) compared to 54.8% for DSA (P = 0.001). The two methods were concordant in only 116/228 (50.9%) patients. The kappa coefficient demonstrated good intrareader consistency for all documented MRI findings of AHVs (κ = 0.626 for caliber and κ = 0.65 for angles). CONCLUSION: More AHVs were visible on MRI LAVA sequences than on conventional DSA. LEVEL OF EVIDENCE: 4 J. Magn. Reson. Imaging 2017;45:401-409.

Accessory hepatic vein stenting to treat primary Budd-Chiari syndrome / 中华肝胆外科杂志

Objective To study the safety and efficacy of accessory hepatic vein (AHV) stenting to treat primary Budd-Chiari syndrome (BCS).Methods The clinical data of 20 BCS patients with AHV ostial stenosis or occlusion were retrospectively analyzed.These 20 patients underwent balloon dilation and AHV stenting.Thirteen patients underwent AHV stenting via the right jugular vein approach,5 patients via the right femoral vein approach,and 2 patients via the percutaneous transhepatic combined with the right femoral vein approach.On follow-up,patency of the AHV stent was evaluated by color Doppler ultrasound.The cumulative primary and secondary patency rates were assessed with the Kaplan-Meier curves.Results AHV stenting was successful in 20 patients.Angiography showed that the AHV was patent after stenting.The mean pressure gradient between the AHV and the inferior vena cava reduced from (19.2 ± 4.8) cmH2O (1 cmH2O =0.098 kPa) before treatment to (4.5 ± 1.9) cmH2O after treatment (t =7.119,P ＜ 0.01).During the procedure,rupture of the AHV caused by balloon dilation occurred in one patient.This was treated successfully by a covered stent placement.On follow-up from 1 to 80 months [(32.1 ±27.4) months]after treatment for the 20 patients,re-stenosis of the AHV were found in 5 patients.They were treated successfully with re-dilation.The cumulative 1-,3-,and 5-year primary patency rates were 100％,85.1％ and 74.5％,respectively.The cumulative 1-,3-,and 5-year secondary patency rates were 100％,90.9％ and 90.9％,respectively.One patient died of hepatic failure 3 years after the treatment.Conclusion AHV stenting was a safe and efficacious treatment for BCS and it provided good mid-and long-term results.

Evaluation of Numerical and Positional Variations of the Hepatic Veins: A Cadaveric Study.

INTRODUCTION: Hepatic veins are the major linking vessels between systemic and portal circulation. Numerical and positional variation of the hepatic veins can play a significant role during surgical interventions on the liver. MATERIALS AND METHODS: Gross anatomical study regarding the number and arrangement pattern of hepatic veins was undertaken on 88 adult livers which were stored in 10% formalin after the regular dissection classes. RESULT: Six livers (7%) were found to be drained only by major hepatic veins, whereas 82 out of 88 livers (93%) had accessory (minor) hepatic veins. The total number of persistent hepatic veins ranged from 2 to 10 with the highest prevalence of four hepatic veins (35.2%) followed by 5 (19.3%) and 6 (17%). The presence of three major veins was seen in 45 (51%) livers while 41 (47%) livers had two major hepatic veins. Remaining two livers (2%) showed the presence of four major hepatic veins. In 95% specimens, the minor hepatic veins entered the inferior vena cava below the level of entry of major veins. In 2.5% cases, their entry point was above the major veins and in 2.5% cases, the entry point was below major veins. CONCLUSION: The data resulting from this study provides a clear idea about the number and drainage pattern of the hepatic veins into the liver. Knowledge of numerical and positional variations of hepatic veins could be useful in normal Doppler ultrasound hepatic vein flow velocities and their variation with respiration in healthy adults as comparable with the similar approach of superior vena cava.

Use of Accessory Hepatic Vein Intervention in the Treatment of Budd-Chiari Syndrome.

PURPOSE: To evaluate the clinical value of accessory hepatic vein (AHV) intervention in the treatment of Budd-Chiari syndrome (BCS). PATIENTS AND METHODS: From August 2008 to July 2014, consecutive patients with BCS caused by obstruction of three hepatic veins (HVs) with or without obstruction of inferior vena cava (IVC) were treated by recanalization or transjugular intrahepatic portosystemic shunt in our center. Patients who had the compensatory AHV and successfully underwent recanalization of AHV outflow were enrolled in this retrospective study. The clinical response to AHV drainage was analyzed. RESULTS: Compensatory AHV was found in 69 of 97 (71.1%) patients, and 66 patients successfully underwent recanalization of AHV outflow (IVC recanalization, n = 49; AHV recanalization, n = 15; both, n = 2). In total, 78 AHVs were used instead of HV as the hepatic drainage vein after treatment. Fifty-five patients had one AHV, 10 patients had two AHVs, and 1 patient had three AHVs. The average diameter of all AHV stems was 8.0 ± 2.6 mm (range 5-21 mm). Clinical response to AHV drainage was positive in all patients. Patients' symptoms and liver function improved progressively after treatment. During the follow-up of 3-74 months (average 39.4 ± 11.0 months), 11 patients experienced reobstruction at 6 to 36 months (average 16.8 ± 9.8 months) after treatment. CONCLUSION: Compensatory AHV can be effectively used instead of HV for drainage of hepatic blood in patients with BCS. AHV intervention can help to simplify the BCS treatment procedure.

Significance of an accessory hepatic vein in the interventional treatment of Budd-Chiari syndrome / 中华肝胆外科杂志

Objective To investigate the significance of an accessory hepatic vein (AHV) in the interventional treatment of Budd-Chiari syndrome (BCS).Methods From Mar.2011 to Jun.2013,35 patients with BCS who also had an AHV were included into this study.The patients were divided into two groups according to whether the AHV was obstructive:21 patients had obstruction to the inferior vena cava (IVC) and to the 3 hepatic veins (HV),but the AHV was open; 14 patients had obstruction to the AHV and the 3 HVs.In 13 of these patients the IVC was open,but 1 patient had obstruction to the IVC.During treatment,the patients in the AHV open group underwent balloon dilation or stent insertion of IVC ; patients in the AHV obstruction group underwent balloon dilation or stent insertion of AHV.The patient with obstruction to the IVC underwent balloon dilation of IVC first.Results All patients were successfully treated without any procedure-related complications.In the AHV open group,the average pressure of the AHV decreased from (28.81 ± 6.23) cmH2 O (1 cmH2O =0.098 kPa) before treatment to (18.62 ± 5.06) cmH2O after treatment (P ＜ 0.01) ; the average serum TBIL decreased from (23.24 ± 6.41) μmol/L before treatment to (19.52 ± 4.31) μmol/L after treatment (P ＜ 0.01) ; the average serum albumin changed from (33.76 ± 3.74) g/L before treatment to (34.05 ± 3.62) g/L after treatment (P =0.485).In the AHV obstruction group,the average pressure of the AHV decreased from (36.29 ± 11.65) cmH2O before treatment to (22.07 ± 7.67) cmH2O after treatment (P ＜ 0.01) ; the average serum TBIL decreased from (31.24 ± 9.54) μmol/L before treatment to (20.93 ±7.26) μmol/L after treatment (P ＜0.01) ; the average serum albumin changed from (32.14 ± 4.55) g/L before treatment to (32.11 ± 4.47) g/L after treatment (P =0.861).During follow-up,no patients experienced recurrence of symptoms in the AHV open group; one patient experienced recurrence of symptoms 5 months after treatment in the AHV obstruction group.This patient received a second balloon dilation of the AHV.Conclusions For patients with BCS with IVC and the 3 HVs obstruction,if the AHV was open,we could only treat the IVC.For patients with BCS with AHV and the 3 HVs obstruction,AHV dilation followed by recanalization of AHV was also effective.