Balloon cavoplasty in membranous obstruction of vena cava

Abstract

A hepatic venous outflow tract obstruction at any level is considered as Budd Chiari syndrome (BCS). Primary BCS is usually due to a congenital membrane causing the obstruction; referred to as membranous obstruction of vena Cava (MOVC). In the past MOVC was predominantly treated through surgery, percutaneous transluminal balloon angioplasty (PTBA) is an alternative and effective form of treatment. Case scenario of a 32-year-old gentleman presented himself with complaints of hematemesis for one year and hematochezia for three months. Hepatomegaly was noted. An ultrasonogram revealed a dilated IVC, till its hepatic portion, and also the Hepatic Veins. There was a fibrous membrane like structure of about 5 mm thickness that was obstructing the IVC flow. Patient was taken up for venogram for conformation of diagnosis and intervention. 6F NIH catheter was introduced from Femoral vein, an injection into the IVC showed contrast not flowing into right atrium and there was a membranous obstruction for the forward flow. A Brockenbrough’s trans-septal needle with Mullins Sheath was used to puncture the membrane and right atrium was entered. A 22 mm Inouye mitral valvuloplasty balloon (Single Balloon, Toray Medical, Tokyo) was taken and positioned at the membrane and inflated and deflated several times with incremental pressures till the waist of the balloon disappeared. Conclusion membranous obstruction of vena cava (MOVC) is a common cause of primary Budd Chiari syndrome. Percutaneous transluminal angioplasty using Inoue or mansfield balloon with or without stenting is a safe and effective treatment option.