Budd-Chiari Syndrome Transplant, Meso-Atrial Shunt or Combined Portocaval Shunt With Cavo-Atrial Shunt

apy for esophageal varices in men with alcoholic liver disease: a randomized, single blind, multicenter clinical trial. New Engl.apy for esophageal varices: long-term results of a single center trial. cirrhotics selected by endoscopic criteria a multicenter randomized controlled trial. (1992) Treatment of Budd-Chiari syndrome due to inferior oena caoa occlusion by combined portal and oena caval decompression. This study concerns Budd-Chiari syndrome (BCS) caused by occlusion of the subdiaphragmatic inferior vena cava (IVC). It describes the experimental and clinical evaluation of the treatment of this disorder by one-stage combined portal and vena caval decompression with a direct side-to-side portacaval shunt (PCS) and a caval-atrial shunt (CAS) graft. BCS was produced in rats by gradual occlusion of the suprahepatic IVC with an ameroid constrictor. When ascites and portal hyperten-sion were established, 12 control rats survived a sham thoracolaparotomy, 16 rats survived a mesoatrial shunt, and 16 rats survived combined PCS and CAS graft. All control rats reformed ascites and died within 2 months. Nine of 16 rats with mesoatrial shunt developed graft thrombosis, reformed ascites, and died within 2 months. In contrast, only 2 of 16 rats that underwent combined PCS and CAS developed graft thrombosis, reformed ascites, and died. Liver biopsies showed reversal of severe pathologic changes in rats with patent grafts. Clinical evaluation of combined PCS and CAS using a 20-mm ring-reinforced Gore-Tex graft has been undertaken in five patients with BCS and ascites, hepatosplenomegaly, intense hepatic congestion on biopsy, and angiography showing occlusion of both the IVC and hepatic veins. All five patients were alive and well 6 months to 7.5 years postoperatively with patent grafts, no ascites or need for diuretics, no encephalo-pathy, normal liver function, and reversal of liver pathology. It is concluded that combined PCS and CAS create a high-flow shunt that decompresses both the portal system and IVC, has a low incidence of graft thrombosis, has been consistently effective in relieving BCS caused by IVC occlusion, and appears to be superior to mesoatrial shunt.