Anticoagulation and Budd-Chiari syndrome

To the Editor,

We read with interest the article by Shukla and Bhatia [1] in a recent issue of the Journal. The authors found that 6 of their patients could not undergo the standard radiological procedures because of technical reasons; reasons for this technical failure were however, not provided. In our experience of adult patients, the TIPSS procedure is usually possible. Of 58 patients who underwent TIPSS, we faced technical difficulty in only one patient who had acute Budd-Chiari syndrome; the massive hepatomegaly caused an increase in distance between the IVC and narrowed portal vein (unpublished data). Technical difficulties usually arise in infants when the vein size is too small for stenting. In 14 children with Budd-Chiari syndrome, we could perform radiological intervention successfully in 11; the procedure failed due to small vessel size in 3 patients [2].

The authors found that those with more severe disease did not do well in the long term with anticoagulation alone. These are precisely the patients who benefit with radiological intervention [3]. We have successfully done TIPSS in a four-year-old child with Budd-Chiari syndrome who presented with fulminant liver failure [4].

The use of anti-coagulation alone in the treatment of Budd Chiari syndrome is a compromise rather than an alternative treatment.