conventional venoplasty of post - liver transplant inferior vena cava ( ivc ) stenoses is limited by a high primary treatment failure rate and problematic durability . while ivc
stenting may deliver a successful outcome after failed angioplasty , this approach , however , is not always suitable .
hepatic vein ostial coverage may not be desired , device migration may be a concern , and excessive risk for intra - stent stenosis may be perceived in specific cases , rendering definitive balloon dilation therapy as the lone possible minimally invasive treatment option . recognizing that single - session balloon venoplasty may not successfully and consistently address ivc stenoses , the percutaneous management approach of fibrotic , benign biliary strictures , namely , scheduled sequential balloon dilation sessions , may be adapted for the treatment of analogously scarred vascular lesions .
herein , we describe the case of a young patient with an initially angioplasty - resistant post - transplant ivc stenosis who was successfully treated with programmed successive balloon dilation , and highlight the utility of this approach in managing cases where stent insertion is undesirable .
institutional review board approval is not required for single retrospective case study at our institution . a 36-year - old woman with a history of autoimmune hepatitis and two prior orthotopic liver transplants in 1998 and 2008 (
the second transplant was performed due to rejection of the first graft ) presented 5 years after her most recent transplant with a chief complaint of progressive bilateral lower extremity edema and weight gain over the preceding 8 weeks . on physical examination ,
duplex ultrasonography and computed tomography ( ct ) imaging revealed a focal thrombus within the hepatic level ivc .
compression stockings and diuretic therapy provided minimal symptomatic relief , and the patient 's condition continued to worsen in terms of leg swelling despite initiation of therapeutic anticoagulation .
the patient was subsequently referred to interventional radiology ( ir ) for catheter - directed venous thrombolysis .
she received intra - thrombus , low - dose ( 0.5 mg / h ) tissue plasminogen activator ( tpa ) for 48 h , which resulted in complete clearance of the ivc clot , but revealed an underlying high - grade stenosis of the hepatic ivc at the level of the end - to - side transplant anastomosis just superior to the hepatic vein ostium [ figure 1 ] .
the lesion was dilated using a 10-mm balloon after thrombolysis termination , but recoil afforded no luminal caliber improvement .
the patient 's lower extremity edema thus persisted [ figure 2 ] despite systemic anticoagulation given for 2 months post - procedure .
the patient also developed a mild increase in her bilirubin ( 1.7 mg / dl ) and creatinine ( 1.5 mg / dl ) levels ; further intervention was thus clinically indicated .
her case was discussed among a multidisciplinary team comprising transplant surgeons , hepatologists , and interventional radiologists .
stenting of the lesion was considered , but was felt to be undesirable given the relative young age of the patient , which placed her at high lifetime risk of intra - stent stenosis and future recurrent complications , while the preference of the transplant surgeon to avoid impeding the hepatic vein ostium limited the choice of stent to shorter models with a concomitantly higher risk of migration .
36-year - old woman with a history of autoimmune hepatitis and two prior orthotopic liver transplants who presented 5 years after her most recent transplant with a chief complaint of progressive bilateral lower extremity edema and weight gain was diagnosed with transplant - related , initially angioplasty - resistant ivc stenosis .
inferior vena cavagram reveals high - grade stenosis of hepatic level ivc ( arrowhead ) , with 2 - 3 mm luminal caliber at this site .
36-year - old woman with a history of autoimmune hepatitis and two prior orthotopic liver transplants who presented 5 years after her most recent transplant with a chief complaint of progressive bilateral lower extremity edema and weight gain was diagnosed with transplant - related , initially angioplasty - resistant ivc stenosis .
sequential treatment sessions were scheduled at 2 - 3 week intervals . in general , the patient was positioned supine and her right neck prepared in standard sterile fashion .
the right internal jugular vein was localized with ultrasound , after which the overlying soft tissue was anesthetized with 2% lidocaine and the vessel accessed with a 21-gauge needle under real - time sonographic guidance .
the percutaneous access was then dilated to accept a 12-french vascular sheath , which was then advanced into the upper ivc . at the first treatment session
, angioplasty of the lesion was performed using a 10-mm balloon ( mustang ; boston scientific , natick , ma , usa ) with prolonged ( 2 - 3 min ) inflation .
, an 8-mm cutting balloon ( peripheral cutting balloon ; boston scientific ) and a 12-mm high - pressure balloon ( mustang ) were sequentially dilated at the site of the stenosis three times each , with the idea that the atherotomes would assist with disruption of fibrotic and scarred tissue , as in the case of benign anastomotic biliary strictures .
further angioplasty was then performed using a 16-mm balloon ( xxl vascular ; boston scientific ) with three inflations until the balloon waist was fully expanded , followed by prolonged inflation .
sequential dilation was performed using 14-mm ( xxl vascular ) , 16-mm ( xxl esophageal ; boston scientific ) , and 18-mm ( maxi ld ; cordis , bridgewater township , nj , usa ) balloons that were advanced to the stenosis and sequentially inflated twice each for 2 - 3 min per inflation .
each of the balloons reached its nominal diameter except for the 18-mm balloon , which had a small residual waist .
esophageal ) and 18-mm ( maxi ld ) balloons sequentially inflated twice each for 2 - 3 min per inflation .
upon completion of the sequential dilations , completion cavogram demonstrated an excellent response to treatment [ figure 3 ] .
36-year - old woman with a history of autoimmune hepatitis and two prior orthotopic liver transplants who presented 5 years after her most recent transplant with a chief complaint of progressive bilateral lower extremity edema and weight gain was diagnosed with transplant - related , initially angioplasty - resistant ivc stenosis .
inferior vena cavagram performed following multiple venoplasty sessions reveals excellent response to therapy , with luminal diameter enlargement to 10 - 11 mm ( arrowhead ) .
over the course of the next 3 - 4 weeks , the patient reported a fluid weight loss of approximately 90 pounds with concurrent reduction in her lower extremity edema [ figure 4 ] .
moreover , her serum creatinine value normalized from 1.5 mg / dl pre - procedure to 1.0 mg / dl post - procedure .
a low - level pre - procedure total bilirubin elevation also normalized ( from 1.7 to 0.9 mg / dl ) .
the patient had returned to her baseline level of functioning without recurrence of edema , and ct venography confirmed stable caliber of the previously dilated hepatic ivc segment .
future follow - up with clinical assessment and repeat ct venography at 6-month intervals was planned .
36-year - old woman with a history of autoimmune hepatitis and two prior orthotopic liver transplants who presented 5 years after her most recent transplant with a chief complaint of progressive bilateral lower extremity edema and weight gain was diagnosed with transplant - related , initially angioplasty - resistant ivc stenosis .
in this report , we described the case of a 36-year - old woman with a recalcitrant ivc stenosis related to liver transplantation . after failing to respond to initial balloon angioplasty , the patient underwent four additional sessions over the course of 2 months , ultimately achieving dramatic clinical improvement in conjunction with expansion of the caval lumen from 2 - 3 mm to 10 - 11 mm .
this case exemplifies the potential role of a programmed approach to balloon venoplasty employing multiple sessions and including use of a cutting balloon , similar to that used for benign biliary stricture dilation .
this method affords a more vigorous approach to treatment of the fibrotic neointimal hyperplasia of vascular anastomotic stenoses refractory to single - session therapy , while averting the need for stent deployment .
the small incremental gains in ivc luminal caliber achieved at each treatment session may have been deemed ineffective when taken on its own , but were markedly successful in enhancing ivc patency when taken together .
ideally , the sequential dilation approach will result in sustained clinical and angiographic response ; at minimum , it may be employed as a temporizing measure that does not preclude the possibility of subsequent stenting or increase the technical difficulty of future surgical intervention .
notably , however , ivc stenosis and/or hepatic veno - occlusive disease may increase the technical complexity of liver transplant surgery , and such circumstances may require arduous dissection requiring meticulous care , and may necessitate auxiliary or advanced vascular reconstructive maneuvers .
venous outflow obstruction is a rare complication of liver transplantation , with an incidence below 2% .
signs and symptoms of caval stenosis resemble those of budd  chiari syndrome : abdominal pain , lower extremity edema , ascites , and hepatic dysfunction .
obstruction occurring in the early postoperative period is typically the result of technical factors , whereas delayed presentation may be related to intimal hyperplasia , perivascular fibrosis , or extrinsic caval compression .
recently , immune - mediated processes have been shown to contribute to graft failure and development of hepatic venous outflow obstruction , suggesting a role for preventative immunosuppressive strategies .
data regarding post - transplant ivc obstruction , although limited to retrospective studies and case series , suggest that such lesions typically respond favorably to conventional percutaneous treatment . in a recent retrospective study , lorenz et al . , reported technical and clinical success rates of 96% and 88% , respectively , in 25 patients with ivc obstruction who underwent primary venoplasty with additional stent placement for refractory or recurrent stenosis .
in contrast , among the 17 patients stented for refractory or recurrent stenosis , the cumulative primary and primary assisted patency rates were 86% and 100% at 6 months and 7 years , respectively .
given the proven and long - lasting efficacy of stent placement , several authors have advocated this approach as first - line treatment .
stenting may increase the technical difficulty of future surgical interventions , while the risk of migration or fracture , though minor , must be considered . in the current report , stenting was deferred due to concern regarding the high likelihood of in - stent stenosis over the patient 's lifetime coupled with the need for a short stent with a high risk of migration .
serial balloon dilation was pursued as an alternative to re - transplantation , which is a resource - intensive procedure associated with mortality rates as high as 41.6% .
although long - term stricture recurrence may ensue in the reported patient , whose stenosis was felt to be most likely related to anastomotic perivascular fibrosis or intimal hyperplasia , long - term primary assisted patency may be nonetheless achieved ; the patient was thus enrolled in a clinical and imaging surveillance program to help identify any need for repeat balloon angioplasty intervention .
in summary , sequential balloon angioplasty may produce a favorable outcome in cases of initially angioplasty - resistant ivc obstruction .
although the report of a single case does not constitute evidence of efficacy , operators should not consider non - response to one session of balloon dilation a treatment failure , and may consider use of successive interventional procedures to achieve therapeutic success . as a final note ,
such a treatment plan warrants substantial patient cooperation , with an expectation for responsible follow - up for scheduled sessions .
 obstruction of the inferior vena cava ( ivc ) is a rare complication of liver transplantation with significant consequences including intractable ascites and hepatic dysfunction . 
 although venoplasty and stenting are effective in many cases , patients who fail first - line treatment may require surgical intervention or re - transplantation . 
 scheduled sequential balloon dilation , an approach frequently used to treat fibrotic , benign biliary strictures , but less commonly vascular lesions , may avert the need for such high - risk alternatives while achieving favorable clinical and angiographic response . 
 herein , we report the case of a 36-year - old woman with transplant - related , initially angioplasty - resistant ivc stenosis that was successfully treated with sequential balloon dilation . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION