Australasian Radiology (2005) 49, 140–143 Case Report Case Report Transjugular intrahepatic cavoportal shunt for Budd–Chiari syndrome T ul Haq, K Munir, Z Haider, J Yaqoob and U Usman Department of Radiology, The Aga Khan University Hospital, Karachi, Pakistan SUMMARY Budd–Chiari syndrome (BCS) is characterized by obstruction of the hepatic venous outflow tract. Therapeutic options for BCS are limited. We report a case of a 21-year-old woman with protein S and C deficiency with gross ascites. Treatment with transjugular intrahepatic portosystemic shunt (TIPS) was attempted, which revealed occluded hepatic veins, so transcaval TIPS was performed. No serious procedure-related complication occurred. After successful shunt creation, the patient’s symptoms subsided and she was discharged and followed up for 6 months. Key words: Budd–Chiari syndrome; interventional procedures; portal; portosystemic; shunts. INTRODUCTION Budd–Chiari syndrome (BCS) is a rare cause of portal hypertension that results from thrombotic or non-thrombotic occlusion of small or large hepatic veins, or of the hepatic or suprahepatic inferior vena cava (IVC). It leads to hepatic centri- lobular congestion and necrosis. 1,2 Budd–Chiari syndrome manifests itself in acute and chronic forms. Several medical, surgical, and interventional therapeutic options have been reported for both forms. Especially in chronic BCS, treatment comprising portal decompression is often difficult due to advanced chronic liver disease with features of portal hypertension. It has been reported that transjugular intrahepatic porto- systemic shunt (TIPS) is a useful procedure in the treatment of patients with uncontrolled variceal haemorrhage or intract- able abdominal ascites resulting from portal hypertension. 3 It is an interventional procedure leading to decompression of the splanchnic venous system in patients with portal hypertension by creating a low-resistance channel between an intrahepatic branch of the portal vein and a main hepatic vein. Although it has gained wide acceptance for the management of portal hypertension, a number of major problems such as an increased risk of hepatic encephalopathy and a high rate of shunt dysfunction have been associated with the technique. 4–7 Typically in TIPS, there is placement of a shunt between a hepatic vein and a portal vein. But when the hepatic vein is thrombosed or cannot be catheterized or is too small to create a new shunt, a direct shunt between the retrohepatic IVC and the portal vein can be safely performed. We report a case of BCS in which hepatic veins were thrombosed and could not be cannulated, and thus TIPS was carried out by the transcaval approach. CASE REPORT A 21-year-old woman was referred to The Aga Khan University Hospital with a 2-month history of abdominal distension, nausea and vomiting. She had delivered a baby girl 3 months previously. On examination, the patient had marked ascites and hepatomegaly. At that time, her liver profile showed elevation of SGPT (152 IU/L), SGOT (92 IU/L), GGT (53 IU/L), and total bilirubin (2.4 mg/L). Ultrasound examination of the abdomen revealed an enlarged liver, especially the caudate lobe, and gross ascites. T ul Haq MB BS, MCPS, FCPS, FRCR (UK); K Munir MB BS, MCPS, FCPS; Z Haider MB BS, MCPS, FCPS; J Yaqoob MB BS, MCPS, FCPS; U Usman MB BS, MCPS, FCPS. Correspondence: Dr Zishan Haider, Department of Radiology, The Aga Khan University Hospital, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan. Email: zishan110pk@msn.com Submitted 9 September 2003; resubmitted 17 May 2004; accepted 16 June 2004.