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The diagnosis of pelvic congestion syndrome (PCS) continues to challenge all physicians involved especially those in such specialties as anesthesia, gastroenterology, general surgery, obstetrics and gynecology, and interventional radiology. When other pelvic pathology is ruled out, an interventional radiologist may be consulted for additional evaluation and treatment of PCS. A heightened awareness and clinical suspicion for the specific symptomatology and associated findings may bring about a more rapid progression toward treatment. For most interventional radiologists who treat PCS patients, magnetic resonance imaging/MR venography (MRI/MRV), diagnostic venogram, and embolotherapy are at the center of diagnosis and treatment of PCS.

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Repair of cholecystectomy-related bile duct injuries can run 4.5 to 26.0 times the cost of the uncomplicated procedure and carries a significant mortality rate. Intraoperative recognition of such an injury with immediate conversion to an open procedure for definitive repair can result in significant cost savings and relates directly to a decreased morbidity, mortality, length of hospitalization, and number of outpatient care days.

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ObjectiveTo assess the outcomes of current treatment strategies for Budd-Chiari syndrome. Summary Background DataBudd-Chiari syndrome, occlusion or obstruction of hepatic venous outflow, is a disease traditionally managed by portal or mesenteric-systemic shunting. The development of other treatment options, such as catheter-directed thrombolysis, transjugular portosystemic shunting (TIPS), and liver transplantation, has expanded the therapeutic algorithm. MethodsThe authors reviewed the medical records of all patients diagnosed with Budd-Chiari syndrome at the Johns Hopkins Hospital during the past 20 years. ResultsA total of 54 patients were identified: 13 (24%) male patients and 41 (76%) female patients, ranging in age from 2 to 76 years (median 33 years). Twenty-one (39%) had polycythemia vera, 3 (5.6%) used estrogens, 11 (20%) had a myeloproliferative or coagulation disorder, and in 7 (13%) the cause remained unknown. Forty-three patients were treated with surgical shunting, 24 mesocaval and 19 mesoatrial. Actuarial survival rates at 1, 3, and 5 years after shunting were 83%, 78%, and 75%, respectively. Of 33 patients surviving more than 4 years, 28 (85%) had relief of clinical symptoms. Five patients required shunt revision and eight had radiologic procedures to maintain shunt patency. Primary and secondary shunt patency rates were 46% and 69% respectively for mesoatrial shunts and 70% and 85% respectively for mesocaval shunts. Clot lysis was successful as primary treatment in seven patients. TIPS was performed in three patients, one after a failed mesocaval shunt. During an average of 4 years of follow-up, these patients required multiple procedures to maintain TIPS patency. Six patients underwent liver transplantation. Of these, three had previous shunt procedures. Five of the transplant recipients are alive with follow-up of 2 to 9 years (median 6). ConclusionsBoth shunting and transplantation can result in a 5-year survival rate of at least 75%, and other treatment modalities may be appropriate for highly selected patients. Optimal management requires that treatment be directed by the predominant clinical symptom (liver failure or portal hypertension) and anatomical considerations and be tempered by careful assessment of surgical risk.

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