Safety and Efficacy of Steerable Sheath-Assisted AngioJet Thrombectomy for Budd-Chiari Syndrome Complicated by Inferior Vena Cava Thrombosis

Safety and Efficacy of Steerable Sheath-Assisted AngioJet Thrombectomy for Budd-Chiari Syndrome Complicated by Inferior Vena Cava Thrombosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Safety and Efficacy of Steerable Sheath-Assisted AngioJet Thrombectomy for Budd-Chiari Syndrome Complicated by Inferior Vena Cava Thrombosis Gaopo Cai, Yanhua Dong, Nanyi Zhou, Shirui Liu, Zhaohui Hua, Zhen Li, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8712007/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective To evaluate the safety and efficacy of the steerable sheath combined with the AngioJet thrombectomy system in patients with Budd–Chiari syndrome (BCS) complicated by inferior vena cava thrombosis (IVCT). Methods We retrospectively reviewed 32 patients treated from January 2020 to August 2024. All patients presented with symptomatic BCS and IVC obstruction with concomitant thrombosis. Mechanical thrombectomy was performed using the AngioJet system delivered via a steerable sheath to maximize vessel wall apposition. This was followed by a standardized “staged balloon angioplasty” protocol. Patients were followed for 7–24 months. Results Technical success was 100%. Immediate IVC recanalization was obtained in 93.8% of patients, with Grade III thrombus clearance (> 90%) achieved in 90.6%. No pulmonary embolism or severe renal injury occurred. Perioperative survival was 100.0%. During a median follow-up of 22.0 months, the cumulative primary patency rate at 24 months was 80.1%. Five patients (15.6%) developed restenosis or occlusion during surveillance. All underwent re-intervention (balloon angioplasty, n = 3; stenting, n = 2). While one patient experienced recurrent occlusion, definitive patency was restored in the remaining four, resulting in a secondary patency rate of 95.8% at 24 months. Conclusion The use of a steerable sheath-assisted AngioJet thrombectomy is safe and effective for BCS with IVCT, yielding high thrombus clearance and satisfactory mid-term patency rates. Budd-Chiari Syndrome Inferior vena cava thrombosis AngioJet Steerable Sheath Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Budd–Chiari syndrome (BCS) is a disorder characterized by hepatic venous outflow tract obstruction, leading to post-hepatic portal hypertension. While hepatic vein thrombosis associated with myeloproliferative neoplasms predominates in Western populations, membranous or segmental obstruction of the inferior vena cava (IVC) is the leading etiology in Asian countries, particularly in the Yellow River and Huai River basins of China[ 1 , 2 ]. The distinct prevalence in these regions is hypothesized to be linked to dietary factors, water hygiene, and specific genetic susceptibilities that induce endothelial injury and subsequent membrane formation[ 2 ]. Inferior vena cava thrombosis (IVCT) represents a critical complication affecting 5–20% of patients with BCS, particularly within Asian populations where membranous or segmental obstruction predominates[ 3 – 5 ]. The pathogenesis is driven by a localized Virchow’s triad: severe venous stasis within the high-pressure segment inferior to the obstruction, turbulent hemodynamics, and secondary hypercoagulability. Clinically, the superimposed thrombosis aggravates venous hypertension, manifesting as exacerbated lower-limb edema, extensive thoracoabdominal collateral formation, and signs of chronic venous insufficiency. Furthermore, proximal propagation of the thrombus may compromise renal vein outflow, precipitating renal dysfunction, while occlusion of the hepatic vein ostia can lead to refractory ascites and rapid hepatic decompensation[ 2 , 6 , 7 ]. Current therapeutic strategies for BCS complicated by IVCT encompass a spectrum of interventions, from systemic anticoagulation and thrombolysis to endovascular recanalization and surgical shunting[ 7 – 10 ]. While anticoagulation is foundational, it is often insufficient for rapid resolution of bulky or organized thrombi. Percutaneous transluminal angioplasty (PTA) effectively relieves hemodynamic obstruction; however, balloon dilation alone in the presence of a heavy thrombus burden carries a significant risk of lethal pulmonary embolism (PE) due to mechanical dislodgement. Furthermore, even when mechanical thrombectomy is attempted, the anatomical dimensions of the IVC present a significant challenge. As the IVC is a large-diameter vessel, conventional straight thrombectomy catheters tend to "tunnel" through the thrombus center, failing to contact the vessel wall for complete clearance. Surgical shunting and liver transplantation are associated with high perioperative morbidity and are largely restricted to refractory cases[ 9 ]. Consequently, there is a critical need for endovascular strategies that accommodate the large IVC caliber to achieve efficient clearance while minimizing distal embolization risks. The combination of catheter-directed aspiration and staged balloon dilation offers theoretical advantages for IVCT in BCS by facilitating rapid debulking and minimizing thrombolytic dosage[ 11 , 12 ]. While the AngioJet rheolytic thrombectomy system is well-established, its efficacy in the large IVC is frequently limited by the inability of standard catheters to maintain consistent wall contact. The incorporation of a steerable sheath addresses this limitation, allowing the operator to actively manipulate the AngioJet catheter to match the IVC's anatomy and perform a circumferential "sweeping" motion. Despite these advantages, clinical data evaluating the long-term safety and patency of this technique in BCS patients remain scarce. Therefore, we conducted this single-center retrospective study to evaluate the technical success, complication profile, and mid-term outcomes of steerable sheath–assisted AngioJet thrombectomy followed by staged angioplasty. Materials and Methods 1.1 Study Population This single-center retrospective study was approved by the Ethics Committee of the First Affiliated Hospital of Zhengzhou University (Approval No. 2025-KY-0634-001). We reviewed clinical data from 32 patients with BCS complicated by IVCT admitted between January 2020 and August 2024. Inclusion criteria: (1) Confirmed diagnosis of BCS with imaging evidence of IVC obstruction and thrombus formation; (2) Age 18–80 years; (3) Presence of symptomatic disease (e.g., abdominal distension, ascites, lower-limb edema/ulceration, varices); (4) No prior BCS-related interventions; (5) Written informed consent provided. Exclusion criteria: (1) Severe cardiac, pulmonary, hepatic, or renal dysfunction precluding intervention; (2) Active bleeding or severe coagulopathy (INR > 2.0, platelets < 30×10⁹/L); (3) Allergy to contrast media or thrombolytic agents; (4) Pregnancy or lactation; (5) Recent intracranial or gastrointestinal hemorrhage (< 1 month). 1.2 Thrombus Staging and Definitions IVC thrombosis staging was determined by integrating clinical symptom duration with morphological characteristics on imaging, following the consensus standards of the Society of Interventional Radiology[13, 14]. Thrombosis was categorized into three stages: acute (≤ 14 days), subacute (15–28 days), and chronic (> 28 days). Given the often insidious onset of BCS, radiological findings served as critical corroborative factors for staging. Acute stage: Characterized by venous distension with a hypodense (CT) or hypoechoic (US) filling defect, and the absence of significant collateral circulation. Chronic stage: Defined by vessel retraction or collapse, thrombus calcification, and the presence of extensive collateral networks. Subacute stage: Exhibited intermediate features between the acute and chronic phases (Fig. 1). 1.3 Baseline Characteristics The mean patient age was 60.2 ± 8.5 years (range, 45–75 years), comprising 18 men and 14 women. All patients presented with clinical manifestations of portal hypertension or venous obstruction. Duplex ultrasonography or CT venography confirmed partial or complete IVC obstruction with concomitant thrombus in all cases. Baseline characteristics are summarized in Table 1. 1.4 Endovascular Procedure 1.4.1 Preoperative Preparation Patients underwent comprehensive evaluation, including coagulation profiles and liver/renal function tests. Imaging defined thrombus extent and IVC anatomy. Low-molecular-weight heparin (LMWH) was initiated preoperatively. 1.4.2 Operative Technique Venous access Under local anesthesia, access was obtained via the right common femoral vein (5-Fr sheath). IVC venography was performed to assess thrombus burden and collateral flow. For complete ostial occlusion, dual access via the right internal jugular and femoral veins was established. Mechanical Thrombectomy Mechanical thrombectomy was performed using the AngioJet™ ZelanteDVT™ catheter (Boston Scientific, Marlborough, MA, USA) guided by a 12-Fr Fustar™ steerable introducer (Lifetech Scientific, Shenzhen, China). Urokinase (200,000–400,000 U) was delivered via pulse-spray mode and allowed to dwell for 10–15 minutes. Subsequently, rheolytic aspiration was performed using heparinized saline (5,000 U in 500 mL) with a slow catheter advancement rate of 1–2 mm/s (Fig. 2). Crucially, the adjustable sheath was actively angulated to ensure the catheter tip maintained close apposition to the vessel wall, enabling repeated circumferential passes from proximal to distal segments for maximal clearance. Staged Balloon Angioplasty Following thrombectomy, a diameter-escalation protocol was employed. Initial predilation used small balloons (6–14 mm) at the IVC ostium to restore flow without dislodging residual thrombus. Patients were re-evaluated after approximately one month of anticoagulation. If the IVC showed no unstable residual thrombus, larger balloons (16–26 mm) were used for definitive dilation. Stents were reserved strictly for recurrent stenosis refractory to balloon angioplasty (Fig. 3). 1.4.3 Postoperative Management LMWH was administered for 5–7 days, bridged to rivaroxaban (20 mg/day) for 6–12 months. Routine monitoring of blood counts and organ function was performed. 1.5 Outcome Definitions and Statistical Analysis Thrombus clearance was graded according to the extent of luminal restoration: Graded as Grade III (> 90%), Grade II (50–90%), or Grade I (< 50%). Technical success was defined as restoration of antegrade IVC flow with resolution of collateral circulation. Clinical improvement was assessed by the resolution or alleviation of key symptoms, including abdominal distension, ascites, and lower-limb edema. Complications were defined as procedure-related adverse events, including PE, bleeding, access-site events, transient hemoglobinuria, and cardiopulmonary or renal impairment, all of which were systematically recorded intra- and postoperatively. Follow-up imaging with duplex ultrasound or CT venography was conducted at 1, 3 and every 6 months until the study censorship date. The primary endpoint was primary patency, defined as uninterrupted patency of the target vessel without restenosis (> 50%) or occlusion, and without the need for re-intervention. Statistical analysis was performed using SPSS 25.0. Continuous variables are presented as mean ± SD or median (range) and compared using the Wilcoxon rank-sum test. A P-value < 0.05 was considered statistically significant. Results 2.1 Procedural performance and thrombus clearance Technical success was achieved in all 32 patients (100%). The mean AngioJet activation time was 263.4 ± 46.5 s, and the mean total urokinase dose was 321,400 ± 64,700 U. Postoperative venography demonstrated patent IVC flow with marked reduction in thrombus burden. Thrombus clearance was Grade III in 29 patients (90.6%), Grade II in 2 patients (6.3%), and Grade I in 1 patient (3.1%) (Table 2 ). 2.2 Clinical outcomes and complications Within one week postoperatively, 87.5% (28/32) of patients experienced marked clinical improvement. Ascites resolved or substantially reduced in 84.6% (22/26) of affected patients, and lower-limb edema improved in 83.3% (20/24). The overall complication rate was 9.4% (3/32), all of which were minor. Transient hemoglobinuria occurred in 6.3% (2/32) and resolved with hydration; one patient (3.1%) developed a small access-site hematoma managed conservatively. No pulmonary embolism, severe renal injury, or major bleeding events were recorded. 2.3 Follow-up and Patency Outcomes A total of 32 patients were included in the analysis. The median follow-up duration was 22.0 months, and the mean follow-up was 20.8 ± 4.5months (range, 7–24 months). During the surveillance period, loss of primary patency (restenosis or occlusion) was observed in 5 patients (5/32; 15.6%). The intervals to patency loss were 7, 12, 15, 18, and 22 months, respectively. Four of these events were detected during routine duplex ultrasound surveillance as asymptomatic restenosis, while one was identified due to the recurrence of mild abdominal distension. All 5 cases underwent re-intervention (PTA alone, n = 3; stenting, n = 2). During subsequent follow-up, four patients maintained patency. However, one patient (who initially developed restenosis at 12 months) experienced a recurrent occlusion 2 months after the re-intervention (at 14 months) and could not be recanalized endovascularly. Based on the Kaplan-Meier analysis, the cumulative primary patency rates were 100% at 6 months, 93.3% at 12 months, and 80.1% at 24 months (Fig. 4 ). Following successful re-interventions, the final duplex ultrasound follow-up confirmed restored flow in all cases. Following successful re-interventions, secondary patency rates were significantly maintained, recorded at 100%, 100%, and 95.8% at 6, 12, and 24 months, respectively (Fig. 4 ). In terms of survival, no procedure-related or disease-related deaths occurred; the cumulative survival rate was 100%. Discussion This study demonstrates that combining a steerable sheath with the AngioJet rheolytic thrombectomy system is a safe and effective strategy for treating BCS complicated by IVC thrombosis. By enabling real-time deflection of the guiding sheath, this technique allows the thrombectomy catheter to overcome the anatomical challenges of the large-caliber IVC, ensuring close wall apposition and efficient circumferential thrombus removal. Our cohort achieved a 100% technical success rate and 90.6% Grade III clearance, with significant clinical improvement and satisfactory mid-term patency. The etiological landscape of BCS varies globally. Unlike the hepatic vein thrombosis predominant in the West, idiopathic IVC obstruction accounts for 60–70% of BCS cases in China, making IVCT a frequent and complex clinical entity[ 15 , 16 ]. Previous studies have demonstrated that in most patients with BCS and IVCT, individualized endovascular therapy tailored to thrombus characteristics and extent is both safe and effective[ 14 , 15 ]. Reported advantages include low PE rates, high IVCT clearance rates, high technical success, durable patency, and significant clinical improvement[ 15 – 19 ]. A meta-analysis reported pooled IVC recanalization and clinical improvement rates of 99% and 92%, respectively[ 16 , 20 ]. These data underscore the importance of accurate preoperative assessment of thrombus characteristics. Individualized endovascular strategies, based on thrombus type (fresh, organized, or mixed) and extent, are more likely to achieve optimal clearance and clinical benefit. Preoperative imaging, intraoperative venography, and clinical history allow for an approximate classification of thrombus type, which can be further refined by the macroscopic appearance of thrombus aspirated through the sheath during the procedure[ 21 , 22 ]. Fresh and mixed thrombi generally respond well to catheter-directed thrombolysis, mechanical aspiration, and balloon predilation, as evidenced by immediate venographic improvement. In our series, technical success (100%) and thrombus clearance (90.6%) closely mirrored the meta-analysis data, further validating those individualized strategies—guided by thrombus pathology and anatomic features—can achieve effective acute thrombus debulking. Residual mural thrombi were predominantly chronic, firmly adherent to the endothelium, and difficult to completely remove. However, previous studies have shown that once IVC patency is restored, residual thrombus may gradually regress or resolve completely, likely due to the combined effects of sustained laminar flow mechanically “washing” the thrombus and concurrent systemic anticoagulation[ 4 , 22 , 23 ]. The large diameter of the IVC presents a significant challenge for standard AngioJet thrombectomy. Conventional straight catheters often "tunnel" through the center of the thrombus without touching the vessel wall, leading to incomplete clearance. To address this, we used a steerable sheath in all cases. This sheath allowed us to actively steer the catheter and press it against the vessel wall, enabling a "sweeping" motion that cleared thrombus even in difficult areas, such as the hepatic vein confluence or renal vein openings. Consequently, this approach yielded Grade III clearance (> 90%) in 90.6% of patients, confirming that the steerable sheath significantly improves precision compared to the catheter alone. Additionally, our success relied on a clear "staging" strategy. By combining symptom duration with imaging findings, we tailored the treatment: rheolytic thrombectomy was most effective for fresh thrombi, while chronic, organized lesions were managed with staged balloon angioplasty. Pulmonary embolism (PE) resulting from thrombus dislodgement remains the primary safety concern during IVC recanalization in BCS, a risk that historically rendered such interventions contraindicated[ 24 ]. To mitigate this, we adopted a strategy combining maximal thrombus debulking with graded balloon angioplasty. By strictly limiting initial balloon diameters to 6–12 mm, we were able to gradually restore venous outflow. This cautious approach minimizes the risk of distal embolization by preventing the abrupt hemodynamic shifts and sudden high-velocity flow that can dislodge residual thrombus. Consequently, we achieved immediate IVC recanalization with a 0% incidence of PE in our cohort. This stepwise "thrombolysis–thrombectomy–angioplasty" protocol offers a distinct safety advantage over prolonged catheter-directed thrombolysis, which carries higher bleeding risks. Our findings align with reduced PE risks reported in the broader literature: a review of 16 studies involving 695 patients identified only 9 PE events (1.3%), the majority of which were non-fatal and managed medically[ 16 ]. Collectively, these data reinforce that endovascular therapy for BCS-associated IVCT is safe when a disciplined, stepwise recanalization protocol is employed. Long-term clinical success is primarily dictated by the incidence of restenosis and recurrent thrombosis. These complications predominantly manifest within the first six months following intervention, typically resulting from neointimal hyperplasia, elastic vessel recoil, or the propagation of residual mural thrombus[ 5 , 25 ]. Notably, emerging evidence suggests that the risk of restenosis correlates less with the specific thrombectomy technique employed and more strongly with the underlying morphological characteristics of the IVC lesion (specifically, long-segmental versus membranous obstruction) [ 16 ]. Consequently, a rigorous post-procedural surveillance regimen is paramount. Given that the first postoperative year represents the peak incidence window for restenosis, management strategies must prioritize structured follow-up to ensure early detection of recurrent lesions[ 26 ]. In the event of restenosis, salvage balloon angioplasty serves as the first-line treatment to restore patency, with stent placement reserved strictly for recalcitrant or repeatedly recurrent cases. Our study strongly supports this "stent-sparing" philosophy. Although the primary patency rate declined to 80.1% at 24 months due to five recurrence events, prompt re-intervention (including targeted stenting in only two cases) successfully salvaged four of these patients. This resulted in a high secondary patency rate of 95.8%, demonstrating that restenosis is manageable and does not necessitate prophylactic stenting in the initial setting. Furthermore, adopting a stent-sparing strategy is particularly crucial. Avoiding permanent metallic implants in the IVC preserves future surgical options and avoids the complex challenge of managing in-stent restenosis. In terms of safety, the procedure demonstrated a favorable profile. The overall complication rate was 9.4% (3/32), with all adverse events classified as minor. Specifically, no major complications—such as severe renal injury, symptomatic pulmonary embolism, or bleeding requiring transfusion—were observed. The transient hemoglobinuria noted in two patients is a well-documented physiological response to rheolytic thrombectomy, resulting from mechanical hemolysis induced by the device’s high-velocity saline jets. In all cases, this resolved spontaneously following aggressive hydration and alkalization. This low incidence of procedure-related morbidity corroborates the clinical feasibility and safety of this combined endovascular approach. Limitations This single-center, retrospective study has several limitations. First, the sample size was small, and the lack of a control group limits our ability to make direct comparisons with other treatments. Second, the follow-up period was relatively short; longer-term observation is required to confirm the durability of IVC patency. Finally, patient adherence to anticoagulation therapy was not strictly monitored, which could have influenced the restenosis rates. Future multicenter studies are needed to validate these findings. Conclusion In conclusion, the integration of a steerable sheath with AngioJet thrombectomy, followed by staged balloon angioplasty, constitutes a safe and highly effective therapeutic strategy for BCS complicated by IVC thrombosis. By overcoming the geometric limitations of the large-caliber IVC, this technique ensures precise, circumferential thrombus clearance and supports a stent-sparing management philosophy. The observed high technical success, durable mid-term patency, and favorable safety profile suggest that this combined approach should be considered a promising and viable alternative to conventional interventions for this complex patient population. Abbreviations BCS Budd-Chiari syndrome IVC Inferior Vena Cava IVCT Inferior Vena Cava Thrombosis PE Pulmonary Embolism PTA Percutaneous Transluminal Angioplasty LMWH Low-molecular-weight heparin CTV Computed tomography venography. Declarations Ethics approval and consent to participate This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of The First Affiliated Hospital of Zhengzhou University (Approval No. 2025-KY-0634-001). Written informed consent was obtained from all individual participants included in the study. Consent for publication The participants signed informed consent regarding the publication of their data and photographs. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing Interests The authors declare that they have no conflict of interest. Funding This work was supported by the National Natural Science Foundation of China (Grant No. 8237021652). Authors’ contributions All authors contributed to the study conception and design. Material preparation and data collection were performed by Gaopo Cai, Yanhua Dong, and Zhaohui Hua. Data analysis was conducted by Nanyi Zhou and Shirui Liu. The first draft of the manuscript was written by Zhen Li and Gaopo Cai. Hui Cao supervised the project and critically revised the manuscript for important intellectual content. All authors commented on previous versions of the manuscript, and read and approved the final manuscript. Clinical trial number: Not applicable. Acknowledgements ： Not applicable. References Garcia-Pagán, J. C. & Valla, D.-C. Primary Budd–Chiari Syndrome. N Engl J Med 388, 1307–1316 (2023). Zhang, W. et al. Budd-Chiari Syndrome in China: A Systematic Analysis of Epidemiological Features Based on the Chinese Literature Survey. Gastroenterology Research and Practice 2015, 1–8 (2015). Han, X.-W., Ding, P.-X., Li, Y.-D., Wu, G. & Li, M.-H. 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Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 29, 304–307 (2019). Fu, Y.-F. et al. Combined thrombus aspiration and recanalization in treating Budd–Chiari syndrome with inferior vena cava thrombosis. Radiol med 120, 1094–1099 (2015). Sun, J. et al. Clinical Outcomes of Warfarin Anticoagulation after Balloon Dilation Alone for the Treatment of Budd–Chiari Syndrome Complicated by Old Inferior Vena Cava Thrombosis. Annals of Vascular Surgery 28, 1862–1868 (2014). Ding, P.-X. et al. Treatment of Budd-Chiari syndrome with urokinase following predilation in patients with old inferior vena cava thrombosis. Radiol med 116, 56–60 (2011). Murad, S. D. et al. Etiology, Management, and Outcome of the Budd-Chiari Syndrome. Ann Intern Med 151, 167–175 (2009). Zhang, W. et al. Restenosis after recanalization for Budd-Chiari syndrome: Management and long-term results of 60 patients. WJCC 8, 2930–2941 (2020). Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8712007","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":602269296,"identity":"48135f99-6c98-4a50-8f49-776d28bdfc7a","order_by":0,"name":"Gaopo Cai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYDCCA0CcAGYxHwNTbOzEa2FLA7PYmInRAgE8ZhDNhLTw3T788MODX3Zy5uw93x58/LFNno+ZgfHDxxzcWiTPpRlLJPYlG1v2nN1uOCPhtmEbMwOz5MxtuLUYnOFhkEjsYU7ccCN3mzRPwm1GoBY2Zl78Wph/JPbUA7XkPANpsSdGC5tEwo/DIC1sIC2JBLVInmEzs0hsOA70yzEzyRlpt5PbmBmb8fqF7wzz45s//lQDQ6z5mcQHm9u289ubD374iEcLGDC2AV2IxG0goB4E/qBoGQWjYBSMglGACgBapVDFmrNJAwAAAABJRU5ErkJggg==","orcid":"","institution":"First Affiliated Hospital of Zhengzhou University","correspondingAuthor":true,"prefix":"","firstName":"Gaopo","middleName":"","lastName":"Cai","suffix":""},{"id":602269297,"identity":"bd0a6872-3d4e-4f4d-a72b-a83b7d6e16c8","order_by":1,"name":"Yanhua Dong","email":"","orcid":"","institution":"Third Affiliated Hospital of Zhengzhou University","correspondingAuthor":false,"prefix":"","firstName":"Yanhua","middleName":"","lastName":"Dong","suffix":""},{"id":602269298,"identity":"4ab0265b-5f97-479d-ba44-987cba2e552d","order_by":2,"name":"Nanyi Zhou","email":"","orcid":"","institution":"First Affiliated Hospital of Zhengzhou University","correspondingAuthor":false,"prefix":"","firstName":"Nanyi","middleName":"","lastName":"Zhou","suffix":""},{"id":602269299,"identity":"4f704150-09a9-4a54-ba88-8833bbf90381","order_by":3,"name":"Shirui Liu","email":"","orcid":"","institution":"First Affiliated Hospital of Zhengzhou University","correspondingAuthor":false,"prefix":"","firstName":"Shirui","middleName":"","lastName":"Liu","suffix":""},{"id":602269300,"identity":"88d682a0-8178-4f7a-9138-0137304c5d76","order_by":4,"name":"Zhaohui Hua","email":"","orcid":"","institution":"First Affiliated Hospital of Zhengzhou University","correspondingAuthor":false,"prefix":"","firstName":"Zhaohui","middleName":"","lastName":"Hua","suffix":""},{"id":602269301,"identity":"bba4f59a-315a-4ba1-8eba-38df3345d659","order_by":5,"name":"Zhen Li","email":"","orcid":"","institution":"First Affiliated Hospital of Zhengzhou University","correspondingAuthor":false,"prefix":"","firstName":"Zhen","middleName":"","lastName":"Li","suffix":""},{"id":602269302,"identity":"bc1f6505-46c1-4b26-82af-2fdd837d41aa","order_by":6,"name":"Hui Cao","email":"","orcid":"","institution":"First Affiliated Hospital of Zhengzhou University","correspondingAuthor":false,"prefix":"","firstName":"Hui","middleName":"","lastName":"Cao","suffix":""}],"badges":[],"createdAt":"2026-01-27 15:08:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8712007/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8712007/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104337913,"identity":"2d6c8f4d-ab4c-4f42-8d59-4f1b8e5ea435","added_by":"auto","created_at":"2026-03-10 16:16:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1097230,"visible":true,"origin":"","legend":"\u003cp\u003eRadiological characterization of inferior vena cava (IVC) thrombosis stages in Budd-Chiari syndrome using CT venography and Duplex Ultrasound. (A–B) Acute (fresh) thrombosis: The IVC lumen is markedly dilated, with a centrally located low-attenuation filling defect surrounded by peripheral contrast enhancement (rim sign). (C) Chronic (old) thrombosis: The IVC appears narrowed, atrophic, and cord-like. The thrombus is hyperdense, accompanied by punctate calcifications. (D) Isoechoic IVC thrombosis associated with diaphragmatic membranous occlusion suggests an early or subacute stage. (E) Heterogeneous echogenicity within the IVC suggests a complex or mixed-stage lesion. (F) The hyperechoic appearance of the thrombus signifies a chronic, organized stage characterized by fibrosis.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8712007/v1/6cc1726c2b51acb05c2c1cf9.png"},{"id":104780170,"identity":"88d5f26f-1caa-4201-b559-1442a963beda","added_by":"auto","created_at":"2026-03-17 07:51:13","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1220198,"visible":true,"origin":"","legend":"\u003cp\u003eA 69-year-old woman presenting with membranous obstruction of the inferior vena cava (IVC) complicated by concomitant thrombosis in the IVC and left renal vein. (A) Computed tomography venography (CTV) reveals low-density thrombi with irregular margins extending into both the IVC and the left renal vein (arrow). (B) Initial inferior vena cavagram demonstrates non-visualization of the IVC, with drainage occurring via sparse compensatory collaterals (arrow). (C–D) Angiography following thrombectomy shows the absence of filling defects in the IVC and left renal vein, indicating effective thrombus clearance. (E) Balloon angioplasty of the occluded IVC segment performed using a 16-mm diameter balloon catheter (arrow). (F) Post-dilation venogram confirms resolution of the stenosis and restoration of antegrade blood flow. (G) Postoperative CTV depicts complete normalization of the IVC caliber and luminal patency. (H) Follow-up Doppler ultrasonography demonstrates sustained long-term patency of the IVC without recurrent thrombosis.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8712007/v1/8814c740b0fb3bae2c1b6b22.png"},{"id":104337912,"identity":"ea4a22a2-bebe-470f-b82f-32af1604d507","added_by":"auto","created_at":"2026-03-10 16:16:52","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1212218,"visible":true,"origin":"","legend":"\u003cp\u003eA 45-year-old male with a 4-month history of IVC thrombosis following conservative anticoagulation therapy without revascularization. (A) Computed tomography venography (CTV) identifies an intrahepatic IVC thrombus (arrow) characterized by punctate calcifications, accompanied by imaging features of hepatic cirrhosis. (B) Initial inferior vena cavagram reveals complete occlusion with non-visualization of the IVC (arrow). (C) Rheolytic thrombectomy performed using an AngioJet catheter facilitated by a 12-Fr steerable sheath for precise navigation within the IVC. (D) Subsequent balloon angioplasty of the occluded segment using a 10-mm diameter balloon catheter (arrow) following thrombus debulking. (E) Completion venogram demonstrates restoration of normal vessel caliber and physiological flow dynamics, with no evidence of residual thrombosis. (F–G) During the 1.5-year follow-up period, recurrent ostial stenosis was managed via repeat angioplasty using 20-mm (F) and 26-mm (G) balloon catheters (arrows), respectively. (H) Two years post-procedure, due to refractory recurrent stenosis, an 18 mm × 80 mm stent was implanted, achieving definitive resolution of the obstruction.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8712007/v1/4205ef4f71ae4a6534d3b66a.png"},{"id":104337914,"identity":"a1ef3303-662e-4eb0-b4be-34d55637ed2e","added_by":"auto","created_at":"2026-03-10 16:16:52","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":537997,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier survival analysis showing the durability of IVC recanalization (n=32). The cumulative primary patency (orange) and secondary patency (blue) rates at 24 months were 80.1% and 95.8%, respectively. The number at risk table provided below demonstrates sustained follow-up in the majority of patients. Tick marks indicate censored data points.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8712007/v1/95b15398eaceb6fddff52d06.png"},{"id":108794800,"identity":"ce6230da-f47d-491b-b7fe-09cbaa8468fd","added_by":"auto","created_at":"2026-05-08 13:11:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4298949,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8712007/v1/9a6db038-4502-4813-9329-c12c7d1e64f7.pdf"},{"id":104337911,"identity":"10f9ffee-7bc7-423d-8936-448b5214cd51","added_by":"auto","created_at":"2026-03-10 16:16:52","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":18776,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8712007/v1/872fcb770620fe724632e8f4.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Safety and Efficacy of Steerable Sheath-Assisted AngioJet Thrombectomy for Budd-Chiari Syndrome Complicated by Inferior Vena Cava Thrombosis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBudd\u0026ndash;Chiari syndrome (BCS) is a disorder characterized by hepatic venous outflow tract obstruction, leading to post-hepatic portal hypertension. While hepatic vein thrombosis associated with myeloproliferative neoplasms predominates in Western populations, membranous or segmental obstruction of the inferior vena cava (IVC) is the leading etiology in Asian countries, particularly in the Yellow River and Huai River basins of China[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The distinct prevalence in these regions is hypothesized to be linked to dietary factors, water hygiene, and specific genetic susceptibilities that induce endothelial injury and subsequent membrane formation[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInferior vena cava thrombosis (IVCT) represents a critical complication affecting 5\u0026ndash;20% of patients with BCS, particularly within Asian populations where membranous or segmental obstruction predominates[\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The pathogenesis is driven by a localized Virchow\u0026rsquo;s triad: severe venous stasis within the high-pressure segment inferior to the obstruction, turbulent hemodynamics, and secondary hypercoagulability. Clinically, the superimposed thrombosis aggravates venous hypertension, manifesting as exacerbated lower-limb edema, extensive thoracoabdominal collateral formation, and signs of chronic venous insufficiency. Furthermore, proximal propagation of the thrombus may compromise renal vein outflow, precipitating renal dysfunction, while occlusion of the hepatic vein ostia can lead to refractory ascites and rapid hepatic decompensation[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrent therapeutic strategies for BCS complicated by IVCT encompass a spectrum of interventions, from systemic anticoagulation and thrombolysis to endovascular recanalization and surgical shunting[\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. While anticoagulation is foundational, it is often insufficient for rapid resolution of bulky or organized thrombi. Percutaneous transluminal angioplasty (PTA) effectively relieves hemodynamic obstruction; however, balloon dilation alone in the presence of a heavy thrombus burden carries a significant risk of lethal pulmonary embolism (PE) due to mechanical dislodgement. Furthermore, even when mechanical thrombectomy is attempted, the anatomical dimensions of the IVC present a significant challenge. As the IVC is a large-diameter vessel, conventional straight thrombectomy catheters tend to \"tunnel\" through the thrombus center, failing to contact the vessel wall for complete clearance. Surgical shunting and liver transplantation are associated with high perioperative morbidity and are largely restricted to refractory cases[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Consequently, there is a critical need for endovascular strategies that accommodate the large IVC caliber to achieve efficient clearance while minimizing distal embolization risks.\u003c/p\u003e \u003cp\u003eThe combination of catheter-directed aspiration and staged balloon dilation offers theoretical advantages for IVCT in BCS by facilitating rapid debulking and minimizing thrombolytic dosage[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. While the AngioJet rheolytic thrombectomy system is well-established, its efficacy in the large IVC is frequently limited by the inability of standard catheters to maintain consistent wall contact. The incorporation of a steerable sheath addresses this limitation, allowing the operator to actively manipulate the AngioJet catheter to match the IVC's anatomy and perform a circumferential \"sweeping\" motion. Despite these advantages, clinical data evaluating the long-term safety and patency of this technique in BCS patients remain scarce. Therefore, we conducted this single-center retrospective study to evaluate the technical success, complication profile, and mid-term outcomes of steerable sheath\u0026ndash;assisted AngioJet thrombectomy followed by staged angioplasty.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\"\u003e\n \u003ch2\u003e1.1 Study Population\u003c/h2\u003e\n \u003cp\u003eThis single-center retrospective study was approved by the Ethics Committee of the First Affiliated Hospital of Zhengzhou University (Approval No. 2025-KY-0634-001). We reviewed clinical data from 32 patients with BCS complicated by IVCT admitted between January 2020 and August 2024.\u003c/p\u003e\n \u003cp\u003eInclusion criteria: (1) Confirmed diagnosis of BCS with imaging evidence of IVC obstruction and thrombus formation; (2) Age 18–80 years; (3) Presence of symptomatic disease (e.g., abdominal distension, ascites, lower-limb edema/ulceration, varices); (4) No prior BCS-related interventions; (5) Written informed consent provided. Exclusion criteria: (1) Severe cardiac, pulmonary, hepatic, or renal dysfunction precluding intervention; (2) Active bleeding or severe coagulopathy (INR \u0026gt; 2.0, platelets \u0026lt; 30×10⁹/L); (3) Allergy to contrast media or thrombolytic agents; (4) Pregnancy or lactation; (5) Recent intracranial or gastrointestinal hemorrhage (\u0026lt; 1 month).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\"\u003e\n \u003ch2\u003e1.2 Thrombus Staging and Definitions\u003c/h2\u003e\n \u003cp\u003eIVC thrombosis staging was determined by integrating clinical symptom duration with morphological characteristics on imaging, following the consensus standards of the Society of Interventional Radiology[13, 14]. Thrombosis was categorized into three stages: acute (≤ 14 days), subacute (15–28 days), and chronic (\u0026gt; 28 days). Given the often insidious onset of BCS, radiological findings served as critical corroborative factors for staging. Acute stage: Characterized by venous distension with a hypodense (CT) or hypoechoic (US) filling defect, and the absence of significant collateral circulation. Chronic stage: Defined by vessel retraction or collapse, thrombus calcification, and the presence of extensive collateral networks. Subacute stage: Exhibited intermediate features between the acute and chronic phases (Fig.\u0026nbsp;1).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\"\u003e\n \u003ch2\u003e1.3 Baseline Characteristics\u003c/h2\u003e\n \u003cp\u003eThe mean patient age was 60.2 ± 8.5 years (range, 45–75 years), comprising 18 men and 14 women. All patients presented with clinical manifestations of portal hypertension or venous obstruction. Duplex ultrasonography or CT venography confirmed partial or complete IVC obstruction with concomitant thrombus in all cases. Baseline characteristics are summarized in Table\u0026nbsp;1.\u003c/p\u003e\n \u003cdiv\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\"\u003e\n \u003ch2\u003e1.4 Endovascular Procedure\u003c/h2\u003e\n \u003cdiv id=\"Sec7\"\u003e\n \u003ch2\u003e1.4.1 Preoperative Preparation\u003c/h2\u003e\n \u003cp\u003ePatients underwent comprehensive evaluation, including coagulation profiles and liver/renal function tests. Imaging defined thrombus extent and IVC anatomy. Low-molecular-weight heparin (LMWH) was initiated preoperatively.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003e1.4.2 Operative Technique\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eVenous access\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eUnder local anesthesia, access was obtained via the right common femoral vein (5-Fr sheath). IVC venography was performed to assess thrombus burden and collateral flow. For complete ostial occlusion, dual access via the right internal jugular and femoral veins was established.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMechanical Thrombectomy\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMechanical thrombectomy was performed using the AngioJet™ ZelanteDVT™ catheter (Boston Scientific, Marlborough, MA, USA) guided by a 12-Fr Fustar™ steerable introducer (Lifetech Scientific, Shenzhen, China). Urokinase (200,000–400,000 U) was delivered via pulse-spray mode and allowed to dwell for 10–15 minutes. Subsequently, rheolytic aspiration was performed using heparinized saline (5,000 U in 500 mL) with a slow catheter advancement rate of 1–2 mm/s (Fig.\u0026nbsp;2). Crucially, the adjustable sheath was actively angulated to ensure the catheter tip maintained close apposition to the vessel wall, enabling repeated circumferential passes from proximal to distal segments for maximal clearance.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eStaged Balloon Angioplasty\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eFollowing thrombectomy, a diameter-escalation protocol was employed. Initial predilation used small balloons (6–14 mm) at the IVC ostium to restore flow without dislodging residual thrombus. Patients were re-evaluated after approximately one month of anticoagulation. If the IVC showed no unstable residual thrombus, larger balloons (16–26 mm) were used for definitive dilation. Stents were reserved strictly for recurrent stenosis refractory to balloon angioplasty (Fig.\u0026nbsp;3).\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec9\"\u003e\n \u003ch2\u003e1.4.3 Postoperative Management\u003c/h2\u003e\n \u003cp\u003eLMWH was administered for 5–7 days, bridged to rivaroxaban (20 mg/day) for 6–12 months. Routine monitoring of blood counts and organ function was performed.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\"\u003e\n \u003ch2\u003e1.5 Outcome Definitions and Statistical Analysis\u003c/h2\u003e\n \u003cp\u003eThrombus clearance was graded according to the extent of luminal restoration: Graded as Grade III (\u0026gt; 90%), Grade II (50–90%), or Grade I (\u0026lt; 50%). Technical success was defined as restoration of antegrade IVC flow with resolution of collateral circulation. Clinical improvement was assessed by the resolution or alleviation of key symptoms, including abdominal distension, ascites, and lower-limb edema. Complications were defined as procedure-related adverse events, including PE, bleeding, access-site events, transient hemoglobinuria, and cardiopulmonary or renal impairment, all of which were systematically recorded intra- and postoperatively.\u003c/p\u003e\n \u003cp\u003eFollow-up imaging with duplex ultrasound or CT venography was conducted at 1, 3 and every 6 months until the study censorship date. The primary endpoint was primary patency, defined as uninterrupted patency of the target vessel without restenosis (\u0026gt; 50%) or occlusion, and without the need for re-intervention.\u003c/p\u003e\n \u003cp\u003eStatistical analysis was performed using SPSS 25.0. Continuous variables are presented as mean ± SD or median (range) and compared using the Wilcoxon rank-sum test. A P-value \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003e2.1 Procedural performance and thrombus clearance\u003c/h2\u003e\n \u003cp\u003eTechnical success was achieved in all 32 patients (100%). The mean AngioJet activation time was 263.4\u0026thinsp;\u0026plusmn;\u0026thinsp;46.5 s, and the mean total urokinase dose was 321,400\u0026thinsp;\u0026plusmn;\u0026thinsp;64,700 U. Postoperative venography demonstrated patent IVC flow with marked reduction in thrombus burden. Thrombus clearance was Grade III in 29 patients (90.6%), Grade II in 2 patients (6.3%), and Grade I in 1 patient (3.1%) (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003e2.2 Clinical outcomes and complications\u003c/h2\u003e\n \u003cp\u003eWithin one week postoperatively, 87.5% (28/32) of patients experienced marked clinical improvement. Ascites resolved or substantially reduced in 84.6% (22/26) of affected patients, and lower-limb edema improved in 83.3% (20/24). The overall complication rate was 9.4% (3/32), all of which were minor. Transient hemoglobinuria occurred in 6.3% (2/32) and resolved with hydration; one patient (3.1%) developed a small access-site hematoma managed conservatively. No pulmonary embolism, severe renal injury, or major bleeding events were recorded.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003e2.3 Follow-up and Patency Outcomes\u003c/h2\u003e\n \u003cp\u003eA total of 32 patients were included in the analysis. The median follow-up duration was 22.0 months, and the mean follow-up was 20.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5months (range, 7\u0026ndash;24 months). During the surveillance period, loss of primary patency (restenosis or occlusion) was observed in 5 patients (5/32; 15.6%). The intervals to patency loss were 7, 12, 15, 18, and 22 months, respectively. Four of these events were detected during routine duplex ultrasound surveillance as asymptomatic restenosis, while one was identified due to the recurrence of mild abdominal distension. All 5 cases underwent re-intervention (PTA alone, n\u0026thinsp;=\u0026thinsp;3; stenting, n\u0026thinsp;=\u0026thinsp;2). During subsequent follow-up, four patients maintained patency. However, one patient (who initially developed restenosis at 12 months) experienced a recurrent occlusion 2 months after the re-intervention (at 14 months) and could not be recanalized endovascularly.\u003c/p\u003e\n \u003cp\u003eBased on the Kaplan-Meier analysis, the cumulative primary patency rates were 100% at 6 months, 93.3% at 12 months, and 80.1% at 24 months (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). Following successful re-interventions, the final duplex ultrasound follow-up confirmed restored flow in all cases. Following successful re-interventions, secondary patency rates were significantly maintained, recorded at 100%, 100%, and 95.8% at 6, 12, and 24 months, respectively (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). In terms of survival, no procedure-related or disease-related deaths occurred; the cumulative survival rate was 100%.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrates that combining a steerable sheath with the AngioJet rheolytic thrombectomy system is a safe and effective strategy for treating BCS complicated by IVC thrombosis. By enabling real-time deflection of the guiding sheath, this technique allows the thrombectomy catheter to overcome the anatomical challenges of the large-caliber IVC, ensuring close wall apposition and efficient circumferential thrombus removal. Our cohort achieved a 100% technical success rate and 90.6% Grade III clearance, with significant clinical improvement and satisfactory mid-term patency.\u003c/p\u003e \u003cp\u003eThe etiological landscape of BCS varies globally. Unlike the hepatic vein thrombosis predominant in the West, idiopathic IVC obstruction accounts for 60\u0026ndash;70% of BCS cases in China, making IVCT a frequent and complex clinical entity[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Previous studies have demonstrated that in most patients with BCS and IVCT, individualized endovascular therapy tailored to thrombus characteristics and extent is both safe and effective[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Reported advantages include low PE rates, high IVCT clearance rates, high technical success, durable patency, and significant clinical improvement[\u003cspan additionalcitationids=\"CR16 CR17 CR18\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A meta-analysis reported pooled IVC recanalization and clinical improvement rates of 99% and 92%, respectively[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These data underscore the importance of accurate preoperative assessment of thrombus characteristics. Individualized endovascular strategies, based on thrombus type (fresh, organized, or mixed) and extent, are more likely to achieve optimal clearance and clinical benefit. Preoperative imaging, intraoperative venography, and clinical history allow for an approximate classification of thrombus type, which can be further refined by the macroscopic appearance of thrombus aspirated through the sheath during the procedure[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Fresh and mixed thrombi generally respond well to catheter-directed thrombolysis, mechanical aspiration, and balloon predilation, as evidenced by immediate venographic improvement. In our series, technical success (100%) and thrombus clearance (90.6%) closely mirrored the meta-analysis data, further validating those individualized strategies\u0026mdash;guided by thrombus pathology and anatomic features\u0026mdash;can achieve effective acute thrombus debulking. Residual mural thrombi were predominantly chronic, firmly adherent to the endothelium, and difficult to completely remove. However, previous studies have shown that once IVC patency is restored, residual thrombus may gradually regress or resolve completely, likely due to the combined effects of sustained laminar flow mechanically \u0026ldquo;washing\u0026rdquo; the thrombus and concurrent systemic anticoagulation[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe large diameter of the IVC presents a significant challenge for standard AngioJet thrombectomy. Conventional straight catheters often \"tunnel\" through the center of the thrombus without touching the vessel wall, leading to incomplete clearance. To address this, we used a steerable sheath in all cases. This sheath allowed us to actively steer the catheter and press it against the vessel wall, enabling a \"sweeping\" motion that cleared thrombus even in difficult areas, such as the hepatic vein confluence or renal vein openings. Consequently, this approach yielded Grade III clearance (\u0026gt;\u0026thinsp;90%) in 90.6% of patients, confirming that the steerable sheath significantly improves precision compared to the catheter alone. Additionally, our success relied on a clear \"staging\" strategy. By combining symptom duration with imaging findings, we tailored the treatment: rheolytic thrombectomy was most effective for fresh thrombi, while chronic, organized lesions were managed with staged balloon angioplasty.\u003c/p\u003e \u003cp\u003ePulmonary embolism (PE) resulting from thrombus dislodgement remains the primary safety concern during IVC recanalization in BCS, a risk that historically rendered such interventions contraindicated[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. To mitigate this, we adopted a strategy combining maximal thrombus debulking with graded balloon angioplasty. By strictly limiting initial balloon diameters to 6\u0026ndash;12 mm, we were able to gradually restore venous outflow. This cautious approach minimizes the risk of distal embolization by preventing the abrupt hemodynamic shifts and sudden high-velocity flow that can dislodge residual thrombus. Consequently, we achieved immediate IVC recanalization with a 0% incidence of PE in our cohort. This stepwise \"thrombolysis\u0026ndash;thrombectomy\u0026ndash;angioplasty\" protocol offers a distinct safety advantage over prolonged catheter-directed thrombolysis, which carries higher bleeding risks. Our findings align with reduced PE risks reported in the broader literature: a review of 16 studies involving 695 patients identified only 9 PE events (1.3%), the majority of which were non-fatal and managed medically[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Collectively, these data reinforce that endovascular therapy for BCS-associated IVCT is safe when a disciplined, stepwise recanalization protocol is employed.\u003c/p\u003e \u003cp\u003eLong-term clinical success is primarily dictated by the incidence of restenosis and recurrent thrombosis. These complications predominantly manifest within the first six months following intervention, typically resulting from neointimal hyperplasia, elastic vessel recoil, or the propagation of residual mural thrombus[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Notably, emerging evidence suggests that the risk of restenosis correlates less with the specific thrombectomy technique employed and more strongly with the underlying morphological characteristics of the IVC lesion (specifically, long-segmental versus membranous obstruction) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Consequently, a rigorous post-procedural surveillance regimen is paramount. Given that the first postoperative year represents the peak incidence window for restenosis, management strategies must prioritize structured follow-up to ensure early detection of recurrent lesions[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In the event of restenosis, salvage balloon angioplasty serves as the first-line treatment to restore patency, with stent placement reserved strictly for recalcitrant or repeatedly recurrent cases. Our study strongly supports this \"stent-sparing\" philosophy. Although the primary patency rate declined to 80.1% at 24 months due to five recurrence events, prompt re-intervention (including targeted stenting in only two cases) successfully salvaged four of these patients. This resulted in a high secondary patency rate of 95.8%, demonstrating that restenosis is manageable and does not necessitate prophylactic stenting in the initial setting. Furthermore, adopting a stent-sparing strategy is particularly crucial. Avoiding permanent metallic implants in the IVC preserves future surgical options and avoids the complex challenge of managing in-stent restenosis.\u003c/p\u003e \u003cp\u003eIn terms of safety, the procedure demonstrated a favorable profile. The overall complication rate was 9.4% (3/32), with all adverse events classified as minor. Specifically, no major complications\u0026mdash;such as severe renal injury, symptomatic pulmonary embolism, or bleeding requiring transfusion\u0026mdash;were observed. The transient hemoglobinuria noted in two patients is a well-documented physiological response to rheolytic thrombectomy, resulting from mechanical hemolysis induced by the device\u0026rsquo;s high-velocity saline jets. In all cases, this resolved spontaneously following aggressive hydration and alkalization. This low incidence of procedure-related morbidity corroborates the clinical feasibility and safety of this combined endovascular approach.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThis single-center, retrospective study has several limitations. First, the sample size was small, and the lack of a control group limits our ability to make direct comparisons with other treatments. Second, the follow-up period was relatively short; longer-term observation is required to confirm the durability of IVC patency. Finally, patient adherence to anticoagulation therapy was not strictly monitored, which could have influenced the restenosis rates. Future multicenter studies are needed to validate these findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the integration of a steerable sheath with AngioJet thrombectomy, followed by staged balloon angioplasty, constitutes a safe and highly effective therapeutic strategy for BCS complicated by IVC thrombosis. By overcoming the geometric limitations of the large-caliber IVC, this technique ensures precise, circumferential thrombus clearance and supports a stent-sparing management philosophy. The observed high technical success, durable mid-term patency, and favorable safety profile suggest that this combined approach should be considered a promising and viable alternative to conventional interventions for this complex patient population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBCS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBudd-Chiari syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIVC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInferior Vena Cava\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIVCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInferior Vena Cava Thrombosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePulmonary Embolism\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePTA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePercutaneous Transluminal Angioplasty\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMWH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow-molecular-weight heparin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCTV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed tomography venography.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of The First Affiliated Hospital of Zhengzhou University (Approval No. 2025-KY-0634-001). Written informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participants signed informed consent regarding the publication of their data and photographs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Natural Science Foundation of China (Grant No. 8237021652).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation and data collection were performed by Gaopo Cai, Yanhua Dong, and Zhaohui Hua. Data analysis was conducted by Nanyi Zhou and Shirui Liu. The first draft of the manuscript was written by Zhen Li and Gaopo Cai. Hui Cao supervised the project and critically revised the manuscript for important intellectual content. All authors commented on previous versions of the manuscript, and read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGarcia-Pag\u0026aacute;n, J. C. \u0026amp; Valla, D.-C. 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Q. \u003cem\u003eet al.\u003c/em\u003e Strategy and Long-term Outcomes of Endovascular Treatment for Budd\u0026ndash;Chiari Syndrome Complicated by Inferior Vena Caval Thrombosis. \u003cem\u003eEuropean Journal of Vascular and Endovascular Surgery\u003c/em\u003e 47, 550\u0026ndash;557 (2014).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShukla, A. \u003cem\u003eet al.\u003c/em\u003e Budd-Chiari syndrome: consensus guidance of the Asian Pacific Association for the study of the liver (APASL). \u003cem\u003eHepatol Int\u003c/em\u003e 15, 531\u0026ndash;567 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeng, X. \u003cem\u003eet al.\u003c/em\u003e Endovascular Management of Budd-Chiari Syndrome with Inferior Vena Cava Thrombosis: A 14-Year Single-Center Retrospective Report of 55 Patients. \u003cem\u003eJournal of Vascular and Interventional Radiology\u003c/em\u003e 27, 1592\u0026ndash;1603 (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurad, S. D. \u003cem\u003eet al.\u003c/em\u003e Determinants of survival and the effect of portosystemic shunting in patients with Budd-Chiari syndrome. \u003cem\u003eHepatology\u003c/em\u003e 39, 500\u0026ndash;508 (2004).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMukhiya, G. \u003cem\u003eet al.\u003c/em\u003e Evaluation of outcome from endovascular therapy for Budd-Chiari syndrome: a systematic review and meta-analysis. \u003cem\u003eSci Rep\u003c/em\u003e 12, 16166 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu, C. \u003cem\u003eet al.\u003c/em\u003e Effectiveness and Postoperative Prognosis of Using Preopening and Staged Percutaneous Transluminal Angioplasty of the Inferior Vena Cava in Treating Budd-Chiari Syndrome Accompanied with Inferior Vena Cava Thrombosis. \u003cem\u003eAnnals of Vascular Surgery\u003c/em\u003e 60, 52\u0026ndash;60 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMichieletti, E. \u003cem\u003eet al.\u003c/em\u003e Acute Budd-Chiari Syndrome with Complete Portal Vein Thrombosis Complicated by Hepato-Renal Syndrome Treated Successfully by Emergent TIPS with Rheolytic Thrombectomy. \u003cem\u003eJournal of Clinical and Experimental Hepatology\u003c/em\u003e 13, 549\u0026ndash;551 (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDoyle, A., Nicoll, A. \u0026amp; Dowling, R. Use of the AngioJet percutaneous thrombectomy system for the treatment of acute Budd-Chiari syndrome. \u003cem\u003eBMJ Case Reports\u003c/em\u003e bcr2013008632 (2013) doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bcr-2013-008632\u003c/span\u003e\u003cspan address=\"10.1136/bcr-2013-008632\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVedantham, S. \u003cem\u003eet al.\u003c/em\u003e Society of Interventional Radiology Position Statement on the Endovascular Management of Acute Iliofemoral Deep Vein Thrombosis. \u003cem\u003eJournal of Vascular and Interventional Radiology\u003c/em\u003e 34, 284\u0026ndash;299.e7 (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcAree, B. \u003cem\u003eet al.\u003c/em\u003e Inferior vena cava thrombosis: A review of current practice. \u003cem\u003eVasc Med\u003c/em\u003e 18, 32\u0026ndash;43 (2013).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDing, P.-X. \u003cem\u003eet al.\u003c/em\u003e An Individualised Strategy and Long-Term Outcomes of Endovascular Treatment of Budd\u0026ndash;Chiari Syndrome Complicated by Inferior Vena Cava Thrombosis. \u003cem\u003eEuropean Journal of Vascular and Endovascular Surgery\u003c/em\u003e 55, 545\u0026ndash;553 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun, X., Qin, T., Zhang, J. \u0026amp; Wang, M. The outcomes of interventional treatment for Budd-Chiari Syndrome complicated by inferior vena cava thrombosis: Systematic review and meta-analysis. \u003cem\u003eGastroenterolog\u0026iacute;a y Hepatolog\u0026iacute;a\u003c/em\u003e 44, 405\u0026ndash;417 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang, X.-L., Cheng, T. O. \u0026amp; Chen, C.-R. Successful Treatment by Percutaneous Balloon Angioplasty of Budd-Chiari Syndrome Caused by Membranous Obstruction of Inferior Vena Cava: 8-Year Follow-Up Study. \u003cem\u003eJournal of the American College of Cardiology\u003c/em\u003e 28, 1720\u0026ndash;1724 (1996).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZeng, Y.-W. \u003cem\u003eet al.\u003c/em\u003e Sequential interventional therapy for Budd-Chiari syndrome associated with fresh inferior vena cava thrombosis. \u003cem\u003eJ Vasc Surg Venous Lymphat Disord\u003c/em\u003e 8, 945\u0026ndash;952 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHemachandran, N. \u003cem\u003eet al.\u003c/em\u003e Long-Term Outcomes of Endovascular Interventions in More than 500 patients with Budd\u0026ndash;Chiari Syndrome. \u003cem\u003eJournal of Vascular and Interventional Radiology\u003c/em\u003e 32, 61\u0026ndash;69.e1 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMukhiya, G., Jiao, D., Han, X., Zhou, X. \u0026amp; Pokhrel, G. Survival and clinical success of endovascular intervention in patients with Budd-Chiari syndrome: A systematic review. \u003cem\u003eJCIS\u003c/em\u003e 13, 5 (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang, F. \u003cem\u003eet al.\u003c/em\u003e Catheter Aspiration With Recanalization for Budd-Chiari Syndrome With Inferior Vena Cava Thrombosis. \u003cem\u003eSurgical Laparoscopy, Endoscopy \u0026amp; Percutaneous Techniques\u003c/em\u003e 29, 304\u0026ndash;307 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFu, Y.-F. \u003cem\u003eet al.\u003c/em\u003e Combined thrombus aspiration and recanalization in treating Budd\u0026ndash;Chiari syndrome with inferior vena cava thrombosis. \u003cem\u003eRadiol med\u003c/em\u003e 120, 1094\u0026ndash;1099 (2015).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun, J. \u003cem\u003eet al.\u003c/em\u003e Clinical Outcomes of Warfarin Anticoagulation after Balloon Dilation Alone for the Treatment of Budd\u0026ndash;Chiari Syndrome Complicated by Old Inferior Vena Cava Thrombosis. \u003cem\u003eAnnals of Vascular Surgery\u003c/em\u003e 28, 1862\u0026ndash;1868 (2014).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDing, P.-X. \u003cem\u003eet al.\u003c/em\u003e Treatment of Budd-Chiari syndrome with urokinase following predilation in patients with old inferior vena cava thrombosis. \u003cem\u003eRadiol med\u003c/em\u003e 116, 56\u0026ndash;60 (2011).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurad, S. D. \u003cem\u003eet al.\u003c/em\u003e Etiology, Management, and Outcome of the Budd-Chiari Syndrome. \u003cem\u003eAnn Intern Med\u003c/em\u003e 151, 167\u0026ndash;175 (2009).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang, W. \u003cem\u003eet al.\u003c/em\u003e Restenosis after recanalization for Budd-Chiari syndrome: Management and long-term results of 60 patients. \u003cem\u003eWJCC\u003c/em\u003e 8, 2930\u0026ndash;2941 (2020).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Budd-Chiari Syndrome, Inferior vena cava thrombosis, AngioJet, Steerable Sheath","lastPublishedDoi":"10.21203/rs.3.rs-8712007/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8712007/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo evaluate the safety and efficacy of the steerable sheath combined with the AngioJet thrombectomy system in patients with Budd\u0026ndash;Chiari syndrome (BCS) complicated by inferior vena cava thrombosis (IVCT).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e We retrospectively reviewed 32 patients treated from January 2020 to August 2024. All patients presented with symptomatic BCS and IVC obstruction with concomitant thrombosis. Mechanical thrombectomy was performed using the AngioJet system delivered via a steerable sheath to maximize vessel wall apposition. This was followed by a standardized \u0026ldquo;staged balloon angioplasty\u0026rdquo; protocol. Patients were followed for 7\u0026ndash;24 months.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTechnical success was 100%. Immediate IVC recanalization was obtained in 93.8% of patients, with Grade III thrombus clearance (\u0026gt;\u0026thinsp;90%) achieved in 90.6%. No pulmonary embolism or severe renal injury occurred. Perioperative survival was 100.0%. During a median follow-up of 22.0 months, the cumulative primary patency rate at 24 months was 80.1%. Five patients (15.6%) developed restenosis or occlusion during surveillance. All underwent re-intervention (balloon angioplasty, n\u0026thinsp;=\u0026thinsp;3; stenting, n\u0026thinsp;=\u0026thinsp;2). While one patient experienced recurrent occlusion, definitive patency was restored in the remaining four, resulting in a secondary patency rate of 95.8% at 24 months.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe use of a steerable sheath-assisted AngioJet thrombectomy is safe and effective for BCS with IVCT, yielding high thrombus clearance and satisfactory mid-term patency rates.\u003c/p\u003e","manuscriptTitle":"Safety and Efficacy of Steerable Sheath-Assisted AngioJet Thrombectomy for Budd-Chiari Syndrome Complicated by Inferior Vena Cava Thrombosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-10 16:16:47","doi":"10.21203/rs.3.rs-8712007/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0806c793-e181-4e6f-81d1-20645c849ea5","owner":[],"postedDate":"March 10th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-08T12:58:25+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T13:10:28+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-10 16:16:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8712007","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8712007","identity":"rs-8712007","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}