How should I treat Budd-Chiari syndrome after liver transplantation with inferior vena cava occlusion?

BACKGROUND: A 64-year-old male with Budd-Chiari syndrome (BCS) due to inferior vena cava (IVC) occlusion after liver transplant presented with massive ascites and lower extremity oedema. INVESTIGATION: A computed tomography venogram (CTV) of the abdomen and pelvis was performed after workup including venous ultrasound could not identify the aetiology of the oedema. DIAGNOSIS: The patient was found to have chronic total occlusion (CTO) of the suprahepatic IVC with thrombosis in the hepatic, renal, and iliac veins and the infrahepatic IVC. MANAGEMENT: Venography of the IVC along with catheter directed thrombolysis were performed on the first day. Subsequently, a transseptal needle was used to transverse the occlusion. A snare was used from the IVC to retract a guidewire cranially through the tract. The lesion in the IVC was then dilated and stented with the help of IVUS.