Shirai et al. Journal of Medical Case Reports 2011, 5:124 http://www.jmedicalcasereports.com/content/5/1/124 lesion of the IVC through a combination of several diag- nostic modalities, such as Doppler US, 3-D CT, and MRI. After the accurate diagnosis, optimized therapy should be employed for acute BCS. As in our case, about one third of patients harbor short-segment steno- sis of either the hepatic veins or IVC. Since such patients are candidates for PTA [2], we first performed PTA and achieved good clinical results for one year. However, it has been reported that PTA has a high level of recurrence and sometimes needs to be repeated. About half the patients who underwent PTA developed re-stenosis within one year. Likewise, our patient had re-stenosis approximately one year after the first PTA [8]. Esophageal varices and ascites developed very quickly along with re-stenosis. We attempted PTA again, but the second time was not effective. The IVC was temporarily dilated but soon re-stenosed. It was reported that an expandable metallic stent (EMS) can be useful for overcoming and reducing the occurrence of re-stenosis or obstructions after PTA [2]. However, in our case, the stenosis level of the IVC and debouch of the hepatic veins were very close. The radiologist in our hospital concluded that we could not employ EMS in this case since sufficient long-term blood flow could not be guaranteed. Liver transplantation has been used as an alternative to, or after failure of, surgical interventions for BCS [9]. It has been proposed that patients with fulminant hepa- tic failure consequent to BCS should be listed with the United Network for Organ Sharing system status 1A [10]. However, in Japan, it is extremely difficult to wait for DLDT due to the severe shortage of the number of donors. Although the surgical techniques of LDLT are different from those of DLDT, refined techniques were developed in Japan thanks to the enormous efforts of Japanese surgeons [9]. Although patients with BCS account for only 1-2% of all orthotopic liver transplants, fortunately the department of surgery in our hospital has experience with LDLT. Since our patient’s brother suggested becoming a donor for LDLT, we could per- form LDLT in the current case. As our patient suffered acute liver failure, all other therapies were less likely to be successful. LDLT was successfully performed, and all the patient’s clinical manifestations were significantly alleviated. Therefore, liver transplantation should be considered as one of the alternative options for thera- peutic salvage. Conclusion We described the case of a patient with recurrent BCS in whom the first PTA was successful, but the second PTA failed to re-open the stenosis of the IVC. We per- formed salvage LDLT from his brother. The transplanta- tion was successfully performed, and all clinical Page 4 of 5 manifestations were significantly alleviated. In cases of recurrent BCS, the blocked hepatic venous outflow is not always relieved, even with invasive therapies. We have to consider the possibility of adopting alternative salvage therapies if the first therapeutic modalities fail. When invasive therapeutic modalities such as PTA fail, liver transplantation should be considered as an alterna- tive option. Consent Written informed consent was obtained from the patient for publication of this case report and any accompany- ing images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Acknowledgements The authors acknowledge (anonymously) the patient on whom this case report is based. Author details 1Third Department of Internal Medicine, Nara Medical University, Nara, Japan. 2Department of Surgery, Nara Medical University, Nara, Japan. Authors’ contributions YS and HY described the clinical case, obtained informed consent from the patient, conceived the study, participated in its design, assisted in data collection, coordinated and helped draft the manuscript. HY undertook the literature research and contributed to the writing. SK, MY, YI, RN, CM, KK, YA, KN, JY, MT, AM, MS, MY, MF, MU, YN, and HF were responsible for the diagnosis, patient management and review. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 22 July 2010 Accepted: 29 March 2011 Published: 29 March 2011 References 1. Valla DC: Primary Budd-Chiari syndrome. J Hepatol 2009, 50(1):195-203. 2. 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