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Ko E, Kim J, Gwon DI, Chu HH, Kim GH, Ko GY. Emergency Plug-Assisted Retrograde Transvenous Obliteration for Active Bleeding from Ruptured Gastric Varices. J Vasc Interv Radiol 2025; 36:994-1001. [PMID: 39900141 DOI: 10.1016/j.jvir.2025.01.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2024] [Revised: 01/18/2025] [Accepted: 01/26/2025] [Indexed: 02/05/2025] Open
Abstract
PURPOSE To evaluate the safety and effectiveness of emergency plug-assisted retrograde transvenous obliteration (PARTO) for active bleeding from ruptured gastric varices (GVs). MATERIALS AND METHODS Twenty-one patients with active bleeding from ruptured GVs were included in this retrospective study. Ten patients (47.6%) showed life-threatening hemorrhage (systolic blood pressure, <90 mm Hg) just before emergency PARTO. All patients underwent emergency PARTO after initial ineffective endoscopic cyanoacrylate injection (n = 9) or because endoscopic injection was not possible (n = 12). RESULTS Emergency PARTO was technically successful in all 21 patients. Mean fluoroscopic time was 30.8 minutes (range, 10-62 minutes). There were no procedure-related adverse events. Hemostasis was obtained in 20 (95.2%) of 21 patients immediately after PARTO. In 16 patients who underwent computed tomography (CT), complete thrombosis or obliteration of GVs and portosystemic shunt was observed. With the exception of 1 patient who underwent external transfer, 15 patients died within a mean of 196 days (range, 1-1,111 days), whereas 5 remained alive for a mean of 38.9 months (range, 17.1-74.2 months). Seven died within 30 days due to ischemia-related multiorgan failure (n = 5), hypovolemic shock (n = 1), or rapid progression of hepatocellular carcinoma (HCC) (n = 1). The causes of death in the remaining 9 patients were bleeding from esophageal varices (n = 2), liver failure (n = 2), and rapid progression of HCC (n = 5). The median patient survival time was 47 days (95% confidence interval, 0‒124 days). There was no case of rebleeding or recurrence of GVs. CONCLUSIONS Emergency PARTO appears to be a fast, safe, and effective treatment option to stop active bleeding from ruptured GVs; however, survival in this population is modest because of comorbidities and complications of shock.
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Affiliation(s)
- Eunbyeol Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jeongyeon Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Dong Il Gwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
| | - Hee Ho Chu
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Gun Ha Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Gi-Young Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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Patel RK, Tripathy T, Panigrahi MK, Nayak HK, Samal SC, Pattnaik B, Dutta T, Gupta S, Mohakud S, Naik S, Deep Bag N. Is salvage Plug-Assisted Retrograde Transvenous Obliteration (PARTO) safe and effective for bleeding gastric varices ?- A preliminary single-center experience. Emerg Radiol 2024; 31:359-365. [PMID: 38664278 DOI: 10.1007/s10140-024-02232-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/16/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Vascular plug-assisted retrograde transvenous obliteration (PARTO) obliterates the gastric varices and portosystemic shunt, thus resulting in a lower rebleeding rate than endoscopic glue/sclerotherapy. AIMS To evaluate the safety and efficacy of PARTO as salvage therapy in liver cirrhosis with gastric variceal bleed (GVB) after failed endotherapy. We assessed the clinical success rate and changes in liver function at 6- months. MATERIALS AND METHODS Patients who underwent salvage PARTO after failed endotherapy for GVB (between December 2021 and November 2022) were searched and analyzed from the hospital database. Clinical success rate and rebleed rate were obtained at six months. Child-Pugh score (CTP) and Model for end-stage liver disease (MELD) score were calculated and compared between baseline and 6-month follow-up. RESULTS Fourteen patients (n = 14, Child-Pugh class A/B) underwent salvage PARTO. Nine had GOV-2, and five had IGV-1 varices. The mean shunt diameter was 11.6 ± 1.6 mm. The clinical success rate of PARTO was 100% (no recurrent gastric variceal hemorrhage within six months). No significant deterioration in CTP (6.79 ± 0.98 vs. 6.21 ± 1.52; p = 0.12) and MELD scores (11.5 ± 4.05 vs. 10.21 ± 3.19; p = 0.36) was noted at 6 months. All patients were alive at 6 months. One patient (n = 1, 7.1%) bled from esophageal varices after three days of PARTO and was managed with variceal banding. 21.4% (3/14) patients had progression of esophageal varices at 6 months requiring prophylactic band ligation. Three patients (21.4%) had new onset or worsening ascites and responded to low-dose diuretics therapy. CONCLUSIONS PARTO is a safe and effective procedure for bleeding gastric varices without any deterioration in liver function even after six months. Patient selection is critical to prevent complications. Further prospective studies with larger sample size are required to validate our findings.
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Affiliation(s)
- Ranjan Kumar Patel
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Taraprasad Tripathy
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India.
| | - Manas Kumar Panigrahi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Hemant Kumar Nayak
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Subash Chandra Samal
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Bramhadatta Pattnaik
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Tanmay Dutta
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Sunita Gupta
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Sudipta Mohakud
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Suprava Naik
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Nerbadyeswari Deep Bag
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
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Lee EW, Eghtesad B, Garcia-Tsao G, Haskal ZJ, Hernandez-Gea V, Jalaeian H, Kalva SP, Mohanty A, Thabut D, Abraldes JG. AASLD Practice Guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage. Hepatology 2024; 79:224-250. [PMID: 37390489 DOI: 10.1097/hep.0000000000000530] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023]
Affiliation(s)
- Edward Wolfgang Lee
- Department of Radiology and Surgery, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Bijan Eghtesad
- Department of General Surgery, Digestive Disease and Surgery Institute Cleveland Clinic, Cleveland, Ohio, USA
| | - Guadalupe Garcia-Tsao
- Yale University School of Medicine, Department of Internal Medicine, Section of Digestive Diseases, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging/Interventional Radiology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Universitat de Barcelona (UB). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Hamed Jalaeian
- Department of Interventional Radiology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | | | - Arpan Mohanty
- Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Dominique Thabut
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'Hépato-gastroentérologie, Paris, France
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
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Khakwani A, Trivedi M, Afzal M, Kahlon P, Khola, Patel P, Chirumamilla PC, Vohra RR, Ratheesh R, Mathew M, Abdin ZU, Nazir Z. Use of Balloon Occluded Retrograde Transvenous Obliteration (BRTO) for Treatment of Gastric Varices: A Narrative Review. Cureus 2023; 15:e38233. [PMID: 37257163 PMCID: PMC10225054 DOI: 10.7759/cureus.38233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 06/02/2023] Open
Abstract
Gastric Varices occur as a result of portal hypertension. Balloon Retrograde Transvenous Obliteration (BRTO) is a modality for managing gastric varices. The ultimate goal of this review is to promote the broader adoption of BRTO in managing gastric varices and to promote further research to improve patient outcomes. Before this study, an electronic literature search was undertaken based on identified concepts, keywords, and other pertinent descriptions. Search databases were developed and included "Gastric varices" AND "BRTO" OR "intervention" OR "treatment" OR "procedure" OR "glue" OR "adhesive". The databases selected and thoroughly searched were PubMed, Cochrane Library and ScienceDirect. Following the first search, 274 articles were found in total. By applying inclusion criteria of full-text articles and a period of fewer than five years, the database was reduced to 37 articles, which was then further filtered to include only articles on adults over 19 years old, leaving a total count of 17 articles. BRTO is a relatively simple procedure to perform once the essential skill is attained and helpful in both emergency and elective management of gastric varices. Its use still needs to be improved by the unavailability and lack of skills. However, there are side effects associated with BRTO as it causes elevation of portal hypertension, recurrent bleeding, hemoglobinuria and pain post procedure. This review emphasizes the need for further research in this field, focusing on refining patient selection criteria, improving the technical aspect of the procedure and enhancing long-term outcomes.
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Affiliation(s)
- Anum Khakwani
- Internal Medicine/Gastroenterology, Nishtar Medical University, Multan, PAK
| | - Manan Trivedi
- Department of Surgery, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, IND
| | - Maham Afzal
- Medicine and Surgery, Shalamar Medical and Dental College, Lahore, PAK
| | - Puneet Kahlon
- Medicine, American International Medical University, Gros Islet, LCA
| | - Khola
- Internal Medicine, Shalamar Medical and Dental College, Lahore, PAK
| | - Parakh Patel
- Medicine, American International Medical University, Gros Islet, LCA
| | | | - Rimsha R Vohra
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Rani Ratheesh
- Internal Medicine, Dr MGR Medical University, Tamilnadu, IND
| | - Midhun Mathew
- Department of Internal Medicine, Pennsylvania Hospital, Philadelphia, USA
| | - Zain U Abdin
- Medicine, District Head Quarter Hospital, Faisalabad, PAK
| | - Zahra Nazir
- Internal Medicine/Clinical Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Left Gastric Vein Width Is an Important Risk Factor for Exacerbation of Esophageal Varices Post Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Varices in Cirrhotic Patients. Medicina (B Aires) 2022; 58:medicina58020205. [PMID: 35208529 PMCID: PMC8875323 DOI: 10.3390/medicina58020205] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 01/22/2022] [Accepted: 01/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: Balloon-occluded retrograde transvenous obliteration (BRTO) could be currently one of the best therapies for patients with gastric varices. This study examined the exacerbation rates for esophageal varices following BRTO for gastric varices in patients with hepatic cirrhosis. Materials and Methods: We enrolled 91 cirrhotic patients who underwent BRTO for gastric varices. In total, 50 patients were examined for exacerbation rates of esophageal varices following BRTO. Esophageal varices and their associated exacerbation were evaluated by upper gastrointestinal endoscopy. Patients were allocated into two groups according to the main inflow tract for gastric varices: (1) 36 patients in the left gastric vein (LGV) group with an LGV width of more than 3.55 mm, and (2) 14 patients in the non-LGV group who had short gastric vein or posterior gastric vein. Moreover, treatment outcomes were retrospectively analyzed. Results: LGV width (p < 0.01) was the major risk factor for the deterioration of esophageal varices post BRTO. In addition, LGV was the most common inflow tract, and the LGV group contained 74% (37/50) of patients. The exacerbation rates of esophageal varices at 1, 2, 3, and 4 years post BRTO were 40%, 62%, 65%, and 68%, respectively. The comparison of the exacerbation rates for esophageal varices following BRTO according to inflow tract showed that the exacerbation rates were significantly higher in the LGV group than those of the non-LGV group (p = 0.03). In more than half of the subjects, LGV was the main inflow tract for gastric varices, and this group experienced more frequent exacerbations of esophageal varices following BRTO compared to patients with different inflow tract sources. Conclusion: Careful attention should be paid to the LGV width when BRTO is performed for gastric varices.
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Waguri N, Osaki A, Watanabe Y. Balloon-occluded retrograde transvenous obliteration for treatment of gastric varices. World J Hepatol 2021; 13:650-661. [PMID: 34239700 PMCID: PMC8239489 DOI: 10.4254/wjh.v13.i6.650] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/12/2021] [Accepted: 05/22/2021] [Indexed: 02/06/2023] Open
Abstract
Rupture of gastric varices (GVs) can be fatal. Balloon-occluded retrograde transvenous obliteration (BRTO), as known as retrograde sclerotherapy, has been widely adopted for treatment of GVs because of its effectiveness, ability to cure, and utility in emergency and prophylactic treatment. Simplifying the route of blood flow from GVs to the gastrorenal shunt is important for the successful BRTO. This review outlines BRTO indications and contraindications, describes basic BRTO procedures and modifications, compares BRTO with other GVs treatments, and discusses various combination therapies. Combined BRTO and partial splenic embolization may prevent exacerbation of esophageal varices and shows promise as a treatment option.
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Affiliation(s)
- Nobuo Waguri
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata 950-1197, Japan
| | - Akihiko Osaki
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata 950-1197, Japan
| | - Yusuke Watanabe
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata 950-1197, Japan
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Kim CY, Pinchot JW, Ahmed O, Braun AR, Cash BD, Feig BW, Kalva SP, Knavel Koepsel EM, Scheidt MJ, Schramm K, Sella DM, Weiss CR, Hohenwalter EJ. ACR Appropriateness Criteria® Radiologic Management of Gastric Varices. J Am Coll Radiol 2020; 17:S239-S254. [PMID: 32370968 DOI: 10.1016/j.jacr.2020.01.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 12/13/2022]
Abstract
Hemorrhage, resulting from gastric varies, can be challenging to treat, given the various precipitating etiologies. A wide variety of treatment options exist for managing the diverse range of the underlying disease processes. While cirrhosis is the most common cause for gastric variceal bleeding, occlusion of the portal or splenic vein in noncirrhotic states results in a markedly different treatment paradigm. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Charles Y Kim
- Duke University Medical Center, Durham, North Carolina.
| | | | | | - Aaron R Braun
- St Elizabeth Regional Medical Center, Lincoln, Nebraska
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Barry W Feig
- The University of Texas MD Anderson Cancer Center, Houston, Texas; American College of Surgeons
| | | | | | | | - Kristofer Schramm
- University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | | | | | - Eric J Hohenwalter
- Specialty Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
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Lee EW, Shahrouki P, Alanis L, Ding P, Kee ST. Management Options for Gastric Variceal Hemorrhage. JAMA Surg 2020; 154:540-548. [PMID: 30942880 DOI: 10.1001/jamasurg.2019.0407] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Varices are one of the main clinical manifestations of cirrhosis and portal hypertension. Gastric varices are less common than esophageal varices but are often associated with poorer prognosis, mainly because of their higher propensity to bleed. Observations Currently, treatments used to control and manage gastric variceal bleeding include β-blockers, endoscopic injection sclerotherapy, endoscopic variceal ligation, endoscopic variceal obturation, shunt surgery, transjugular intrahepatic portosystemic shunts, balloon-occluded retrograde transvenous obliteration (BRTO), and modified BRTO. In the past few decades, Western (United States and Europe) interventional radiologists have preferred transjugular intrahepatic portosystemic shunts that aim to decompress the liver and reduce portal pressure. Conversely, Eastern radiologists (Japan and South Korea) have preferred BRTO that directly targets the gastric varices. Over the past 20 years, BRTO has evolved and procedure-related risks have decreased. Owing to its safety and efficiency in treating gastric varices, BRTO is now starting to gain popularity among Western interventional radiologists. In this review, we present a comprehensive literature review of current and emerging management options, including BRTO and modified BRTO, for the treatment of gastric varices in the setting of cirrhosis and portal hypertension. Conclusions and Relevance Balloon-occluded retrograde transvenous obliteration has emerged as a safe and effective alternative treatment option for gastric variceal hemorrhage. A proper training, evidence-based consensus and guideline, thorough preprocedural and postprocedural evaluation, and a multidisciplinary team approach with BRTO and modified BRTO are strongly recommended to ensure best patient care.
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Affiliation(s)
- Edward Wolfgang Lee
- Division of Interventional Radiology, Department of Radiology, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles.,Division of Liver and Pancreas Transplantation, Department of Surgery, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles
| | - Puja Shahrouki
- Division of Interventional Radiology, Department of Radiology, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles
| | - Lourdes Alanis
- Division of Interventional Radiology, Department of Radiology, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles
| | - Pengxu Ding
- Division of Interventional Radiology, Department of Radiology, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles
| | - Stephen T Kee
- Division of Interventional Radiology, Department of Radiology, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles
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Mukund A, Rangarh P, Shasthry SM, Patidar Y, Sarin SK. Salvage Balloon Occluded Retrograde Transvenous Obliteration for Gastric Variceal Bleed in Cirrhotic Patients With Endoscopic Failure to Control Bleed/Very Early Rebleed: Long-term Outcomes. J Clin Exp Hepatol 2020; 10:421-428. [PMID: 33029050 PMCID: PMC7527839 DOI: 10.1016/j.jceh.2020.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 04/09/2020] [Indexed: 12/12/2022] Open
Abstract
AIMS To analyze the outcomes of balloon occluded retrograde transvenous obliteration (BRTO) as salvage therapy in cirrhotic patients with gastric variceal bleed (GVB) after failed endotherapy or very early rebleeds. We assessed for technical/clinical success of BRTO and transplantation-free survival. MATERIAL AND METHODS Patients with GVB who underwent BRTO as salvage therapy (between 2011 and 2017) were analyzed. Rebleed rate, Child Pugh score (CTP), Model for end-stage liver disease (MELD) values were calculated at 1,6,12, and 24 months follow-up. RESULTS Fifty-two patients who underwent BRTO as salvage therapy were assessed for rebleed rate and transplantation-free survival. Technical success was 100% with rebleed rate being 1.9% (n = 1) and clinical success rate of 92.3% (n = 48) at 12-months follow-up and transplantation-free one-year survival of 90.4% (n = 47). Five patients (9.6%) failed to achieve one-year transplantation-free survival. Four patients died within 30 days; one rebleed, 3 (all Child C) progressive liver and multiorgan failure and one required liver transplantation (day 88) after BRTO. Thus, a total of 4 of 9 (44.4%) Child C patients failed to achieve one-year transplantation-free survival. Improvement in liver functions was noted in the rest with improved CTP, MELD scores, and albumin levels in the 12-month follow-up. Six of 52 (11.5%) developed new onset medically manageable ascites, whereas 7 of 52 (13.5%) had progression of esophageal varices at 12-months follow-up requiring prophylactic band ligation in follow-up. CONCLUSIONS Salvage BRTO is a safe and effective procedure for patients with acute GVB with failure to control bleed with endotherapy or very early rebleed after endotherapy. Salvage BRTO has good short/long-term outcomes with lower rebleed, higher survival, and improved liver disease severity.
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Affiliation(s)
- Amar Mukund
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India,Address for correspondence: Dr Amar Mukund, Additional Professor, Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
| | - Pulkit Rangarh
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Saggere Muralikrishna Shasthry
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India,Address for correspondence: Dr Saggere Muralikrishna Shasthry, Associate Professor, Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
| | - Yashwant Patidar
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
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Long-Term Outcomes of Balloon-Occluded Retrograde Transvenous Obliteration for the Treatment of Gastric Varices: A Comparison of Ethanolamine Oleate and Sodium Tetradecyl Sulfate. Cardiovasc Intervent Radiol 2017; 41:578-586. [DOI: 10.1007/s00270-017-1869-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 12/14/2017] [Indexed: 12/24/2022]
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Hatanaka T, Kakizaki S, Suzuki Y, Ueno T, Shimada Y, Takizawa D, Katakai K, Sato K, Kusano M, Yamada M. Isolated Gastric Varices Refractory to Balloon-occluded Retrograde Transvenous Obliteration (BRTO) Successfully Treated by Shunt-occluded Endoscopic Injection Sclerotherapy (SO-EIS): A Case Report and Review of the Literature. Intern Med 2017; 56:1041-1048. [PMID: 28458309 PMCID: PMC5478564 DOI: 10.2169/internalmedicine.56.7761] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 09/08/2016] [Indexed: 12/15/2022] Open
Abstract
Balloon-occluded retrograde transvenous obliteration (BRTO) is widely used to treat isolated gastric varices (IGVs) in Japan. However, BRTO is difficult to perform for IGVs with many small collateral veins, and no secondary treatment has been established. We herein report a rare case of IGVs refractory to BRTO successfully treated by shunt-occluded endoscopic injection sclerotherapy (SO-EIS), which is a combination therapy of major shunt occlusion by a balloon catheter and endoscopic injection sclerotherapy. Since SO-EIS can be performed regardless of the IGVs' anatomical configuration, it may be a promising alternative treatment for IGVs refractory to BRTO.
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Affiliation(s)
- Takeshi Hatanaka
- Department of Internal Medicine, Isesaki Municipal Hospital, Japan
- Department of Gastroenterology, Takasaki General Medical Center, National Hospital Organization, Japan
| | - Satoru Kakizaki
- Department of Medicine and Molecular Sciences, Gunma University Graduate School of Medicine, Japan
| | - Yuhei Suzuki
- Department of Internal Medicine, Isesaki Municipal Hospital, Japan
- Department of Internal Medicine, Sanshikai Kusunoki Hospital, Japan
| | - Takashi Ueno
- Department of Internal Medicine, Isesaki Municipal Hospital, Japan
| | - Yasushi Shimada
- Department of Internal Medicine, Isesaki Municipal Hospital, Japan
| | - Daichi Takizawa
- Department of Internal Medicine, Isesaki Municipal Hospital, Japan
- Department of Gastroenterology, Maebashi Red Cross Hospital, Japan
| | - Kenji Katakai
- Department of Internal Medicine, Katakai Clinic, Japan
| | - Ken Sato
- Department of Medicine and Molecular Sciences, Gunma University Graduate School of Medicine, Japan
| | - Motoyasu Kusano
- Department of Medicine and Molecular Sciences, Gunma University Graduate School of Medicine, Japan
| | - Masanobu Yamada
- Department of Medicine and Molecular Sciences, Gunma University Graduate School of Medicine, Japan
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An Algorithm for Management After Transjugular Intrahepatic Portosystemic Shunt Placement According to Clinical Manifestations. Dig Dis Sci 2017; 62:305-318. [PMID: 28058594 DOI: 10.1007/s10620-016-4399-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 11/29/2016] [Indexed: 12/16/2022]
Abstract
We propose an algorithm for management after transjugular intrahepatic portosystemic shunt (TIPS) placement according to clinical manifestations. For patients with an initial good clinical response, surveillance Doppler ultrasound is recommended to detect stenosis or occlusion. A TIPS revision can be performed using basic or advanced techniques to treat stenosis or occlusion. In patients with an initial poor clinical response, a TIPS venogram with pressure measurements should be performed to assess shunt patency. The creation of a parallel TIPS may also be required if the patient is symptomatic and the portal pressure remains high after TIPS revision. Additional procedures may also be necessary, such as peritoneovenous shunt (Denver shunt) placement for refractory ascites, tunneled pleural catheter for hepatic hydrothorax, and balloon-occluded retrograde transvenous obliteration procedure for gastric variceal bleeding. A TIPS reduction procedure can also be performed in patients with uncontrolled hepatic encephalopathy or hepatic failure.
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Philips CA, Arora A, Shetty R, Kasana V. A Comprehensive Review of Portosystemic Collaterals in Cirrhosis: Historical Aspects, Anatomy, and Classifications. Int J Hepatol 2016; 2016:6170243. [PMID: 28074159 PMCID: PMC5198179 DOI: 10.1155/2016/6170243] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 11/01/2016] [Accepted: 11/17/2016] [Indexed: 02/07/2023] Open
Abstract
Portosystemic collateral formation in cirrhosis plays an important part in events that define the natural history in affected patients. A detailed understanding of collateral anatomy and hemodynamics in cirrhotics is essential to envisage diagnosis, management, and outcomes of portal hypertension. In this review, we provide detailed insights into the historical, anatomical, and hemodynamic aspects to portal hypertension and collateral pathways in cirrhosis with emphasis on the various classification systems.
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Affiliation(s)
- Cyriac Abby Philips
- Department of Hepatology and Transplant Medicine, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
| | - Ankur Arora
- Department of Radiodiagnosis, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
| | - Rajesh Shetty
- Department of Radiodiagnosis, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
| | - Vivek Kasana
- Department of Radiodiagnosis, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
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Kim SK, Sauk S, Guevara CJ. Transjugular intrahepatic portosystemic shunts versus balloon-occluded retrograde transvenous obliteration for the management of gastric varices: Treatment algorithm according to clinical manifestations. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii150030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Seung Kwon Kim
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO, USA
| | - Steven Sauk
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO, USA
| | - Carlos J. Guevara
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO, USA
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Lee EW, So N, Chapman R, McWilliams JP, Loh CT, Busuttil RW, Kee ST. Usefulness of intra-procedural cone-beam computed tomography in modified balloon-occluded retrograde transvenous obliteration of gastric varices. World J Radiol 2016; 8:390-396. [PMID: 27158425 PMCID: PMC4840196 DOI: 10.4329/wjr.v8.i4.390] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 01/22/2016] [Accepted: 02/17/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate whether intra-procedural cone-beam computed tomography (CBCT) performed during modified balloon-occluded retrograde transvenous obliteration (mBRTO) can accurately determine technical success of complete variceal obliteration.
METHODS: From June 2012 to December 2014, 15 patients who received CBCT during mBRTO for treatment of portal hypertensive gastric variceal bleeding were retrospectively evaluated. Three-dimensional (3D) CBCT images were performed and evaluated prior to the end of the procedure, and these were further analyzed and compared to the pre-procedure contrast-enhanced computed tomography to determine the technical success of mBRTO including: Complete occlusion/obliteration of: (1) gastrorenal shunt (GRS); (2) gastric varices; and (3) afferent feeding veins. Post-mBRTO contrast-enhanced CT was used to confirm the accuracy and diagnostic value of CBCT within 2-3 d.
RESULTS: Intra-procedural 3D-CBCT images were 100% accurate in determining the technical success of mBRTO in all 15 cases. CBCT demonstrated complete occlusion/obliteration of GRS, gastric varices, collaterals and afferent feeding veins during mBRTO, which was confirmed with post-mBRTO CT. Two patients showed incomplete obliteration of gastric varices and feeding veins on CBCT, which therefore required additional gelfoam injections to complete the procedure. No patient required additional procedures or other interventions during their follow-up period (684 ± 279 d).
CONCLUSION: CBCT during mBRTO appears to accurately and immediately determine the technical success of mBRTO. This may improve the technical and clinical success/outcome of mBRTO and reduce additional procedure time in the future.
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Gwon DI, Kim YH, Ko GY, Kim JW, Ko HK, Kim JH, Shin JH, Yoon HK, Sung KB. Vascular Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Varices and Hepatic Encephalopathy: A Prospective Multicenter Study. J Vasc Interv Radiol 2015; 26:1589-1595. [PMID: 26316136 DOI: 10.1016/j.jvir.2015.07.011] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/14/2015] [Accepted: 07/14/2015] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To evaluate technical and clinical outcomes of vascular plug-assisted retrograde transvenous obliteration (PARTO) for the treatment of gastric varices (GVs) and hepatic encephalopathy (HE). MATERIALS AND METHODS From March 2012 to June 2014, 73 consecutive patients (47 men, 26 women; mean age, 59 y; range, 28-79 y) who had undergone PARTO were evaluated in a prospective multicenter study. Among 57 patients with GVs, 28 had GVs in danger of rupture, 23 had experienced recent bleeding, and 6 had active variceal bleeding. The 16 patients with HE had been treated unsuccessfully with medical therapies. RESULTS Placement of the vascular plug and subsequent gelatin sponge embolization were technically successful in all 73 patients. There were no procedure-related complications. Follow-up CT obtained within 1 wk after PARTO showed complete thrombosis of GVs and portosystemic shunts in 72 of 73 patients (98.6%). Sixty patients who underwent follow-up longer than 3 mo showed complete obliteration of GVs and portosystemic shunts. There were no cases of variceal bleeding or HE at the end of follow-up (mean, 544 d). Improvement in Child-Pugh score was observed in 24 patients (40%) at 1-mo follow-up. Worsening of ascites and esophageal varices was observed in 14 (23.3%) and 16 (26.7%) patients at 3-mo follow-up. CONCLUSIONS The present results of PARTO indicate that it can be rapidly performed with high technical success and durable clinical efficacy for the treatment of GVs and HE in the presence of a portosystemic shunt. Therefore, PARTO might be considered a first-line treatment in appropriate patients.
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Affiliation(s)
- Dong Il Gwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea.
| | - Young Hwan Kim
- Department of Radiology, Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea
| | - Gi-Young Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Jong Woo Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Heung Kyu Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Jin Hyoung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Hyun-Ki Yoon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Kyu-Bo Sung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
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Itou C, Koizumi J, Hashimoto T, Myojin K, Kagawa T, Mine T, Imai Y. Balloon-Occluded Retrograde Transvenous Obliteration for the Treatment of Gastric Varices: Polidocanol Foam Versus Liquid Ethanolamine Oleate. AJR Am J Roentgenol 2015; 205:659-666. [PMID: 26295655 DOI: 10.2214/ajr.14.13389] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the clinical results of the management of gastric varices by balloon-occluded retrograde transvenous obliteration with polidocanol foam versus ethanolamine oleate. MATERIALS AND METHODS Twenty patients treated with ethanolamine oleate and 21 patients treated with polidocanol foam were enrolled in this study. Early therapeutic effects were assessed mainly by dynamic contrast-enhanced CT. Subjective symptoms, objective findings associated with the procedures, and changes in laboratory data during the obliteration process were evaluated. Rebleeding from gastric varices was assessed after the procedures. RESULTS Complete obliteration was confirmed in all but one case of early recanalization after treatment with polidocanol foam. One patient died of acute respiratory distress syndrome after treatment with ethanolamine oleate. The total sclerosant volume was significantly lower for 3% polidocanol foam (13.5 ± 6.8 mL) than for 5% ethanolamine oleate (30.6 ± 15.6 mL) (p < 0.01). Polidocanol foam caused fewer severe reactions, including pain, during and after injection. High body temperature, hemoglobinuria, and reactive pleural effusion were not observed with polidocanol foam. The variance in laboratory data values associated with hemolysis was significantly greater with ethanolamine oleate. No postprocedural rebleeding from the gastric varices was observed during a median follow-up time of 39.5 months after procedures with ethanolamine oleate and 34 months after procedures with polidocanol foam. CONCLUSION Polidocanol foam can achieve obliteration of gastric varices comparable to that of ethanolamine oleate but with a significantly lower sclerosant dose and reduced risk of hemolysis-induced complications and harmful reactions, including pain and fever.
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Affiliation(s)
- Chihiro Itou
- 1 Department of Diagnostic Radiology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan
| | - Jun Koizumi
- 1 Department of Diagnostic Radiology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan
| | - Takeshi Hashimoto
- 2 Department of Diagnostic Radiology, Kouseikai Hospital, Aichi, Japan
| | - Kazunori Myojin
- 3 Department of Diagnostic Radiology, Tokai University Oiso Hospital, Kanagawa, Japan
| | - Tatehiro Kagawa
- 4 Department of Gastroenterology and Hepatology, Tokai University School of Medicine, Kanagawa, Japan
| | - Tetsuya Mine
- 4 Department of Gastroenterology and Hepatology, Tokai University School of Medicine, Kanagawa, Japan
| | - Yutaka Imai
- 1 Department of Diagnostic Radiology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan
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Abstract
Bleeding from gastric varices is a major complication of portal hypertension. Although less common than bleeding associated with esophageal varices, gastric variceal bleeding has a higher mortality. From an endovascular perspective,transjugular intrahepatic portosystemic shunts (TIPS) to decompress the portal circulation and/or balloon-occluded retrograde transvenous obliteration (BRTO) are utilized to address bleeding gastric varices. Until recently, there was a clear medical cultural divide between the strategy of decompressing the portal circulation (TIPS creation, for example) and transvenous obliteration for the management of gastric varices. However, the practice of BRTO is gaining acceptance in the United States and its practice is spreading rapidly. Recently, the American College of Radiology has identified BRTO to be a viable alternative to TIPS in particular anatomical and clinical scenarios. However, the anatomical and clinical applications of BRTO were not defined beyond the conservative approach of resorting to BRTO in non-TIPS candidates. The article discusses the outcomes of BRTO and TIPS for the management of gastric varices individually or in combination. Definitions, endovascular technical concepts and contemporary vascular classifications of gastric variceal systems are described in order to help grasp the complexity of the hemodynamic pathology and hopefully help define the pathology better for future reporting and lay the ground for more defined stratification of patients not only based on comorbidity and hepatic reserve but on anatomy and hemodynamic classifications.
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Coil-Assisted Retrograde Transvenous Obliteration (CARTO) for the Treatment of Portal Hypertensive Variceal Bleeding: Preliminary Results. Clin Transl Gastroenterol 2014; 5:e61. [PMID: 25273155 PMCID: PMC4218931 DOI: 10.1038/ctg.2014.12] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 08/05/2014] [Accepted: 08/05/2014] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES: To describe the technical feasibility, safety, and clinical outcomes of coil-assisted retrograde transvenous obliteration (CARTO) in treating portal hypertensive non-esophageal variceal hemorrhage. METHODS: From October 2012 to December 2013, 20 patients who received CARTO for the treatment of portal hypertensive non-esophageal variceal bleeding were retrospectively evaluated. All 20 patients had at least 6-month follow-up. All patients had detachable coils placed to occlude the efferent shunt and retrograde gelfoam embolization to achieve complete thrombosis/obliteration of varices. Technical success, clinical success, rebleeding, and complications were evaluated at follow-up. RESULTS: A 100% technical success rate (defined as achieving complete occlusion of efferent shunt with complete thrombosis/obliteration of bleeding varices and/or stopping variceal bleeding) was demonstrated in all 20 patients. Clinical success rate (defined as no variceal rebleeding) was 100%. Follow-up computed tomography after CARTO demonstrated decrease in size with complete thrombosis and disappearance of the varices in all 20 patients. Thirteen out of the 20 had endoscopic confirmation of resolution of varices. Minor post-CARTO complications, including worsening of esophageal varices (not bleeding) and worsening of ascites/hydrothorax, were noted in 5 patients (25%). One patient passed away at 24 days after the CARTO due to systemic and portal venous thrombosis and multi-organ failure. Otherwise, no major complication was noted. No variceal rebleeding was noted in all 20 patients during mean follow-up of 384±154 days. CONCLUSIONS: CARTO appears to be a technically feasible and safe alternative to traditional balloon-occluded retrograde transvenous obliteration or transjugular intrahepatic portosystemic shunt, with excellent clinical outcomes in treating portal hypertensive non-esophageal variceal bleeding.
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Occlusion of portosystemic shunts improves hyperinsulinemia due to insulin resistance in cirrhotic patients with portal hypertension. J Gastroenterol 2014; 49:1333-41. [PMID: 24096983 DOI: 10.1007/s00535-013-0893-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 09/25/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Liver cirrhosis (LC) is often complicated by hyperinsulinemia due to insulin resistance (IR), which is considered to be closely related to shunt formation and impaired liver function. This study evaluates whether balloon-occluded retrograde transvenous obliteration (B-RTO) can affect glucose and insulin metabolism in patients with LC. METHODS Twenty-five cirrhotic patients (mean age = 69.6 years; female/male = 12/13; hepatitis C virus/alcohol/nonalcoholic steatohepatitis = 14/6/5; Child-Pugh's class A/B = 10/15) with gastric varices and/or hepatic encephalopathy caused by portosystemic shunts (PSS) due to portal hypertension (PH) underwent B-RTO at our hospital. Testing was performed before and at 1 month after the procedure. RESULTS Shunt occlusion resulted in a decrease in extrahepatic collateral blood flow and an increase in portal venous flow, as well as a dramatic improvement in hepatic function markers. In addition, B-RTO significantly decreased homeostasis model assessment (HOMA) of IR without a statistical decline of HOMA of β-cell function. The 75-g oral glucose tolerance test (75-OGTT) revealed that occlusion of PSS reduced both fasting immunoreactive insulin (IRI) levels and the area under the curve for IRI. However, no significant change in preprandial or postprandial plasma glucose levels was observed. Furthermore, according to the criteria of the American Diabetes Association, B-RTO led to an improved 75-OGTT profile in 58.3 % of patients who had impaired glucose tolerance or diabetes mellitus before the procedure. CONCLUSIONS Shunt occlusion improves IR-related hyperinsulinemia through increased portal venous flow, ameliorated liver function, and consequent augmented hepatic insulin clearance in cirrhotic patients with PH.
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Risk Factors for Rebleeding and Prognostic Factors for Postoperative Survival in Patients with Balloon-Occluded Retrograde Transvenous Obliteration of Acute Gastric Variceal Rupture. Cardiovasc Intervent Radiol 2014; 37:1235-42. [DOI: 10.1007/s00270-013-0807-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 11/17/2013] [Indexed: 12/15/2022]
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Balloon-occluded retrograde transvenous obliteration of gastric varices. Cardiovasc Intervent Radiol 2013; 37:299-315. [PMID: 24091750 DOI: 10.1007/s00270-013-0715-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 06/28/2013] [Indexed: 02/07/2023]
Abstract
Balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices is an image-guided transcatheter procedure used to treat gastric varices with sclerosants rather than decompression of the portal venous system. The history of its development, relevant portal venous, and systemic venous anatomic considerations, techniques, indications, and early results will be reviewed. In addition, the status of the practice of BRTO in the United States will be discussed.
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Sonomura T, Ono W, Sato M, Sahara S, Nakata K, Sanda H, Kawai N, Minamiguchi H, Nakai M, Kishi K. Emergency balloon-occluded retrograde transvenous obliteration of ruptured gastric varices. World J Gastroenterol 2013; 19:5125-5130. [PMID: 23964147 PMCID: PMC3746385 DOI: 10.3748/wjg.v19.i31.5125] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 06/14/2013] [Accepted: 07/05/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effectiveness and safety of emergency balloon-occluded retrograde transvenous obliteration (BRTO) for ruptured gastric varices.
METHODS: Emergency BRTO was performed in 17 patients with gastric varices and gastrorenal or gastrocaval shunts within 24 h of hematemesis and/or tarry stool. The gastric varices were confirmed by endoscopy, and the gastrorenal or gastrocaval shunts were identified by contrast-enhanced computed tomography (CE-CT). A 6-Fr balloon catheter (Cobra type) was inserted into the gastrorenal shunt via the right internal jugular vein, or into the gastrocaval shunt via the right femoral vein, depending on the varices drainage route. The sclerosant, 5% ethanolamine oleate iopamidol, was injected into the gastric varices through the catheter during balloon occlusion. In patients with incomplete thrombosis of the varices after the first BRTO, a second BRTO was performed the following day. Patients were followed up by endoscopy and CE-CT at 1 d, 1 wk, and 1, 3 and 6 mo after the procedure, and every 6 mo thereafter.
RESULTS: Complete thrombosis of the gastric varices was not achieved with the first BRTO in 7/17 patients because of large gastric varices. These patients underwent a second BRTO on the next day, and additional sclerosant was injected through the catheter. Complete thrombosis which led to disappearance of the varices was achieved in 16/17 patients, while the remaining patient had incomplete thrombosis of the varices. None of the patients experienced rebleeding or recurrence of the gastric varices after a median follow-up of 1130 d (range 8-2739 d). No major complications occurred after the procedure. However, esophageal varices worsened in 5/17 patients after a mean follow-up of 8.6 mo.
CONCLUSION: Emergency BRTO is an effective and safe treatment for ruptured gastric varices.
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Saad WEA, Nicholson D, Koizumi J. Inventory used for balloon-occluded retrograde (BRTO) and antegrade (BATO) transvenous obliteration: sclerosants and balloon occlusion devices. Tech Vasc Interv Radiol 2013; 15:226-40. [PMID: 23021833 DOI: 10.1053/j.tvir.2012.07.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The inventory used for the balloon-occluded retrograde transvenous obliteration (BRTO) and balloon-occluded antegrade transvenous obliteration procedures includes coaxial introducer sheath, catheters, balloon occlusion catheters, possibly microcatheters, possibly coils and preeminent vascular occlusion devices, and sclerosant mixtures. The inventory can be collectively categorized into "hardware" (sheaths, catheters, balloon occlusion devices, and alloy embolic agents) and sclerosant mixtures (contrast and sclerosing agents). The hardware inventory used in Japan is different from that used in the United States. Moreover, the inventory used in Japan is commonly specifically (purpose-built) designed for the BRTO procedure. Conversely, the hardware inventory used in the United States is a "generic" (multipurpose), which operators use for multiple other anatomical and clinical settings. Using different inventories that are not purposefully designed together requires multiple trials and errors to reach size and length compatibility. From a sclerosant standpoint, there is an ongoing paradigm shift toward foam-state sclerosant mixture in Japan and the United States (as of 2006). This article discusses the inventory used for BRTO and balloon-occluded antegrade transvenous obliteration in Japan and the United States and focuses on the inventory (including compatibility of inventory) that has worked and has become popularly used in the United States. The article also discusses the sclerosant mixture components, types and states (foam, froth, or liquid).
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Affiliation(s)
- Wael E A Saad
- Division of Vascular Interventional Radiology, Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA.
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25
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Acute gastrointestinal hemorrhage: radiologic diagnosis and management. Can Assoc Radiol J 2012; 64:90-100. [PMID: 23245297 DOI: 10.1016/j.carj.2012.08.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 08/03/2012] [Indexed: 02/06/2023] Open
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Balloon-occluded retrograde transvenous obliteration of gastric varices. AJR Am J Roentgenol 2012; 199:721-9. [PMID: 22997361 DOI: 10.2214/ajr.12.9052] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The purpose of this review is to describe the clinical factors related to balloon-occluded retrograde transvenous obliteration, including the preparation needed, the technique and challenges, and the outcomes. CONCLUSION Although the procedure can be performed when transjugular intrahepatic portosystemic shunt is contraindicated or when endoscopic management fails, balloon-occluded retrograde transvenous obliteration is successful as a first-line or second-line therapy. Gastric variceal rebleeding rates are low and serious complications are rare. Randomized controlled trials are required to evaluate the superiority of this procedure over other methods of treating gastric varices and to determine which sclerosant should be used. In the near future, this procedure may play a larger role in emergency care and in the management of nongastric varices.
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Saad WEA, Nicholson D, Lippert A, Wagner CC, Turba CU, Sabri SS, Davies MG, Matsumoto AH, Angle JF. Balloon-occlusion catheter rupture during balloon-occluded retrograde transvenous obliteration of gastric varices utilizing sodium tetradecyl sulfate: incidence and consequences. Vasc Endovascular Surg 2012; 46:664-70. [PMID: 23064824 DOI: 10.1177/1538574412460769] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Balloon-occluded retrograde transvenous obliteration (BRTO) is an established procedure for the management of bleeding gastric varices in Asia. Invariably, the sclerosant utilized in Asia is ethanolamine oleate and the inventory used (vascular sheaths, balloon-occlusion catheters, and microcatheters) is not available outside Asia. A total of 41 BRTO procedures were performed with a technical and obliterative (gastric varix obliteration) success rate of 95% (n = 39 of 41) and 85% (n = 35 of 41), respectively. Complications were 4.9% (n = 2/41). A total of 6 balloon ruptures occurred (14.6%, n = 6 of 41). One rupture (16.7%, n = 1 of 6 of ruptures) lead to a technical failure and 2 ruptures (33.3%, n = 2 of 6 of ruptures) lead to an obliterative failure. Balloon rupture contributed to 50% of technical failures (n = 1/2, P = .274) and 33% of obliteration failures (n = 2/6, P = .148). In conclusion, the incidence of balloon-occlusion catheter rupture utilizing 3% sodium tetradecyl sulfate (STS) and inventory unique to the United States is significantly higher than in Asia (<8% rupture rate). However, these ruptures have no significant technical or clinical consequences.
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Affiliation(s)
- Wael E A Saad
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA, USA.
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Saad WEA. The History and Evolution of Balloon-occluded Retrograde Transvenous Obliteration (BRTO): From the United States to Japan and Back. Semin Intervent Radiol 2012; 28:283-7. [PMID: 22942545 DOI: 10.1055/s-0031-1284454] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The concept of obliterating varices that complicate portal hypertension dates back to the 1970s, but its minimally invasive clinical utilization was probably lost with the advent of the transjugular intrahepatic portosystemic shunt (TIPS). The conception of retrograde obliteration of a gastrorenal shunt via the left renal vein was reported by Olson et al from the University of Indiana. However, the definition, development, technical perfection, and clinical implementation of the balloon-occluded retrograde transvenous obliteration (BRTO) occurred in Japan (by Kanagawa et al and others). The BRTO-procedure is currently undergoing a renaissance in the United States particularly for patients who are not TIPS candidates.
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Affiliation(s)
- Wael E A Saad
- Division of Vascular Interventional Radiology, Department of Radiology, University of Virginia Health System, Charlottesville, Virginia
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Saad WEA, Sabri SS. Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Technical Results and Outcomes. Semin Intervent Radiol 2012; 28:333-8. [PMID: 22942551 DOI: 10.1055/s-0031-1284460] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Variceal bleeding is one of the major complications of portal hypertension. Gastric variceal (GV) bleeding is less common than esophageal variceal (EV) bleeding, however, is associated with a high morbidity and mortality. Balloon-occluded retrograde transvenous obliteration (BRTO) is an established procedure for the management of gastric varices in Japan and has shown promising results in the past decade. The technical success rate, intent-to-treat (including technically failed BRTO-procedures) obliteration rate, and the obliteration rate of gastric varices of technically successful BRTO procedures was 91% (79-100%), 86% (73-100%), and 94% (75-100), respectively. BRTO is successful in controlling active gastric variceal bleeding in 95% of cases (91-100%) and in significantly reducing or resolving encephalopathy in 100% of cases. However, BRTO diverts blood into the portal circulation and increases the portal hypertension, thus aggravating esophageal varices with their potential for bleeding. The 1-, 2-, and 3-year esophageal variceal aggravation rates are 27-35%, 45-66%, and 45-91%, respectively. The gastric variceal rebleed rate of successful BRTO procedures, the intent-to-treat gastric variceal rebleed rate, and the global (all types of varices) variceal rebleed rate are 3.2-8.7%, 10-20%, and 19-31%, respectively. However, the advantage of diverting blood into the portal circulation and potentially toward the liver is improved hepatic function and possible patient survival. Unfortunately, the improved hepatic function is transient (for 6-12 months); however, it is preserved in the long-term (1-3 years). Patient 1-, 2-, 3-, and 5-year survival rates are 83-98%, 76-79%, 66-85%, and 39-69%, respectively. Patient survival is determined by baseline hepatic reserve and the presence of hepatocellular carcinoma.
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Affiliation(s)
- Wael E A Saad
- Division of Vascular Interventional Radiology, Department of Radiology, University of Virginia Health System, Charlottesville, Virginia
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Sabri SS, Saad WEA. Anatomy and classification of gastrorenal and gastrocaval shunts. Semin Intervent Radiol 2012; 28:296-302. [PMID: 22942547 DOI: 10.1055/s-0031-1284456] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The gastric varices communicate with gastrorenal and gastrocaval shunts and are classified according to the pattern of venous inflow into three types, which differ in the number and location of the inflow veins. The gastric varices are also classified according to their venous drainage into four different types, reflecting the size and number of collateral veins communicating with the gastric varices and the gastrorenal/gastrocaval shunt. Lastly, the gastric varices are classified according to their appearance on balloon-occluded retrograde venography into five grades representing the degree of opacification of the gastric varices and the collateral veins. Understanding these anatomic classifications is crucial in planning endovascular obliteration of gastric varices.
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Affiliation(s)
- Saher S Sabri
- Department of Radiology and Medical Imaging, Division of Interventional Radiology, University of Virginia Health System, Charlottesville, Virginia
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Saad WEA, Darcy MD. Transjugular Intrahepatic Portosystemic Shunt (TIPS) versus Balloon-occluded Retrograde Transvenous Obliteration (BRTO) for the Management of Gastric Varices. Semin Intervent Radiol 2012; 28:339-49. [PMID: 22942552 DOI: 10.1055/s-0031-1284461] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Variceal bleeding is one of the major complications of portal hypertension. Gastric variceal bleeding is less common than esophageal variceal bleeding; however, it is associated with a high morbidity and mortality rate and its management is largely uncharted due to a relatively less-established literature. In the West (United States and Europe), the primary school of management is to decompress the portal circulation utilizing the transjugular intrahepatic portosystemic shunt (TIPS). In the East (Japan and South Korea), the primary school of management is to address the gastric varices (GVs) specifically by sclerosing them utilizing the balloon-occluded retrograde transvenous obliteration (BRTO) procedure. The concept (1970s), evolution, and development (1980s-1990s) of both procedures run parallel to one another; neither is newer than the other is. The difference is that one was adopted mostly by the East (BRTO), while the other has been adopted mostly by the West (TIPS). TIPS is effective in emergently controlling bleeding for GVs even though the commonly referenced studies about managing GVs with TIPS are studies with TIPS created by bare stents. However, the results have improved with the use of stent grafts for creating TIPS. Nevertheless, TIPS cannot be tolerated by patients with poor hepatic reserve. BRTO is equally effective in controlling bleeding GVs as well as significantly reducing the GV rebleed rate. But the resultant diversion of blood flow into the portal circulation, and in turn the liver, increases the risk of developing esophageal varices and ectopic varices with their potential to bleed. Unlike TIPS, the blood diversion that occurs after BRTO improves, if not preserves, hepatic function for 6-9 months post-BRTO. The authors discuss the detailed results and critique the literature, which has evaluated and remarked on both procedures. Future research prospects and speculation as to the ideal patients for each procedure are discussed.
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Saad WE, Al-Osaimi AM, Caldwell SH. Pre– and Post–Balloon-Occluded Retrograde Transvenous Obliteration Clinical Evaluation, Management, and Imaging: Indications, Management Protocols, and Follow-up. Tech Vasc Interv Radiol 2012; 15:165-202. [DOI: 10.1053/j.tvir.2012.07.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Saad WE, Khaja MS, Hirota S. Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices: Conception, Evolution, and History. Tech Vasc Interv Radiol 2012; 15:160-4. [DOI: 10.1053/j.tvir.2012.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Saad WEA. Balloon-occluded retrograde transvenous obliteration of gastric varices: concept, basic techniques, and outcomes. Semin Intervent Radiol 2012; 29:118-28. [PMID: 23729982 PMCID: PMC3444869 DOI: 10.1055/s-0032-1312573] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Patients with gastric variceal bleeding require a multidisciplinary team approach including hepatologists, endoscopists, diagnostic radiologists, and interventional radiologists. Upper gastrointestinal endoscopy is the first-line diagnostic and management tool for bleeding gastric varices, as it is in all upper gastrointestinal bleeding scenarios. In the United States when endoscopy fails to control gastric variceal bleeding, a transjugular intrahepatic portosystemic shunt (TIPS) traditionally is performed along the classic teachings of decompressing the portal circulation. However, TIPS has not shown the same effectiveness in controlling gastric variceal bleeding that it has with esophageal variceal bleeding. For the past 2 decades, the balloon-occluded retrograde transvenous obliteration (BRTO) procedure has become common practice in Asia for the management of gastric varices. BRTO is gaining popularity in the United States. It has been shown to be effective in controlling gastric variceal bleeding with low rebleed rates. BRTO has many advantages over TIPS in that it is less invasive and can be performed on patients with poor hepatic reserve and those with encephalopathy (and may even improve both). However, its by-product is occlusion of a spontaneous hepatofugal (TIPS equivalent) shunt, and thus it is contradictory to the traditional American doctrine of portal decompression. Indeed, BRTO causes an increase in portal hypertension, with potential aggravation of esophageal varices and ascites. This article discusses the concept, technique, and outcomes of BRTO within the broader management of gastric varices.
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Affiliation(s)
- Wael E. A. Saad
- Division of Vascular Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia
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Akahoshi T, Tomikawa M, Kamori M, Tsutsumi N, Nagao Y, Hashizume M, Maehara Y. Impact of balloon-occluded retrograde transvenous obliteration on management of isolated fundal gastric variceal bleeding. Hepatol Res 2012; 42:385-93. [PMID: 22176386 DOI: 10.1111/j.1872-034x.2011.00939.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIM Although endoscopic injection of cyanoacrylate (CA) is the only effective method for treating isolated fundal gastric variceal bleeding, the rebleeding rate is relatively high. This study investigated the efficacy of balloon-occluded retrograde transvenous obliteration (B-RTO) for management of isolated fundal gastric variceal bleeding. METHODS Patients (n = 110) with acute or recent bleeding from isolated fundal gastric varices (GV) were retrospectively studied. Acute bleeding was treated by CA injection or balloon tamponade. 44 patients underwent additional endoscopic injection of CA and ethanolamine oleate (EO) weekly until obturation of GVx from 1994 to 2002 (group A). 42 patients from 2003 to 2010 underwent B-RTO after initial hemostasis (group B). Both groups were assessed for the number of sessions required to achieve GV obturation, hospital stay, recurrent bleeding rate, morbidity and mortality. RESULTS Acute gastric variceal bleeding was successfully treated in all patients by CA injection or balloon tamponade. B-RTO was successfully performed except in two patients in group B. The average number of sessions required for obturation was 3.8 for groups A and 2.2 for B (P < 0.05). Recurrent bleeding was observed in 16 and two patients in groups A and B, respectively. The cumulative non-rebleeding rate at 5 years was 58.3% and 98.1% in groups A and B, respectively. The cumulative survival rate at 5 years was 53.8% and 87.6% in groups A and B, respectively. CONCLUSION Balloon-occluded retrograde transvenous obliteration may be superior to endoscopic injection with CA and EO for prevention of rebleeding in patients with isolated fundal GVs with a major shunt.
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Affiliation(s)
- Tomohiko Akahoshi
- Department of Surgery and Science, Graduate School of Medical Sciences Center of Integration of Advanced Medicine, Life Science and Innovative Technology, Kyushu University, Fukuoka, Japan
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Sonomura T, Ono W, Sato M, Sahara S, Nakata K, Sanda H, Kawai N, Minamiguchi H, Nakai M, Kishi K. Three benefits of microcatheters for retrograde transvenous obliteration of gastric varices. World J Gastroenterol 2012; 18:1373-8. [PMID: 22493551 PMCID: PMC3319964 DOI: 10.3748/wjg.v18.i12.1373] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Revised: 02/20/2012] [Accepted: 02/26/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the usefulness of the microcatheter techniques in balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices.
METHODS: Fifty-six patients with gastric varices underwent BRTOs using microcatheters. A balloon catheter was inserted into gastrorenal or gastrocaval shunts. A microcatheter was navigated close to the varices, and sclerosant was injected into the varices through the microcatheter during balloon occlusion. The next morning, thrombosis of the varices was evaluated by contrast enhanced computed tomography (CE-CT). In patients with incomplete thrombosis of the varices, a second BRTO was performed the following day. Patients were followed up with CE-CT and endoscopy.
RESULTS: In all 56 patients, sclerosant was selectively injected through the microcatheter close to the varices. In 9 patients, microcoil embolization of collateral veins was performed using a microcatheter. In 12 patients with incomplete thrombosis of the varices, additional injection of sclerosant was performed through the microcatheter that remained inserted overnight. Complete thrombosis of the varices was achieved in 51 of 56 patients, and the remaining 5 patients showed incomplete thrombosis of the varices. No recurrence of the varices was found in the successful 51 patients after a median follow up time of 10.5 mo. We experienced one case of liver necrosis, and the other complications were transient.
CONCLUSION: The microcatheter techniques are very effective methods for achieving a higher success rate of BRTO procedures.
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Sabri SS, Swee W, Turba UC, Saad WE, Park AW, Al-Osaimi AM, Caldwell SH, Matsumoto AH, Angle JF. Bleeding Gastric Varices Obliteration with Balloon-occluded Retrograde Transvenous Obliteration Using Sodium Tetradecyl Sulfate Foam. J Vasc Interv Radiol 2011; 22:309-16; quiz 316. [DOI: 10.1016/j.jvir.2010.11.022] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Revised: 10/06/2010] [Accepted: 11/16/2010] [Indexed: 02/07/2023] Open
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Abstract
Although the incidence of bleeding from gastric varices is relatively low (10%-36%), the bleeding is massive once it has occurred and it increases the patient's mortality. The management of esophageal variceal bleeding is highly differentiated with several effective treatments available. In contrast, bleeding from gastric varices continues to be a therapeutic challenge. In the last decade, there have been increasing reports regarding the management of gastric varices. In this article we review recent progress in the management of gastric varices and discuss further expected studies.
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Affiliation(s)
- Makoto Hashizume
- Department of Advanced Medical Initiatives, Kyushu University, Fukuoka, Japan.
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Kumamoto M, Toyonaga A, Inoue H, Miyakoda K, Morita Y, Emori K, Sakamoto Y, Oho K, Sata M. Long-term results of balloon-occluded retrograde transvenous obliteration for gastric fundal varices: hepatic deterioration links to portosystemic shunt syndrome. J Gastroenterol Hepatol 2010; 25:1129-35. [PMID: 20594229 DOI: 10.1111/j.1440-1746.2010.06262.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS It is well known that a large portosystemic shunt develops during portal hypertension. In this study, we studied the long-term effects of a large splenorenal shunt (SRS) on liver function and survival. METHODS The subjects were divided into three groups: an SRS (-) group consisting of cirrhotic patients without SRS; an SRS (+) group consisting of patients with gastric fundal varices and SRS; and a balloon-occluded retrograde transvenous obliteration (B-RTO) group with a completely obliterated SRS by B-RTO. We compared the following among these groups: the total bilirubin levels, serum albumin levels, prothrombin times, changes in Child-Pugh scores, and survival rates. RESULTS After a 3-year follow-up period the Child-Pugh scores showed significant differences among the SRS (+), SRS (-), and B-RTO groups. The score worsened for the SRS (+) group. The cumulative survival rates were significantly different between the SRS (+) and SRS (-) groups and between the SRS (+) and B-RTO groups. The vital prognosis worsened for the SRS (+) group. CONCLUSIONS The presence of a large splenorenal shunt (portosystemic shunt) was indicated to lower liver function and vital prognosis. B-RTO, which completely obliterates large splenorenal shunts, inhibited the lowering of hepatic functional reserve and the worsening of vital prognosis, indicating a protective role. Liver pathology and the presence of a large portosystemic shunt each separately result in progressive liver dysfunction and worsen the survival rate. We found that such a pathological condition had occurred due to a large portosystemic shunt, and it should be called 'portosystemic shunt syndrome.'
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Affiliation(s)
- Masafumi Kumamoto
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan.
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Park SJ, Chung JW, Kim HC, Jae HJ, Park JH. The Prevalence, Risk Factors, and Clinical Outcome of Balloon Rupture in Balloon-occluded Retrograde Transvenous Obliteration of Gastric Varices. J Vasc Interv Radiol 2010; 21:503-7. [DOI: 10.1016/j.jvir.2009.11.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2009] [Revised: 11/19/2009] [Accepted: 11/30/2009] [Indexed: 01/08/2023] Open
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Wakatsuki T, Obara K, Irisawa A, Sakamoto H, Kuwana T, Takiguchi F, Saito A, Shishido H, Hikichi T, Oyama H, Shibukawa G, Takagi T, Yamamoto G, Imamura H, Takahashi Y, Sato A, Sato M, Kasukawa R, Ohira H. Analysis of prognostic factors in patients with gastric varices after endoscopic treatment. Dig Endosc 2009; 21:232-8. [PMID: 19961521 DOI: 10.1111/j.1443-1661.2009.00898.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The prognostic factors, including gastric variceal bleeding itself, in patients with gastric varices (GV) after endoscopic treatment remain unclear. The aim of this study was to analyze prognostic factors in patients with GV after endoscopic treatment as well as to evaluate safety and efficacy of our endoscopic treatment. PATIENTS AND METHODS This study enrolled 115 patients who underwent endoscopic treatment for GV between October 1988 and December 2003 using cyanoacrylate and 5% ethanolamine oleate. Successful hemostasis, recurrence rates, rebleeding rates, survival rates, complications and prognostic factors after the treatment were retrospectively reviewed. RESULTS Treatment sessions for GV were performed 3.4 +/- 2.5 times. All cases, including 14 emergency cases, were treated successfully. The cumulative recurrence rates at 1, 3 and 5 years after the treatment were 7.0%, 15.6% and 20.0%, respectively, and the cumulative rebleeding rates at 1, 3 and 5 years were 3.5%, 8.7% and 14.8%, respectively. The overall survival rates were 78.3%, 63.7% and 51.5% at 1, 3 and 5 years, respectively. Grade B or C in Child-Pugh classification, emergency or elective cases, and association with hepatocellular carcinoma were identified as significant negative prognostic factors after endoscopic treatment by multivariate analysis. Although several complications were observed, there was no mortality. CONCLUSIONS Grade B or C in Child-Pugh classification, emergency or elective situation, and association with hepatocellular carcinoma are negative prognostic factors after endoscopic treatment.
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Affiliation(s)
- Takeru Wakatsuki
- Department of Internal Medicine 2, Fukushima Medical University School of Medicine, Fukushima Medical University Hospital, Fukushima City, Fukushima, Japan.
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Tanihata H, Minamiguchi H, Sato M, Kawai N, Sonomura T, Takasaka I, Nakai M, Sahara S, Nakata K, Shirai S. Changes in portal systemic pressure gradient after balloon-occluded retrograde transvenous obliteration of gastric varices and aggravation of esophageal varices. Cardiovasc Intervent Radiol 2009; 32:1209-16. [PMID: 19688368 DOI: 10.1007/s00270-009-9679-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Revised: 06/17/2009] [Accepted: 07/27/2009] [Indexed: 02/07/2023]
Abstract
The purpose of this study was to evaluate change in the portal systemic pressure gradient (PSPG) following balloon-occluded retrograde transvenous obliteration (BRTO) and the aggravation of esophageal varices. The PSPG was monitored before and after BRTO in 19 patients. PSPG changes were obtained by subtracting the PSPG before BRTO from that after BRTO. The development of outflow vessels (e.g., left inferior phrenic vein) was classified into two grades: Grade 1, BRTO alone; and Grade 2, coil embolization plus BRTO. After confirming demonstration of the whole gastric varices on angiography and computed tomography, BRTO was conducted using a 5% ethanolamine-iopamidol mixture. Endoscopy was performed to evaluate gastric and esophageal varices before, within 1 month, and 3-6 months after BRTO. Eradication of gastric varices was obtained in all patients and aggravation of esophageal varices was seen in 11 patients. The PSPG was significantly elevated by BRTO (p=0.0362). The PSPG was significantly elevated in patients with Grade 2 compared with those with Grade 1 (7.7+/-3.7 vs. 3.3+/-4.3 mmHg, respectively; p=0.0314) and in those with esophageal varices before treatment compared with those without (7.4+/-4.0 vs. 3.2+/-3.9 mmHg, respectively; p=0.0482). The cumulative aggravation rate of esophageal varices was significantly higher in 11 patients with a PSPG elevation>5 mmHg than in 8 patients with one of <or=5 mmHg (p=0.0105). In conclusion, BRTO induced a significant elevation in PSPG, with the degree of elevation influencing the aggravation of esophageal varices following BRTO.
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Affiliation(s)
- Hirohiko Tanihata
- Department of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayamashi, Wakayama, 641-8510, Japan
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Long-Term Results of Fundectomy and Periesophagogastric Devascularization in Patients with Gastric Fundal Variceal Bleeding. World J Surg 2009; 33:2144-9. [DOI: 10.1007/s00268-009-0153-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Development of thrombus in the major systemic and portal veins after balloon-occluded retrograde transvenous obliteration for treating gastric variceal bleeding: its frequency and outcome evaluation with CT. J Vasc Interv Radiol 2008; 19:529-38. [PMID: 18375297 DOI: 10.1016/j.jvir.2007.10.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2007] [Revised: 10/03/2007] [Accepted: 10/08/2007] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To investigate the frequency and outcome of the thrombus that developed in the major systemic and portal veins after balloon-occluded retrograde transvenous obliteration (BRTO) by comparing the computed tomographic (CT) scans obtained before and after BRTO treatment. MATERIALS AND METHODS Sixty patients with liver cirrhosis who underwent BRTO to treat gastric variceal bleeding were included in this study. The pre- and postprocedural CT scans in these patients were retrospectively compared to evaluate thrombus development in the major systemic and portal veins after BRTO. Thrombus was classified as having a high attenuation (ie, containing iodized oil), combined attenuation, or low attenuation. The outcome of the thrombus that developed in those veins after BRTO was evaluated by reviewing the serial follow-up CT scans. RESULTS After BRTO, 14 thrombi developed in 13 systemic and portal veins of nine of the 60 patients (15%). Eleven of the 14 thrombi had high attenuation, two thrombi had low attenuation, and one thrombus had a combined attenuation. The 13 affected veins included six splenic veins, four left renal veins, and three main portal veins. On the serial follow-up CT scans (range of the follow-up period, 5-25 months), all 11 high-attenuation thrombi were completely resolved without sequelae in the affected veins. One of the two low-attenuation thrombi disappeared with severe slitlike collapse of the affected left renal vein; the other low-attenuation thrombus had progressed and it caused complete occlusion of the affected main portal vein. One thrombus with a combined attenuation was almost completely resolved without sequelae in the affected splenic vein, despite the transient enlargement of the low-attenuation component. CONCLUSIONS In this study, the frequency of thrombus development in the major systemic and portal veins after BRTO was 15%. Although iodized oil deposited in those veins appears to be of no great importance, the low-attenuation thrombus can be associated with occlusion of the affected vein. These tendencies, however, require validation in a larger series.
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Nakamura S, Torii N, Yatsuji S, Konishi H, Kishino M, Taniai M, Tokushige K, Hashimoto E, Shiratori K. Long-term follow up of esophageal varices after balloon-occluded retrograde transvenous obliteration for gastric varices. Hepatol Res 2008; 38:340-7. [PMID: 18021226 DOI: 10.1111/j.1872-034x.2007.00282.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Because the procedure of balloon-occluded retrograde transvenous obliteration (B-RTO) causes extensive thrombosis of the major shunt that connects the spleen and gastric/renal venous systems, an increase in portal pressure is unavoidable. The aim of the present study was to assess the long-term outcome of B-RTO, including changes in esophageal varices. METHODS B-RTO was conducted in 22 patients with gastric varices, who were divided according to the severity of esophageal varices at baseline; there were no esophageal varices (n = 7), F(1) varices (n = 11), and F(2) varices (n = 4). The outcome measures included the development/worsening of esophageal varices after B-RTO and survival rates. RESULTS The cumulative bleeding-free probability for all 22 patients at 3 years after B-RTO was 100%. The overall 3-year survival was 94.4%. Seven patients who had no esophageal varices prior to B-RTO did not develop any after the procedure. Seven (63.6%) of the 11 patients with stage F(1) esophageal varices prior to B-RTO showed no changes in the varices after B-RTO, while two patients progressed to F(2) varices and two developed F(3) varices. The cumulative treatment-free probability of the esophageal varices at 24 months after B-RTO was 100% for patients without esophageal varices at baseline, 80.8% for patients with pre-existing F(1) varices, and 75% for those with pre-existing F(2) varices. CONCLUSION Although the B-RTO procedure is considered useful for the treatment of gastric varices, changes in hemodynamics due to obliteration of this major shunt must be taken into account and observed closely.
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Affiliation(s)
- Shinichi Nakamura
- Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
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Cho SK, Shin SW, Yoo EY, Do YS, Park KB, Choo SW, Han H, Choo IW. The short-term effects of balloon-occluded retrograde transvenous obliteration, for treating gastric variceal bleeding, on portal hypertensive changes: a CT evaluation. Korean J Radiol 2008; 8:520-30. [PMID: 18071283 PMCID: PMC2627455 DOI: 10.3348/kjr.2007.8.6.520] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective We wanted to evaluate the short-term effects of balloon-occluded retrograde transvenous obliteration (BRTO) for treating gastric variceal bleeding, in terms of the portal hypertensive changes, by comparing CT scans. Materials and Methods We enrolled 27 patients who underwent BRTO for gastric variceal bleeding and they had CT scans performed just before and after BRTO. The pre- and post-procedural CT scans were retrospectively compared by two radiologists working in consensus to evaluate the short-term effects of BRTO on the subsequent portal hypertensive changes, including ascites, splenomegaly, portosystemic collaterals (other than gastrorenal shunt), the gall bladder (GB) edema and the intestinal wall edema. Statistical differences were analyzed using the Wilcoxon signed rank test and the paired t-test. Results Following BRTO, ascites developed or was aggravated in 22 (82%) of 27 patients and it was improved in two patients; the median spleen volumes increased from 438.2 cm3 to 580.8 cm3, and based on a 15% volume change cut-off value, splenic enlargement occurred in 15 (56%) of the 27 patients. The development of new collaterals or worsening of existing collaterals was not observed in any patient. GB wall edema developed or was aggravated in four of 23 patients and this disappeared or improved in five; intestinal wall edema developed or was aggravated in nine of 27 patients, and this disappeared or improved in five. Statistically, we found significant differences for ascites and the splenic volumes before and after BRTO (p = 0.001 and p < 0.001, respectively). Conclusion Some portal hypertensive changes, including ascites and splenomegaly, can be aggravated shortly after BRTO.
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Affiliation(s)
- Sung Ki Cho
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Endoscopic band ligation for cardiac variceal bleeding: safe or fatal? Gastrointest Endosc 2008; 67:189-90. [PMID: 18155440 DOI: 10.1016/j.gie.2007.07.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2007] [Accepted: 07/31/2007] [Indexed: 12/14/2022]
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Hiraga N, Aikata H, Takaki S, Kodama H, Shirakawa H, Imamura M, Kawakami Y, Takahashi S, Toyota N, Ito K, Tanaka S, Kitamoto M, Chayama K. The long-term outcome of patients with bleeding gastric varices after balloon-occluded retrograde transvenous obliteration. J Gastroenterol 2007; 42:663-72. [PMID: 17701130 DOI: 10.1007/s00535-007-2077-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2006] [Accepted: 05/20/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND The purpose of our study was to evaluate the long-term outcome and complications of balloon-occluded retrograde transvenous obliteration (B-RTO) in patients with hemorrhage from gastric fundal varices. METHODS Thirty-four consecutive patients with bleeding from gastric varices who were treated with B-RTO were enrolled in this study between December 1994 and September 2005 (urgent cases, n = 12; elective cases, n = 22). The long-term outcome, complications, and various liver functions were evaluated. RESULTS Complete obliteration was achieved in 31 of 34 (91%) patients with an acute bleeding episode. In one of the remaining patients, there was a technical failure, and the other two had only partial obliteration. The two patients with partial obliteration did not obtain hemostasis. Thus, the rate of hemostasis was 94% (31/33). Gastric varices disappeared in all patients with complete obliteration during the treatment. The rate of gastric variceal eradication was 91%. Variceal rebleeding from esophageal varices occurred in three patients. The rate of rebleeding was 10% (3/31). Rebleeding from gastric varices was not observed after complete obliteration. None of the patients showed worsening of their Child-Pugh score. Although the 5-year cumulative worsening rate of esophageal varices was 52%, neither portal hypertensive gastropathy nor ectopic varices were observed. The patients with worsening esophageal varices were successfully treated with an endoscopic procedure. The 5-year survival rate was 68%. CONCLUSIONS B-RTO is useful for treatment of bleeding gastric varices, achieving high eradication of gastric varices, a low rebleeding rate, and a fairly good prognosis with improved hepatic function.
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Affiliation(s)
- Nobuhiko Hiraga
- Department of Medicine and Molecular Science, Division of Frontier Medical Science, Programs for Biomedical Research, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
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Sugimoto N, Watanabe K, Watanabe K, Ogata S, Shimoda R, Sakata H, Eguchi Y, Mizuta T, Tsunada S, Iwakiri R, Nojiri J, Mizuguchi M, Kudo S, Miyazaki K, Fujimoto K. Endoscopic hemostasis for bleeding gastric varices treated by combination of variceal ligation and sclerotherapy with N-butyl-2-cyanoacrylate. J Gastroenterol 2007; 42:528-32. [PMID: 17653647 DOI: 10.1007/s00535-007-2041-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2007] [Accepted: 03/05/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND Bleeding from esophagogastric varices is a serious complication of portal hypertension. The aim of the present study was to determine whether endoscopic sclerotherapy with injection of N-butyl-2-cyanoacrylate combined with variceal ligation was useful for hemostasis of bleeding gastric varices. METHODS Twenty-seven patients with bleeding gastric varices underwent endoscopic treatment with variceal ligation followed by sclerotherapy with N-butyl-2-cyanoacrylate from November 1995 to November 2000. Patients underwent endoscopic variceal ligation only for the bleeding spot just before sclerotherapy. Injection was continued until varices were engorged. After these therapies, patients were followed for at least for 5 years. Retreatment was applied as necessary. RESULTS Among these patients, 11 had active bleeding and 16 had recent bleeding within 24 h with white or red plaques on gastric varices. All varices presented as nodular or tumorous forms. The hemostasis rate at 1 week after treatment with N-butyl-2-cyanoacrylate was 88.9% (24/27). Among the patients achieving hemostasis at 1 week, 33.3% (8/24) experienced recurrent bleeding between 5 and 53 months after the initial treatment. Five patients with rebleeding were treated with N-butyl-2-cyanoacrylate, and the other three patients were treated by other procedures. The final hemostasis rate was 81.5% (22/27). The 5-year survival rate after initial hemostasis was 63.0% (17/27). CONCLUSIONS This study showed that endoscopic variceal ligation combined with sclerotherapy might become a recommended choice for effective treatment of bleeding gastric varices.
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Affiliation(s)
- Nozomi Sugimoto
- Department of Internal Medicine and Gastrointestinal Endoscopy, Saga Medical School, 5-1-1 Nabeshima, Saga, 849-8501, Japan
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Caldwell SH, Hespenheide EE, Greenwald BD, Northup PG, Patrie JT. Enbucrilate for gastric varices: extended experience in 92 patients. Aliment Pharmacol Ther 2007; 26:49-59. [PMID: 17555421 DOI: 10.1111/j.1365-2036.2007.03351.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM We assessed N-2-butyl-cyanoacrylate (enbucrilate) in 92 patients with gastric variceal bleeding under an FDA-approved investigation. These results extend our prior report of the first 44 patients. METHOD Injection was performed with enbucrilate and ethiodol (1:1). Eighty patients had portal hypertension and 12 had splenic vein thrombosis. RESULTS In the portal hypertensive group, re-bleeding from gastric varices was seen in 4 of 80 (5%) from 0 to 72 h, 5 of 76 (6.5%) from > 72 h to 3 months and 9 of 51 (17%) from > 3 months to 1 year. Re-bleeding and survival were significantly related to the Child-Pugh class. In the splenic vein thrombosis group (n = 12), there was early rebleeding in 2 (17%) patients from 0 to 72 h, 1 (8%) from > 72 h to 3 months and none in the chronic phase (> 3 months to 1 year) although 1-year survival in this group was only 6 (50%) due to the underlying malignancy in most. Serious embolization was suspected in 2 patients (2%). CONCLUSION Enbucrilate offers an important intervention in gastric variceal bleeding which should be further studied in the US. A randomized trial is warranted to compare this intervention to radiological therapy.
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Affiliation(s)
- S H Caldwell
- GI/Hepatology Division, Digestive Health Center of Excellence, University of Virginia Medical Center, Charlottesville, VA 22908-0708, USA.
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