Risk and causes of gastroesophageal bleeding in patients with liver cirrhosis

BACKGROUND/AIM: Variceal bleeding is the most life-threating complication in liver cirrhosis. The aim of this study was to analyze the sources of gastroesophageal bleeding in patients with liver cirrhosis and to ascertain the risk factors of bleeding from esophageal varices. METHODS: This prospective study included 52 patients with liver cirrhosis and portal hypertension. Severity of liver dysfunction according to Child's classification, coagulation parameters, and endoscopic findings were analyzed. In patients with varices we analyzed the size, color, location of varices, and the presence of red signs. The varices were classified as small, medium and large. RESULTS: Esophageal varices were found in 76.9% of the patients. Isolated varices were present in 36.6%, and associated with other findings in 40.3%. Small varices were present in 10%, medium in 25% and large in 65% patients. Of them 55% had variceal bleeding. Variceal bleeding was present in 50% of the patients with medium and in 65.38% of the patients with large varices. There was no bleeding in the patients with small varices. Endoscopy revealed red signs before bleeding in 85% of the patients with large varices. There was a higher incidence of variceal bleeding in the Child's group B. There were no significant differences (p > 0.05) in the coagulation parameters in patients with and without variceal bleeding. Rebleeding was present in 86.36% of the patients. Most of them (52.63%) were rebleeding between 7 weeks and 12 months after the first episode of variceal bleeding. In the patients with the most severe hepatocellular dysfunction (Child's group C) the period between the first bleeding and rebleeding was the shortest (mean, 20.8 days). CONCLUSION: Our study revealed that esophageal varices are the most frequent sources of bleeding in the patients with liver cirrhosis. There is the association between the first bleeding and large varices and the red signs. Coagulation disorders and hepatic dysfunction were not related to the initial episode of variceal bleeding. The risk of early rebleeding was higher in the patients with severe hepatic dysfunction (Child's class C).     

Angiographic treatment of gastrointestinal hemorrhage: comparison of vasopressin infusion and embolization

The results of selective intraarterial vasopressin-infusion therapy and embolization therapy were compared in two groups of patients with major gastrointestinal hemorrhage. The site of bleeding, clinical course, complications, and transfusion requirements were evaluated in each group. Intraarterial vasopressin infusion therapy resulted in successful control of hemorrhage in 16 (70%) of 23 patients. Four patients, however, rebled and an operation was necessary, reducing the overall success rate to 52% (12 of 23). In the group treated with embolization therapy, primary success was achieved in 17 (71%) of 24 patients. Four patients in whom initial embolization failed to control bleeding underwent repeat embolization and in all four permanent control of hemorrhage was obtained, producing an overall success rate of 21 (88%) of 24. Analysis of our results according to site of hemorrhage suggests that at certain sites embolization is a preferred method of treatment; embolization allows earlier control of gastrointestinal hemorrhage and a reduction in transfusion requirements.     

Gastric bleeding: therapy with intraarterial vasopressin and transcatheter embolization

Angiographic therapy to control gastric bleeding was attempted in 200 patients. One hundred ninety-four patients were treated with intraarterial vasopressin and 17 of them were also treated with transcatheter embolization. Six patients underwent primary embolization, and an additional six received intravenous vasopressin. The initial rate of bleeding control in all patients angiographically treated was 73%. When embolization was used in some of the patients who did not respond to vasopressin, the overall control rate increased to 79%. Recurrent bleeding occurred in 18%. When angiographic therapy was attempted again in the patients with recurrent hemorrhage, the bleeding was stopped in 36%. Major complications occurred in 6.5% and minor in 17.5%. Of the patients with bleeding that was angiographically controlled, 73% survived and 27% died of associated clinical conditions. Among the failures of angiographic therapy, 48% died during the same hospital admission. Intraarterial infusions of vasopressin or transcatheter embolization are useful for the control of gastric bleeding.     

Emergency embolization of spontaneous ruptured hepatocellular carcinoma: correlation between survival and Child-Pugh classification

From February 1994 to April 2000, 29 emergency gelfoam embolizations for spontaneous ruptured hepatocellular carcinoma (HCC) performed in 28 patients were retrospectively reviewed. There were 11 patients in Child's A, 11 in Child's B and six in Child's C classification of cirrhosis. The duration of the procedure, artery embolized and complications were reviewed, and the Child-Pugh classification of each patient was correlated with their mean survival period. Embolization was done in 12 right hepatic arteries, two left hepatic arteries and 15 proper hepatic arteries. In one patient, the left hepatic artery was embolized initially but the proper hepatic artery was also embolized because another subcapsular liver tumour was found after reviewing the preangiogram CT scan. The entire procedure took 40-170 min (mean = 86 min) with no periprocedural complication. Following embolization, the mean survival period for Child's A class was 218.3 days, Child's B class was 83.4 days and Child's C class was 11.0 days. Transcatheter embolization is an effective treatment to arrest bleeding in spontaneous ruptured HCC. Patients with Child's A class cirrhosis have the longest survival. Selective embolization of either the right or the left hepatic artery alone carries the potential risk of missing multifocal HCC that might not be easily appreciated during angiography.     

Ethanol thrombotherapy of esophageal varices: further experience

Fifty patients with liver cirrhosis (13 Child class B, 37 class C) were treated for variceal hemorrhage during a 3-year period using the transhepatic selective catheterization and injection of absolute ethanol. Technical failure of the procedure was encountered in 13 instances. The causes were the presence of massive ascites and rigidly contracted liver, cavernous transformation of the main portal vein, and severe coagulopathy. Of the 13 failures, 12 were in Child class C and one in class B. Of 37 initially successfully treated patients, 13 rebled subsequently. Nine of these were Child class C and four were class B. Rebleeding was fatal in five of nine class C patients. Rebleeding was due to recanalization of previously thrombosed access channel in two of 13 patients. Nine patients died, despite successful thrombosis of varices, due to underlying medical conditions. Fifteen patients survived 6 months or more after initial thrombosis without rebleeding. Child class B patients are better candidates for this treatment technique because more favorable treatment results are expected in them. Child class C patients with massive ascites and severely contracted and rigid liver pose a significant technical challenge, but in about one-third, successful control of variceal bleeding can be achieved. Most of those who survived more than 6 months showed varying degrees of improvement in clinical signs and symptoms.     

Emergent Transjugular Intrahepatic Portosystemic Shunt as a First-Line Therapy in Patients with Cirrhosis with Acute Gastroesophageal Variceal Hemorrhage

PurposeTo investigate the safety and effectiveness of emergent transjugular intrahepatic portosystemic shunt (TIPS) as first-line therapy in patients with advanced cirrhosis with acute variceal hemorrhage.Materials and MethodsFrom July 2016 to June 2019, 76 patients with advanced cirrhosis and acute variceal hemorrhage were included in this retrospective study. All patients underwent emergent TIPS as first-line therapy within 24 hours. Gastroesophageal varices in patients with cirrhosis were diagnosed with contrast-enhanced computed tomography because emergent endoscopy has not been routinely performed in this center. The primary outcomes were the control rate of bleeding and the rate of rebleeding. Secondary outcomes were the technical success rate of procedure, transplantation-free survival, the mean hospitalization time, the time of stay in the intensive care unit, and adverse events.ResultsAll patients underwent TIPS creation successfully and were transferred to general wards. The median follow-up time was 21.7 months (interquartile range, 12.6–28.1 months). The control rate of bleeding (≤5 days) was 100%. The rates of early (>5 days to 6 weeks) and late (>6 weeks to 2 years) rebleeding were 6.6% and 1.3%, respectively. The 6-week, 1-year, and 2-year transplantation-free survival rates were 94.7%, 93.4%, and 84.6%, respectively. The incidences of acute liver failure, hepatic encephalopathy, and shunt dysfunction were 5.3%, 25%, and 5.3%, respectively.ConclusionsEmergent TIPS as a first-line therapy in patients with advanced cirrhosis with acute variceal hemorrhage is safe and effective. This study provides an alternative approach for medical centers without emergent endoscopy facility to manage the condition.     

Transhepatic embolization of varices

Percutaneous transhepatic embolization of varices (PTEV) has proved to be effective in the control variceal bleeding, particularly in Child's Class C Category patients whose bleeding was not adequately controlled by pitressin perfusions. PTEV, using Gelfoam soaked in sodium tetradecyl sulfate, controlled acute variceal bleeding in 71–95% of patients and appears to be more effective as an embolizing agent than bucrylate, which controlled 43–57%. Considering the poor condition of the patients particularly during acute bleeding episodes, PTEV is a relatively safe therapeutic procedure that buys time for the surgeons to perform a decompressive shunt electively as definitive surgery. A one-year recurrent bleeding rate of 30% and a two year recurrence of 37.5% was noted. Thus, for long term control of variceal bleeding, a surgical decompressive shunt is recommended in addition to PTEV.     

经皮经肝食管胃底静脉栓塞术治疗肝硬化静脉曲张的疗效评价

目的评价经皮经肝食管胃底静脉栓塞术(PTO)在治疗肝硬化静脉曲张的应用价值。方法对56例肝硬化合并食管胃底静脉曲张患者施行PTO治疗,其中35例因急性上消化道出血行急症止血治疗,10例为消化道出血停止后择期栓塞,11例肝硬化伴重度食管静脉曲张行预防性PTO治疗。结果56例患者食管胃底曲张静脉插管、栓塞成功率达100%。35例急性上消化道出血患者,急症栓塞术后均止血成功;11例行预防性PTO治疗病例,术后复查食管静脉曲张7例接近正常,4例静脉曲张程度由重度降为轻度。47例接受2～60个月随访,再出血5例,死亡4例,原因分别为再发消化道出血(1例),肝功能衰竭(1例),合并肝癌(2例)。结论对于肝硬化食管胃底静脉曲张患者,PTD是一种安全、有效的治疗方法,值得推广应用。     

Direct catheterization of the mesenteric vein: combined surgical and radiologic approach to the treatment of variceal hemorrhage

Minilaparotomy and direct catheterization of the mesenteric vein for variceal embolization was attempted in 15 patients in whom medical and endoscopic treatment of variceal hemorrhage had failed. Hemorrhage was controlled immediately after the procedure in 11 patients. The 30-day survival rate was 60% (n = 9). The cause of death in six patients was variceal bleeding (n = 2), liver failure (n = 3), and respiratory failure (n = 1). The 6-month survival rate was 33% (n = 5), and the 1-year survival rate was 27% (n = 4). Bleeding recurred in 67% of surviving patients; however, fatal variceal bleeding occurred in only 22% (n = 2). Direct mesenteric vein catheterization allows simplified entry into the portal vein for embolization of bleeding esophageal or gastric varices. Early experience suggests that the results are similar to those of percutaneous transhepatic embolization, without the complications and technical demands of a transhepatic approach.     

电影相位对比MRI肝硬化上消化道出血门静脉血流动力学研究

目的:采用电影相位对比MRI定量肝硬化门静脉血流,评价其与消化道出血的关系.方法:对49例门静脉高压症患者行电影相位对比MRI门静脉血流定量测量,依照病史分为出血组31例,无出血组18例;另选对照组19例.结果:门静脉高压出血组及未出血组门静脉主干截面积与正常组比较均显示明显增大(P＜0.05),肝硬化出血组门静脉流速较未出血组流速增高,但较正常对照组减低,该差异无统计学意义(P＞0.05),肝硬化出血组门静脉血流量明显增高,与正常组及肝硬化未出血组比较,差别具有统计学意义(P＜0.05).结论:电影相位对比MRI能客观反映门静脉血流动力学改变.     

Transcatheter embolization versus vasopressin infusion for the control of arteriocapillary gastrointestinal bleeding

The transcatheter method appropriate for use in the control of arteriocapillary gastrointestinal bleeding is a point of controversy. Intraarterial vasopressin infusion, which has been performed in more than 500 patients at the Massachusetts General Hospital, has achieved control in 90% of patients actively bleeding from the stomach and colon. In view of the severity of hemorrhage and associated illnesses in these patients, the complication rate associated with this method was low. Intraarterial vasopressin infusions were ineffective in pyloroduodenal and postoperative bleeding sites and hemorrhage from abscesses. While embolization can control bleeding in these areas, complications have been shown despite precise selective catheter placement. Because of catheterization difficulties and the permanency of the vascular occlusion, embolization is reserved for patients in whom surgical intervention would be associated with extreme risks.     

经颈静脉门腔分流术中Fluency覆膜支架应用的临床观察

目的 评价Fluency覆膜支架在经颈静脉门腔分流术(TIPS)中的临床效果.方法 搜集21例采用Fluency覆膜支架行TIPS治疗患者的临床病例资料进行回顾性分析.本组患者随访时间2.0～24.0个月,平均(10.1±4.6)个月;均为门静脉高压上消化道大出血,其中原发性肝癌门静脉主干癌栓伴大出血1例,布加综合征1例.分析患者术后支架开通情况,门静脉压力及肝功能变化情况.对手术前后门静脉压力及肝功能变化情况的比较采用配对t检验.结果21例患者共放支架25枚,均成功放置,支架直径10 mm 2枚、8 mm为23枚;覆膜支架长度6～8 cm.所有患者术后上消化道出血停止;门静脉压力由术前平均(25.4±3.5)mm Hg(1mm Hg=0.133 kPa)降为(15.4±2.8)mm Hg,手术前后差异有统计学意义(t=12.495,P<0.01).随访期间,1例原发性肝癌伴门静脉主干癌栓患者于术后4个月死亡,1例随访期间发现原发性肝癌的患者术后24个月死亡,1例门静脉高压上消化道大出血患者于术后2个月死于多器官功能衰竭,1例于术后15个月出现肝静脉端狭窄,行第2枚支架治疗效果良好,余17例随访7～17个月支架无狭窄.患者死亡前1周复查超声示支架均通畅.3例术后出现一过性肝性脑病前驱症状,经对症处理后好转.存活6个月以上的19例患者,术前Child肝功能评分(6.3±1.4)分,术后6个月评分(6.4±1.9)分,两者差异无统计学意义(t=0.645,P>0.05).结论采用Fluency覆膜支架行TIPS术,能明显提高TIPS术后开通率,但长期效果及肝性脑病的评价尚需验'证.     

经皮经肝门腔静脉分流术血流动力学与支架构型关系的临床研究

目的介绍一种全新肝内分流预应力支架的结构和在经皮经肝肝内门腔静脉分流术（PTPS）中应用的临床结果。分析应用该支架建立的门腔静脉分流道与经典TIPS所用支架血流动力学之间的区别,探讨其潜在的临床意义。方法38例门静脉高压患者采用预应力支架行经皮经肝途径门腔静脉分流术（PTPS）。静脉曲张出血36例,难治性腹水1例及肝肺综合征1例;Child＇s B级27例、C级11例。经皮经肝穿刺进入门静脉右支,再经门静脉左支矢状部穿刺肝段下腔静脉,经皮经肝植入预应力支架于门静脉左支与肝段下腔静脉之间。结果38例采用预应力支架行PTPS均获成功,技术成功率100％,未出现术中与技术相关并发症,术后门腔压力梯度平均下降14cmH2O,平均随访493d,所有患者未发生再出血,难治性腹水得到有效地控制。初步开通率98．9%,明显高于经典直管形裸支架TIPS。结论采用预应力支架经皮经肝途径建立门腔静脉分流是安全可行的,其血流动力学结果提示：预应力支架形状及与相关血管壁间“吻合”严密,符合正常肝内门静脉血流动力学分布,既起到门静脉部分性降压作用,亦保障了门静脉右支血流的肝内灌注,对预防术后分流道再狭窄及降低肝性脑病发生率具有明显的临床意义。     

Recent variceal bleeding: Doppler US hepatic vein waveform in assessment of severity of portal hypertension and vasoactive drug response

PURPOSE: To prospectively evaluate both the correlation between abnormal Doppler ultrasonography (US) hepatic vein waveforms and the hepatic venous pressure gradient (HVPG) and the response to drug treatment in patients with cirrhosis. MATERIALS AND METHODS: Ethics committee approval and informed consent of patients and control subjects were obtained. In 78 patients with cirrhosis (70 men, eight women; mean age, 49.4 years +/- 9.7 [standard deviation]) and a history of variceal bleeding, both the hepatic vein waveform--as measured with Doppler US--and the HVPG were measured, and the relationship between them was analyzed. Hepatic vein Doppler waveforms were classified as triphasic, biphasic, or monophasic. Severe portal hypertension was defined as an HVPG of more than 15 mm Hg. In a subgroup of 21 patients, changes in hepatic vein waveform and HVPG were evaluated after intravenous administration of 2 mg of terlipressin. Statistical analyses were performed with Spearman rank correlation, logistic regression analysis, and cross tabulation. RESULTS: Abnormal hepatic vein waveforms were seen in 72 patients (92%). Forty-four patients (56%) had biphasic waveforms, 28 (36%) had monophasic waveforms, and six (8%) had triphasic waveforms. A positive correlation was found between the extent of abnormalities in hepatic vein waveforms and the increase in HVPG (P < .05). Monophasic waveforms were associated with severe portal hypertension, with a sensitivity of 74% and a specificity of 95%. Twenty patients in the terlipressin subgroup had abnormal baseline waveforms; the baseline waveform improved in 18 patients in association with the HVPG reduction after injection of terlipressin. CONCLUSION: Doppler US hepatic vein waveform assessment is useful in the noninvasive evaluation of the severity of portal hypertension and the response to vasoactive drugs in patients with portal hypertension and variceal bleeding.     

Transjugular Intrahepatic Portosystemic Shunt (TIPS): Current Status and Future Possibilities

Since the insertion of the first TIPS in 1989 much has been learned about this therapeutic procedure. It has an established role for the treatment of some complications of portal hypertension: prevention of recurrent variceal bleeding and rescue of patients with acute uncontrollable variceal bleeding. In addition TIPS is useful for Budd-Chiari syndrome, refractory ascites and hepatorenal syndrome, although its specific role in these indications remains to be definitively established. However, the decrease in sinusoidal blood flow induced by TIPS can lead to the patient developing hepatic encephalopathy and liver failure in some cases. Therefore, TIPS should be used with caution in patients with very poor liver function. From a technical point of view, successful placement of TIPS is achieved in more than 98% of cases by experienced groups. At present, evaluation of TIPS dysfunction based on morphology probably leads to an overdiagnosis of this complication since most of these cases are not associated with clinical manifestations (recurrent bleeding or refractory ascites). The major disadvantage of TIPS remains its poor long-term patency requiring a mandatory surveillance program. The indicator for shunt function/malfunction should be the portosystemic pressure gradient, which is best assessed by intravascular measurements. Shunt obstructions may be prevented or reduced by the use of stent-grafts in the future.     

TIPS versus transcatheter sclerotherapy for gastric varices

OBJECTIVE: The purpose of our study was to compare the efficacy and long-term results of transjugular intrahepatic portosystemic shunt (TIPS) with those of transcatheter sclerotherapy for the treatment of gastric varices. MATERIALS AND METHODS: A total of 139 cirrhotic patients with gastric varices underwent endovascular treatment. Of the 139 patients, 104 without hepatocellular carcinoma were enrolled; 27 patients were treated with TIPS, and 77 patients with transcatheter sclerotherapy. Bleeding of gastric varices and survival rates were compared between the TIPS and transcatheter sclerotherapy groups. Multivariate analysis was used to identify the prognostic factors for gastric variceal bleeding and survival. Changes in liver function were evaluated in each group. RESULTS: The cumulative gastric variceal bleeding rate at 1 year was 20% in the TIPS group and 2% in the transcatheter sclerotherapy group (p < 0.01). The prognostic factor associated with gastric variceal bleeding was the treatment method. The cumulative survival rates at 1, 3, and 5 years were, respectively, 81%, 64%, and 40% in the TIPS group and 96%, 83%, and 76% in the transcatheter sclerotherapy group (p < 0.01). The prognostic factors for survival were the treatment method and the Child-Pugh classification of liver disease. For patients categorized in Child-Pugh class A, the survival rate was higher in the transcatheter sclerotherapy group than in the TIPS group (p < 0.01). For patients in Child-Pugh classes B and C, no significant difference was seen between the two groups. Liver function tended to improve in the transcatheter sclerotherapy group. CONCLUSION: Transcatheter sclerotherapy may provide better control of gastric variceal bleeding than TIPS. Transcatheter sclerotherapy may contribute to a higher survival rate than TIPS in patients with Child-Pugh class A disease.     

Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Variceal Bleeding: Its Feasibility Compared with Transjugular Intrahepatic Portosystemic Shunt

Objective

To assess the feasibility of balloon-occluded retrograde transvenous obliteration (BRTO) in active gastric variceal bleeding, and to compare the findings with those of transjugular intrahepatic portosystemic shunt (TIPS).

Materials and Methods

Twenty-one patients with active gastric variceal bleeding due to liver cirrhosis were referred for radiological intervention. In 15 patients, contrast-enhanced CT scans demonstrated gastrorenal shunt, and the remaining six (Group 1) underwent TIPS. Seven of the 15 with gastrorenal shunt (Group 2) were also treated with TIPS, and the other eight (Group 3) underwent BRTO. All patients were followed up for 6 to 21 (mean, 14.4) months. For statistical inter-group comparison of immediate hemostasis, rebleeding and encephalopathy, Fisher''s exact test was used. Changes in the Child-Pugh score before and after each procedure in each group were statistically analyzed by means of Wilcoxon''s signed rank test.

Results

One patient in Group 1 died of sepsis, acute respiratory distress syndrome, and persistent bleeding three days after TIPS, while the remaining 20 survived the procedure with immediate hemostasis. Hepatic encephalopathy developed in four patients (one in Group 1, three in Group 2, and none in Group 3); one, in Group 2, died while in an hepatic coma 19 months after TIPS. Rebleeding occurred in one patient, also in Group 2. Except for transient fever in two Group-3 patients, no procedure-related complication occurred. In terms of immediate hemostasis, rebleeding and encephalopathy, there were no statistically significant differences between the groups (p > 0.05). In Group 3, the Child-Pugh score showed a significant decrease after the procedure (p = 0.02).

Conclusion

BRTO can effectively control active gastric variceal bleeding, and because of immediate hemostasis, the absence of rebleeding, and improved liver function, is a good alternative to TIPS in patients in whom such bleeding, accompanied by gastrorenal shunt, occurs.     

Elective Transjugular Intrahepatic Portosystemic Shunt Using Viatorr Stent-Grafts: A Single-Center Experience from China

Background and Aims:Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established approach for the management of variceal bleeding, refractory ascites, hepatic hydrothorax, and preoperative treatment of portal hypertension prior to major abdominal surgery in patients with compensated cirrhosis, and so on. This study aimed to investigate the safety and long-term efficacy of TIPS implantation using Viatorr TIPS stent-grafts.Material and Methods:A cohort of 59 patients undergoing TIPS placement using Viatorr TIPS stent-grafts were included, and the periprocedural events, and long-term mortality, shunt dysfunction, variceal rebleeding and incidence of hepatic encephalopathy (HE) were analyzed.Results:The technical success rate was 100%. The median portosystemic pressure gradient was reduced from 21 mmHg (interquatile range: 19–25) to 13 mmHg (interquatile range: 10–16) before and after TIPS, leading to a hemodynamic success rate of 72.9%. The cumulative rate of overall mortality was 34.2% at five years, and direct bilirubin (hazard ratio [HR] = 1.336, 95% confidence interval [CI]: 1.050–1.700, P = 0.018) and post-TIPS right atrial pressure (HR = 1.238, 95% CI: 1.015–1.510, P = 0.035) were independent predictors for mortality. The cumulative rates of shunt dysfunction and variceal rebleeding were 11.0% and 28.3% at five years, respectively, and portal venous pressure gradient (HR = 2.572, 95% CI: 1.094–6.047, P = 0.030) was the only independent predictor for shunt dysfunction. The cumulative four-year HE-free rate was 48.6%. No severe adverse event was noted during TIPS procedures.Conclusion:Elective TIPS implantation using Viatorr TIPS stent-grafts is generally safe, and the long-term efficacy is favorable for the treatment of cirrhotic patients with recurrent variceal bleeding or refractory ascites.     

Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Variceal Hemorrhage

Objective

To evaluate the feasibility, safety, and clinical outcomes of plug-assisted retrograde transvenous obliteration (PARTO) to treat gastric variceal hemorrhage in patients with portal hypertension.

Materials and Methods

From May 2012 to June 2014, 19 patients (11 men and 8 women, median age; 61, with history of gastric variceal hemorrhage; 17, active bleeding; 2) who underwent PARTO using a vascular plug and a gelfoam pledget were retrospectively analyzed. Clinical and laboratory data were examined to evaluate primary (technical and clinical success, complications) and secondary (worsening of esophageal varix [EV], change in liver function) end points. Median follow-up duration was 11 months, from 6.5 to 18 months. The Wilcoxon signed-rank test was used to compare laboratory data before and after the procedure.

Results

Technical success (complete occlusion of the efferent shunt and complete filling of gastric varix [GV] with a gelfoam slurry) was achieved in 18 of 19 (94.7%) patients. The embolic materials could not reach the GV in 1 patient who had endoscopic glue injection before our procedure. The clinical success rate (no recurrence of gastric variceal bleeding) was the same because the technically failed patient showed recurrent bleeding later. Acute complications included fever (n = 2), fever and hypotension (n = 2; one diagnosed adrenal insufficiency), and transient microscopic hematuria (n = 3). Ten patients underwent follow-up endoscopy; all exhibited GV improvement, except 2 without endoscopic change. Five patients exhibited aggravated EV, and 2 of them had a bleeding event. Laboratory findings were significantly improved after PARTO.

Conclusion

PARTO is technically feasible, safe, and effective for gastric variceal hemorrhage in patients with portal hypertension.     

Hepatic artery stent-grafts for the emergency treatment of acute bleeding

Purpose

We evaluated the technical success and clinical efficacy of stent-graft implantation for the emergency management of acute hepatic artery bleeding.

Methods

Between January 2010 and July 2013, 24 patients with hemorrhage from the hepatic artery were scheduled for emergency implantation of balloon expandable stent-grafts. The primary study endpoints were technical and clinical success, which were defined as successful stent-graft implantation with sealing of the bleeding site at the end of the procedure, and cessation of clinical signs of hemorrhage. The secondary study endpoints were complications during the procedure or at follow-up and 30-day mortality rate.

Results

In 23 patients, hemorrhage occurred after surgery, and in one patient hemorrhage occurred after trauma. Eight patients had sentinel bleeding. In most patients (n = 16), one stent-graft was implanted. In six patients, two overlapping stent-grafts were implanted. The stent-grafts had a target diameter between 4 mm and 7 mm. Overall technical success was 88%. The bleeding ceased after stent-graft implantation in 21 patients (88%). The mean follow-up was 137 ± 383 days. In two patients, re-bleeding from the hepatic artery occurred during follow-up after 4 and 29 days, respectively, which could be successfully treated by endovascular therapy. The complication rate was 21% (minor complication rate 4%, major complication rate 17%). The 30-day mortality rate was 21%.

Conclusions

Implantation of stent-grafts in the hepatic artery is an effective emergency therapy and has a good technical success rate for patients with acute arterial hemorrhage.