球囊逆行阻断胃肾分流道联合经皮肝穿胃静脉栓塞治疗伴胃肾分流道的胃静脉曲张

目的 评价球囊逆行阻断胃肾分流道联合经皮肝穿胃静脉栓塞,治疗自发胃肾分流道形成的胃静脉曲张的临床疗效和安全性.方法 8例男性自发胃肾分流道形成的胃静脉曲张患者,年龄40～61岁,平均(50±8)岁,行经股静脉球囊逆行阻断胃肾分流道联合经皮肝穿胃静脉栓塞治疗.结果 8例患者于术成功,术后门静脉压力平均增高5.5 cm H2O(1 cm H2O=0.098 kPa,手术前为35.0～41.0 cm H2O,手术后为39.0～45.5 cm H2O).本组患者术后随访1～46个月,随访期内均未再发消化道出血.结论 球囊逆行阻断胃肾分流道联合经皮肝穿胃静脉栓塞,治疗自发胃肾分流道形成的胃静脉曲张是安全可行的,可作为治疗难以采用内镜下硬化止血治疗的自发胃肾分流道形成的胃静脉曲张的有效方法.     

球囊逆行阻断胃肾分流道联合经皮肝穿胃静脉栓塞治疗伴胃肾分流道的胃静脉曲张

目的 评价球囊逆行阻断胃肾分流道联合经皮肝穿胃静脉栓塞,治疗自发胃肾分流道形成的胃静脉曲张的临床疗效和安全性.方法 8例男性自发胃肾分流道形成的胃静脉曲张患者,年龄40～61岁,平均(50±8)岁,行经股静脉球囊逆行阻断胃肾分流道联合经皮肝穿胃静脉栓塞治疗.结果 8例患者于术成功,术后门静脉压力平均增高5.5 cm H2O(1 cm H2O=0.098 kPa,手术前为35.0～41.0 cm H2O,手术后为39.0～45.5 cm H2O).本组患者术后随访1～46个月,随访期内均未再发消化道出血.结论 球囊逆行阻断胃肾分流道联合经皮肝穿胃静脉栓塞,治疗自发胃肾分流道形成的胃静脉曲张是安全可行的,可作为治疗难以采用内镜下硬化止血治疗的自发胃肾分流道形成的胃静脉曲张的有效方法.

Abstract：

Objective To evaluate the efficacy and the safety of retrograde gastrorenal shunt balloon occlusion combined with percutaneous transhepatic gastric varices embolization to treat the gastric varices with spontaneous gastrorenal shunt. Methods From Nov. 2006 to Jun. 2010, retrograde gastrorenal shunt balloon occlusion combined with percutaneous transhepatic gastric varices embolization was performed on 8 patients who had gastric varices with spontaneous gastrorenal shunt. All the patients were men and the age ranged from 40 to 61 years. The balloon catheter was inserted into the spontaneous gastrorenal shunt through the right femoral vein, then percutaneous transhepatic splenic vein venograghy was performed to identify the number and morphology of gastric varices. After that gastric varices embolization was performed while the balloon catheter was dilated, which was withdrawn one day after the procedure. Results Technical success of interventional treatment was achieved in all 8 cases with no significant complications. The increase of average portal venous pressure was 5.5 cm H2O (1 cm H2O = 0. 098 kPa,preoperative 35.0 to 41.0 cm H2O,postoperative 39.0 to 45.5 cm H2O). After follow up of 1 to 46 months, no recurrence haemorrhage occurred. Conclusion Retrograde gastrorenal shunt balloon occlusion combined with percutaneous transhepatie gastric variees embolization can be safely performed and could be one of the effective choices for patients who had gastric varices with spontaneous gastrorenal shunt, which is not suitable to treat by the endoscopic sclerotherapy.     

经自发性胃－肾静脉分流道栓塞胃底静脉曲张（附四例报告）

目的：报告４例经自发性胃－肾静脉分流道逆行栓塞胃底静脉曲张的初步结果，旨在评价这一技术的临床应用可行性。材料和方法：４例均有反复呕血或黑便史，胃镜检查均有中度以上胃底及食管静脉曲张。２例因无分流指征而行单纯胃底静脉曲张栓塞术，另２例与经颈静脉肝内门腔静脉内支架分流术（ＴＩＰＳＳ）联合进行。结果：４例技术均成功，无并发症，术后胃底静脉曲张几乎完全消失。结论：经自发性胃－肾静脉分流道逆行栓塞胃底静脉曲张是一安全可行的技术，对闭塞胃底静脉曲张有良好效果；与ＴＩＰＳＳ术中胃冠状静脉栓塞联合应用可减少误栓并发症，加强栓塞效果。     

经自发性胃—肾静脉分流道栓塞胃底静脉曲张：附四例报告

报告４例自发性胃－肾静脉分流道逆行栓塞胃底静脉曲线的初步结果，旨在评价这一技术的临床应用可行性。４例均有反复哎务或黑便中，胃镜检查均有中度以上胃底及食管静脉曲张。２例因无分流指征而行单纯胃底静脉曲张栓塞术，另２例与经颈静脉肝内门腔静脉内支架分流术联合进行。     

急诊TIPSS在控制食管胃底静脉曲张破裂大出血中的应用及意义

目的：观察食管胃底静脉曲张破裂大出血患者行急诊经颈静脉肝内门腔静脉内支架分流术（ＴＩＰＳＳ）的治疗效果，并讨论急诊ＴＩＰＳＳ在方法学方面的特点。材料与方法：２２例患者因食管胃底静脉曲张破裂大出血接受急诊ＴＩＰＳＳ治疗。术中同时行胃冠状静脉和（或）胃短静脉栓塞。３例存在自发脾－肾或胃－肾分流道者，在球囊导管闭塞分流道肾端的前提下，行经分流道逆行胃底静脉曲张栓塞。结果：２２例中，１９例止血成功；１６例建立分流道；术后２４小时再发出血４例，其中２例死亡。结论：急诊ＴＩＰＳＳ是治疗食管胃底静脉曲张破裂大出血的有效方法。在方法学方面，急诊ＴＩＰＳＳ强调尽量通过可能途径栓塞曲张静脉，以获得及时、可靠的止血效果。     

经自发性胃-肾静脉和脾-肾静脉分流道栓塞治疗胃底静脉曲张和肝性脑病

经自发性胃－肾静脉和脾－肾静脉分流道栓塞治疗胃底静脉曲张和肝性脑病崔进国周桂芬张书田田慧琴薛春华张丽丽在门静脉高压症患者中，通过侧支循环形成自发性胃－肾静脉分流（ｓｐｏｎｔａ－ｎｅｏｕｓｇａｓｔｒｏ－ｒｅｎａｌｓｈｕｎｔ）和自发性脾－肾静脉分流（ｓｐ...     

急诊经皮经肝食管胃底静脉栓塞治疗重度肝硬化消化道出血

目的　评价经皮经肝食管胃底静脉栓塞术在重度肝硬化患者急性食管胃底静脉曲张破裂出血中的应用价值。方法　 19例食管胃底静脉曲张破裂出血肝硬化患者 ,肝功能评价均为ChildC级 ,行急诊经皮经肝食管胃底静脉栓塞治疗。结果　 19例门脉穿刺及曲张静脉栓塞手术均获成功。 18例即刻止血成功 ;1例无效 ,行TIPSS治疗。 1～ 12个月随访期内 ,再出血 14例 ;死亡 15例 ;4例存活。严重合并症 1例 ,为腹腔内出血 ,行开腹探查。结论　对于ChildC级肝硬化食管胃底静脉曲张破裂出血患者 ,急诊条件下经皮经肝食管胃底静脉栓塞术止血效果肯定 ,当TIPSS禁忌时 ,可为首选治疗方法     

经皮肝穿刺食管胃底静脉介入栓塞技术的探讨

目的探讨经皮肝穿刺食管胃底静脉栓塞治疗和预防肝硬化、门静脉高压食管胃底静脉曲张破裂出血的介入栓塞技术的临床应用。方法对48例肝硬化门静脉高压食管胃底静脉曲张患者,采用经皮肝穿刺食管胃底静脉栓塞或联合脾动脉部分栓塞术预防和控制上消化道出血。结果经皮肝穿刺食管胃底静脉栓塞手术成功率97.9%,止血率达100%。术中弹簧圈移位1例,发生以血压下降、心率减慢为特点的迷走反射4例;术后出现顽固性(胸)腹水4例,腹腔内出血导致死亡1例。术后连续随访1年:在前6个月内2例死于肝衰竭,再出血2例;在后6个月内3例失访,再出血5例。结论经皮肝穿刺食管胃底静脉栓塞技术是一种微创、有效的方法。注意手术操作细节对提高手术成功率、降低手术并发症有重要意义。     

介入血管栓塞联合内镜注射硬化治疗食管胃底静脉曲张

【摘要】目的：观察多种介入方法联合应用治疗食管胃底静脉曲张的临床效果。方法：25例食管胃底静脉曲张患者,分别行经皮肝穿冠状静脉栓塞（PTVE）和球囊阻断静脉逆行硬化闭塞胃静脉曲张（BRTO）,并发脾功能亢进者,同时行部分脾动脉栓塞（PSE）。术后对有残留食管静脉曲张的病例行内镜硬化剂注射治疗（EIS）。全部治疗完成后常规临床观察,并定期复查胃镜和CT增强扫描。结果：25例患者,7例行PTVE+PSE; 11例行BRTO,6例行BRTO+PSE,1例BRTO手术失败;术后11例患者接受内镜注射治疗一次,4例患者接受二次注射治疗。3例患者死亡,其中1例于术后2月死于再发出血。结论：多种介入方法联合应用,具有可靠的预防上消化道出血的效果。     

逆行性静脉球囊阻塞消除胃静脉曲张的可行性研究

胃静脉曲张破裂出血死亡率达55％,内窥镜硬化/结扎、外科手术、经皮经肝消除及经颈肝内门体分流等疗法疗效欠佳且有较多并发症。1991年Kanagawa等报道采用逆行静脉球囊阻塞消除胃静脉曲张(BORTO),作者通过对一组14例肝硬化性胃静脉曲张患者接受这一新疗法的长期疗效研究来评估其临床可行性。14例中男5例、女9例,平均年龄62.6岁(52～74岁)。9例为预防性BORTO,其中5例胃静脉呈瘤样曲张,4例曲张静脉呈红色征     

Retrograde transvenous obliteration of gastric varices associated with large collateral veins or a large gastrorenal shunt

Balloon-occluded retrograde transvenous obliteration of gastric varices by a microcatheter insertion method was performed in eight patients with large collateral veins or a large gastrorenal shunt. A 3-F microcatheter was selectively inserted into the gastric varices through a 6-F balloon catheter wedged in the left adrenal vein. Selective venography of the gastric varices and injection of the sclerosing agent, a mixture of 10% ethanolamine oleate and iopamidol, through the microcatheter system without occluding the collateral veins was accomplished in one treatment session in all patients. There have been no complications or recurrences of gastric varices in any of the patients during the follow-up period.     

Balloon-occluded retrograde transvenous obliteration for gastric varices via the intercostal vein

Gastric varices are usually associated with a gastrorenal(G-R) shunt.However,the gastric varices described in this case report were not associated with a G-R shunt.The inflow vessel was the posterior gastric vein and the outflow vessels were the narrow inferior phrenic vein and the dilated cardio-phrenic vein.First,percutaneous transhepatic obliteration of the posterior gastric vein was performed,but the gastric varices remained patent.Then,micro-balloon catheterization of the subphrenic vein was carried out via the jugular vein,pericardial vein and cardio-phrenic vein,however,micro-balloon-occluded inferior phrenic venography followed by micro-coil embolization of the cardio-phrenic vein revealed no delineation of gastric varices resulting in no further treatment.Thereafter,as a gastrosubphrenic-intercostal vein shunt developed,a microballoon catheter was advanced to the gastric varices via the intercostal vein and balloon-occluded retrograde transvenous obliteration(BRTO) was performed resulting in the eradication of gastric varices.BRTO for gastric varices via the intercostal vein has not previously been documented.     

Retrograde transvenous obliteration of gastric varices

PURPOSE: To evaluate the clinical efficacy, techniques, and complications associated with balloon-occluded retrograde transvenous obliteration of gastric varices. MATERIALS AND METHODS: Between December 1994 and November 1997, balloon-occluded retrograde transvenous obliteration was performed on 20 patients with gastric varices in danger of rupture and with gastrorenal shunts; three patients also had hepatic encephalopathy. The sclerosant was injected into the gastric varices during balloon occlusion. The degree of progression of the gastric varices and of collateral veins was classified into five grades, with grade 1 being least progression and grade 5 most progression; collateral veins that had developed were treated with embolization. Follow-up consisted of fiberoptic endoscopy and computed tomography. RESULTS: Technical success was achieved in all patients. Occlusion of collateral veins was essential for the occlusion of gastric varices with a grade greater than grade 2. The clinical symptoms of hepatic encephalopathy in the three patients improved remarkably. Follow-up endoscopy 3 months after the procedure revealed the disappearance of gastric varices in 15 patients and reduced variceal size in five. During the follow-up period, 19 patients had no recurrence of gastric varices; three patients had aggravation of the esophageal varices. CONCLUSION: Balloon-occluded retrograde transvenous obliteration is a feasible alternative to a transjugular intrahepatic portosystemic shunt for patients with large gastrorenal shunts or hepatic encephalopathy (or both).     

Endovascular obliteration of bleeding duodenal varices in patients with liver cirrhosis

The purpose of this paper is to describe our experience with endovascular obliteration of duodenal varices in patients with liver cirrhosis and portal hypertension. Balloon-occluded transvenous retrograde and percutaneous transhepatic anterograde embolizations were performed for duodenal varices in five patients with liver cirrhosis, portal hypertension, and decreased liver function. All patients had undergone previous endoscopic treatments that failed to stop bleeding and were poor surgical candidates. Temporary balloon occlusion catheters were used to achieve accumulation of an ethanolamine oleate–iopamidol mixture inside the varices. Elimination of the varices was successful in all patients. Retrograde transvenous obliteration via efferent veins to the inferior vena cava was enough to achieve adequate sclerosant accumulation in three patients. A combined anterograde–retrograde embolization was used in one patient with balloon occlusion of afferent and efferent veins. Transhepatic embolization through the afferent vein was performed in one patient under balloon occlusion of both efferent and afferent veins. There was complete variceal thrombosis and no bleeding was observed at follow-up. No major complications were recorded. Endovascular obliteration of duodenal varices is a feasible and safe alternative procedure for managing patients with portal hypertension and hemorrhage from this source.     

Balloon-occluded retrograde transvenous obliteration of gastric varices with gastrorenal shunt: long-term follow-up in 78 patients

OBJECTIVE: Our aim was to evaluate the long-term clinical results after balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices with spontaneous gastrorenal shunt. MATERIALS AND METHODS: A total of 78 patients with cirrhosis and with gastric varices, successfully treated by B-RTO, were enrolled in this study. Recurrence and bleeding of gastric varices and worsening of esophageal varices were endoscopically evaluated. Univariate and multivariate analyses were used to assess the prognostic factors for worsening of esophageal varices and survival. RESULTS: Recurrence of gastric varices was found in two patients; the 5-year recurrence rate was 2.7%. Bleeding of gastric varices occurred in only one patient after B-RTO; the 5-year bleeding rate was 1.5%. Worsening of esophageal varices was observed in 29 patients, and the worsening rates at 1, 3, and 5 years were 27%, 58%, and 66%, respectively. These esophageal varices were endoscopically treated to prevent rupture. Multivariate analysis showed the presence of esophageal varices before B-RTO was a prognostic factor for worsening (relative risk, 4.956). At a median follow-up of 700 days (range, 137-2,339 days), the survival rates at 1, 3, and 5 years were 93%, 76%, and 54%, respectively. The prognostic factors associated with survival were presence of hepatocellular carcinoma (relative risk, 24.342) and the Child-Pugh classification (relative risk, 5.780). CONCLUSION: B-RTO is an effective method for gastric varices with gastrorenal shunt and provides lower recurrence and bleeding rates. We believe that B-RTO can become a standard treatment for gastric varices with gastrorenal shunt, although treatment of worsened esophageal varices may be necessary after B-RTO.     

Balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices: therapeutic results and problems

PURPOSE: To evaluate the usefulness of balloon-occluded retrograde transvenous obliteration (B-RTO) in the treatment of gastric varices. MATERIALS AND METHODS: Twenty-one patients with ruptured or high-risk gastric varices underwent B-RTO. A 5-7F balloon catheter was advanced into the gastrorenal shunt and/or gastrophrenic shunt from the femoral vein. Five percent ethanolamine oleate iopamidol (EOI) was injected via the balloon catheter or a microcatheter that was advanced through the balloon catheter. EOI was withdrawn via the catheter after stagnation for 30-60 minutes. Contrast enhanced CT findings, endoscopic findings, and liver and renal function tests were evaluated before and after B-RTO. RESULTS: Nineteen patients (90%) were successfully treated with B-RTO. In 17 of them, CT within two weeks after B-RTO showed complete thrombosis of the gastric varices, and the varices had disappeared or markedly regressed on endoscopy after 1-3 months. In the other two patients, in whom CT showed partial thrombosis of the varices, the varices regressed minimally. Liver and renal function tests did not show significant changes in 17 of 19 patients (89%). Transient worsening of liver function was seen in one patient in whom a small amount of EOI moved into the splenic vein during balloon occlusion. Acute renal failure occurred in the other patient with the use of 50 ml of EOI. CONCLUSION: B-RTO is an effective therapy for gastric varices. However, careful attention should be paid to the amount of EOI and hemodynamic change caused by shunt occlusion.     

Spontaneous regression of gastric varices after iatrogenic injury to a gastrorenal shunt

We present a patient with gastric varices complicating portal hypertension caused by liver cirrhosis related to hepatitis C virus. The patient underwent balloon-occluded retrograde transvenous obliteration. The gastric varices almost completely disappeared, without any sclerotic agent being used, after iatrogenic injury of the gastrorenal shunt at the time of the interventional procedure.     

Development of a New Coaxial Balloon Catheter System for Balloon-Occluded Retrograde Transvenous Obliteration (B-RTO)

Purpose To develop a new coaxial balloon catheter system and evaluate its clinical feasibility for balloon-occluded retrograde transvenous obliteration (B-RTO). Methods A coaxial balloon catheter system was constructed with 9 Fr guiding balloon catheter and 5 Fr balloon catheter. A 5 Fr catheter has a high flexibility and can be coaxially inserted into the guiding catheter in advance. The catheter balloons are made of natural rubber and can be inflated to 2 cm (guiding) and 1 cm (5 Fr) maximum diameter. Between July 2003 and April 2005, 8 consecutive patients (6 men, 2 women; age range 33–72 years, mean age 55.5 years) underwent B-RTO using the balloon catheter system. Five percent ethanolamine oleate iopamidol (EOI) was used as sclerosing agent. The procedures, including maneuverability of the catheter, amount of injected sclerosing agent, necessity for coil embolization of collateral draining veins, and initial clinical results, were evaluated retrospectively. The occlusion rate was assessed by postcontrast CT within 2 weeks after B-RTO. Results The balloon catheter could be advanced into the proximal potion of the gastrorenal shunt beyond the collateral draining vein in all cases. The amount of injected EOI ranged from 3 to 34 ml. Coil embolization of the collateral draining vein was required in 2 cases. Complete obliteration of gastric varices on initial follow-up CT was obtained in 7 cases. The remaining case required re-treatment that resulted in complete obstruction of the varices after the second B-RTO. No procedure-related complications were observed. Conclusion B-RTO using the new coaxial balloon catheter is feasible. Gastric varices can be treated more simply by using this catheter system.