Emergency balloon-occluded retrograde transvenous obliteration for gastric varices

Background We evaluated the efficacy of emergency balloon-occluded retrograde transvenous obliteration (B-RTO) performed within 24 h after initial hemostasis for the prevention of rebleeding from ruptured gastric varices. Methods From December 1995 to March 2003, 11 patients who had undergone B-RTO within 24 h after the control of gastric variceal bleeding at Maebashi Red Cross Hospital were investigated. They were followed up for complete eradication, recurrence of varices, and rebleeding. Efficacy was determined by endoscopic examination and computed tomography. Results The 4 patients with acute bleeding from ruptured gastric varices were treated with endoscopic therapy—endoscopic variceal ligation (EVL) in 2 patients, and clipping treatment in 2. Initial hemostasis was achieved in all 4; the other 7 patients had already stopped bleeding at endoscopy. After hemostasis was achieved, emergency B-RTO was immediately performed within 24 h and was successful in all 11 patients. Ten (90.9%) of the 11 gastric varices were obliterated and the other 1 (9.1%) was diminished in size. During the mean follow-up period of 1136 days, no rebleeding or recurrence as found. Four patients died during the follow-up period, but none died from variceal bleeding. Survival rates were 90.9% and 70.7%, respectively, at 1 year and 3 years. In 6 patients, development of esophageal varices appeared during the follow-up period, all of which were controlled by usual endoscopic therapy. No severe side effects were found after the B-RTO treatment. Conclusions Emergency B-RTO is an effective treatment for the prevention of rebleeding from ruptured gastric varices.     

Emergency balloon-occluded retrograde transvenous obliteration of ruptured gastric varices

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 incom plete 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.     

Gastric ulcer after prophylactic balloon-occluded retrograde transvenous obliteration

A 74-year-old man with compensated hepatitis C virus-related liver cirrhosis was admitted for the treatment of small hepatocellular carcinoma (HCC) by radiofrequency ablation therapy (RFA). As a routine pretreatment examination, gastrointestinal endoscopy was performed, and large nodular varices were observed in the gastric fornix, with telangiectasia on top of the varices. As soon as the RFA was completed, prophylactic balloon-occluded retrograde transvenous obliteration (B-RTO) was performed. Seven days after the B-RTO, the patient complicated of upper abdominal pain. Gastrointestinal endoscopy was performed, and a deep ulcer, located at the top of the tumor-shaped gastric varices, was found. The ulcer showed rapid healing after 1-week administration of a proton pump inhibitor (PPI). A severe ulcer after a B-RTO procedure, is extremely rare, because sclerosing agents rarely flow into the gastric mucosa. The ulcer in this patient was deep and large, and it may have been due to direct mucosal damage caused by the sclerosing agent, because mucosal telangiectasia on top of the varices was observed before the B-RTO. It is likely that, in this patient, the mucosal vessels communicated with the submucosal large varices, and ethanolamine oleate (EOI) flowed into the gastric mucosa via this communication. Based on our experience, we recommend periodic follow-up endoscopy.     

The long-term outcome of patients with bleeding gastric varices after balloon-occluded retrograde transvenous obliteration

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.     

Long-term results of balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding and risky gastric varices: a 10-year experience

Background and Aim: Balloon‐occluded retrograde transvenous obliteration (B‐RTO) is a new alternative treatment for gastric varices (GVx), but the long‐term efficacy is not known. We investigated the long‐term effects of B‐RTO on rebleeding, prevention of first bleeding, mortality and occurrence of risky esophageal varices (EVx). Methods: B‐RTO was performed in 68 cirrhotic patients with GVx. Twenty patients had recent bleeding, transiently treated by endoscopic Histoacryl injection or balloon tamponade. Forty‐eight patients had varices likely to bleed, but no bleeding. After B‐RTO, the recurrent bleeding, occurrence of EVx and mortality over the long‐term were evaluated. Results: B‐RTO was successfully performed in 63 of 68 patients (92.6%). Varices eradication was confirmed by endoscopy in 61 of 63 patients (96.6%). During follow up, GVx bleeding occurred in two patients (3.2%). The 8‐year cumulative rebleeding rates of patients with bleeding and risky GVx were 14% and 0%, respectively. Risky EVx occurred in 10 patients (17%) and the cumulative occurrence rate was 22% in 8 years. The cumulative occurrence rate of risky EVx was higher in GVx with EVx (GOV2‐GVx) compared to GVx without EVx (IGV1, P < 0.05). No ectopic variceal bleeding occurred. No patients died from variceal bleeding. Hepatocellular carcinoma was the only significant prognostic factor (P < 0.05). Conclusion: B‐RTO is beneficial over the long‐term, despite worsening EVx in some patients, because of excellent treatment efficacy and improved mortality. We believe that B‐RTO can become a first‐choice radical treatment following hemostasis for gastric variceal bleeding and prophylactic treatment for risky GVx.     

Portal hemodynamics and clinical outcomes of patients with gastric varices after balloon-occluded retrograde transvenous obliteration

Background

Long-term hemodynamic effects and clinical outcomes after balloon-occluded retrograde transvenous obliteration (B-RTO) remain unclear. The purpose of this study was to evaluate long-term clinical results and effects on portal hemodynamics after B-RTO for the treatment of gastric varices with spontaneous gastrorenal shunt.

Methods

A total of 21 patients with cirrhosis and gastric varices treated by B-RTO were evaluated. The cumulative survival rate was calculated, portal blood flow was measured by Doppler ultrasonography, and liver function was estimated on the basis of Child-Pugh classification before and 1 year after B-RTO.

Results

Gastric varices disappeared or decreased markedly in size in all patients. Overall cumulative survival rates at 1, 3 and 5 years were 90.48, 71.11 and 53.71%, respectively. Portal blood flow increased significantly from 681.9 ± 294.9 to 837.0 ± 279.1 ml/min (P = 0.0125) after B-RTO. Child-Pugh score was not significantly changed (P = 0.755) after obliteration, but serum albumin was elevated significantly from 3.49 ± 0.49 to 3.75 ± 0.53 g/dl (P = 0.0459). The ascites score was significantly increased (P = 0.0455) after B-RTO, but all cases of ascites could be controlled with medication.

Conclusions

Balloon-occluded retrograde transvenous obliteration is a safe and effective treatment for gastric varices with gastrorenal shunt. Portal blood flow and serum albumin parameters are increased, and liver function is unchanged after B-RTO.     

Impact of balloon-occluded retrograde transvenous obliteration on management of isolated fundal gastric variceal bleeding

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.     

Combination of transileocolic vein obliteration and balloon-occluded retrograde transvenous obliteration is effective for ruptured duodenal varices

Duodenal varices are a rare site of hemorrhage in patients with portal hypertension, but their rupture is a serious and often fatal event. We report a 65-year-old woman who presented with hematemesis and melena. She was admitted to our department because of prolonged shock, despite having received transfusion of a large volume of blood. Upper gastrointestinal endoscopy revealed nodular varices with active bleeding in the second portion of the duodenum. Endoscopic injection sclerotherapy (EIS) was performed using a tissue adhesive agent, α-cyanoacrylate monomer, with only temporary benefit. However, anemia continued to progress after the procedure. Therefore, we combined transileocolic vein obliteration (TIO) with balloon-occluded retrograde transvenous obliteration (B-RIO), using 5% ethanolamine oleate with iopamidol to obliterate the varices. Complete hemostasis was achieved without complications. Neither recurrence of varices nor further bleeding has occurred for over 3 years. We conclude that combined TIO and B-RTO, which can obstruct both the feeding and the draining vessels of duodenal varices to retain the sclerosing agent completely in the varices, is a safe and effective hemostatic measure for ruptured duodenal varices, when EIS has failed to accomplish complete hemostasis. Received: January 18, 1999 / Accepted: May 28, 1999     

Treatment of patients with gastric variceal hemorrhage: Endoscopic N-butyl-2-cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration

Background and Aim:  Our study aimed to evaluate the therapeutic results of endoscopic N-butyl-2-cyanoacrylate injection (EBC) and balloon-occluded retrograde transvenous obliteration (BRTO) in patients with gastric variceal hemorrhage (GVH) and/or high-risk gastric varices (GV).
Methods:  Twenty-seven patients with GVH and/or high-risk GV (≥ 5 mm in diameter, those with red spots, and a Child–Pugh grading of B or C liver cirrhosis) who were treated with either EBC or BRTO from April 2005 to December 2007 were included in our study.
Results:  EBC or BRTO was initially used for the treatment of GVH in 14 and 13 patients, respectively. Technical success was achieved in all 14 patients (100%) initially treated with EBC, and 10 of 13 patients (76.9%) initially treated with BRTO. Significant rebleeding occurred in 10 patients (71.4%) of the EBC group, and two patients (15.4%) of BRTO group ( P  < 0.01). Five of six patients (83.3%) treated with rescue BRTO due to rebleeding after initial EBC achieved technical success, and all six patients who were treated with rescue BRTO had no rebleeding during the median follow up of 17 (range: 2–37) months. The cumulative survival rate of the EBC with the BRTO rescue group/BRTO group was significantly higher than the EBC group.
Conclusion:  The therapeutic efficacies of EBC and BRTO for the treatment of active GVH and/or high-risk GV appeared to be similar. However, EBC might be associated with a higher rebleeding rate than BRTO. BRTO could be an effective rescue treatment for patients with GVH after initial treatment of EBC.     

Successful balloon-occluded retrograde transvenous obliteration for bleeding duodenal varices using cyanoacrylate

A 76-year-old woman with hepatitis C cirrhosis presented with tarry stools and hematemesis.An endoscopy demonstrated bleeding duodenal varices in the second portion of the duodenum.Contrast-enhanced computed tomography revealed markedly tortuous varices around the wall in the duodenum.Several afferent veins appeared to have developed,and the right ovarian vein draining into the inferior vena cava was detected as an efferent vein.Balloon-occluded retrograde transvenous obliteration (BRTO) of the varices using cyanoacrylate was successfully performed in combination with the temporary occlusion of the portal vein.Although no previous publications have used cyanoacrylate as an embolic agent for BRTO to control bleeding duodenal varices,this strategy can be considered as an alternative procedure to conventional BRTO using ethanolamine oleate when numerous afferent vessels that cannot be embolized are present.     

Balloon-occluded retrograde transvenous obliteration for treatment of gastric varices

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.     

Efficacy of balloon-occluded retrograde transvenous obliteration, percutaneous transhepatic obliteration and combined techniques for the management of gastric fundal varices

AIM: To evaluate the effect of three interventional treatments involving transvenous obliteration for the treatment of gastric varices, and to compare the efficacy and adverse effects of these methods. METHODS: From 1995 to 2004, 93 patients with gastric fundal varices underwent interventional radiologic embolotherapy at our hospital. Of the 93 patients, 75 were treated with the balloon-occluded retrograde transvenous obliteration (BRTO) procedure; 8 were with the percutaneous transhepatic obliteration (PTO) procedure; and 10 were with the combined BRTO and PTO therapy. A follow-up evaluation examined the rates of survival, recurrence and rebleeding of the gastric varices, worsening of esophageal varices and complications in each group. RESULTS: The BRTO, PTO, and combined therapy were technically successful in 81% (75/93), 44% (8/18), and 100% (10/10) patients, respectively. Recurrence of gastric varices was found in 3 patients in the BRTO group and in 3 patients in the PTO group. Rebleeding was observed in 1 patient in the BRTO group and in 1 patient in the PTO group. The 1- and 3-year survival rates were 98% and 87% in the patients without hepatocellular carcinoma (HCC) in the BRTO group, 100% and 100% in the PTO group, and 90% and 75% in the combined therapy group, respectively. CONCLUSION: Combined BRTO and PTO therapy may rescue cases with uncontrollable gastric fundal varices that remained even after treatment with BRTO and/or PTO, though there were limitations of our study, including retrospective nature and discrepancy in sample size between the BRTO, PTO and combined therapy groups.     

Three benefits of microcatheters for retrograde transvenous obliteration of gastric varices

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.     

球囊导管闭塞下逆行性静脉栓塞术治疗胃静脉曲张破裂出血患者疗效分析

目的 胃静脉曲张(GV)破裂出血是肝硬化门脉高压性出血的一种少见类型,但其出血风险最高,内镜下治疗不易控制。本研究旨在探讨球囊导管闭塞下逆行性静脉栓塞术(BRTO)治疗GV破裂出血患者的安全性和短期疗效。方法 2018年11月～2020年1月南京鼓楼医院消化科诊治的13例肝硬化并发GV患者,均接受BRTO治疗。随访观察治疗成功率、技术相关并发症和短期生存等。结果 本组BRTO技术成功实施12例(92.3%),术后短期内未出现严重的致死性并发症,术后2例(16.7%)经超声检查发现新发门静脉血栓形成,给予低分子肝素抗凝治疗后血栓消失;在短期随访期间,未发生食管胃静脉曲张破裂出血,1例(7.7%)患者死于原发性肝癌导致的肝衰竭;新发轻度腹腔积液1例,1例肝性脑病患者术后血氨下降,临床症状缓解。结论 BRTO是一项安全、有效的介入技术,可有效预防胃静脉曲张破裂出血,值得进一步扩大应用和观察。     

Treatment of bleeding stomal varices by balloon-occluded retrograde transvenous obliteration

Although stomal varices are a rare complication, bleeding stomal varices often need to be treated owing to symptoms of hypovolemic shock, recurrence of stomal bleeding, or deterioration in the quality of life. Various treatment strategies for the management of bleeding stomal varices have thus far been reported. We report the case of a 60-year-old woman with refractory recurrent bleeding from varices in a sigmoid stoma, along with nonalcoholic steatohepatitis and marked splenomegaly. A physical examination revealed that the skin was discolored and bluish around the circumference of the sigmoid stoma. The venous phase of a celiac arteriogram revealed an afferent vein from the splenic vein and another from the inferior mesenteric vein, and veins draining into the left superficial epigastric vein. A balloon-occluded retrograde transvenous obliteration (BRTO) procedure was performed. The skin around the stoma, initially discolored bluish, improved markedly. After 10 months of follow-up, the patient has remained well without further episodes of stomal bleeding. To our knowledge, this is the first case of recurrent hemorrhage from stomal varices that was successfully treated by BRTO in a patient with portal hypertension.     

Respiratory effects of balloon occluded retrograde transvenous obliteration of gastric varices: a prospective controlled study

Background and Aim: We evaluated the respiratory effects of balloon‐occluded retrograde transvenous obliteration (BRTO) performed for the treatment of gastric varices complicating liver cirrhosis. Methods: From 2005 to 2009, we performed BRTO in 20 patients with gastric fundal varices, by intravariceal injection of 5% ethanolamine oleate (EO) as the sclerosant. We studied the effect of BRTO on the respiratory gas exchange, chest X‐ray findings, computed tomography (CT) findings, pulmonary function parameters, and ^99mTc‐MAA lung perfusion scintigraphy findings. Subjects undergoing balloon‐occluded retrograde transvenous varicerography (BRTV) without injection of the sclerosant served as the controls. Results: Arterial blood gas analysis revealed a decrease in the mean arterial partial oxygen tension (PaO₂) (P < 0.01), and increase in the alveolar‐arterial oxygen tension difference (AaDO₂) after BRTO (P < 0.01), as compared with the results obtained before the BRTO, while breathing room air. No changes were observed after BRTV as compared with the previous findings. In addition, a significant correlation was observed between the change of the PaO₂ and the volume of the sclerosant injected (rs = 0.511, P = 0.011). Left‐pleural effusion was noted on the chest CT in 20% of the patients. On pulmonary function testing, decrease of the vital capacity was noted in two of the 20 patients after BRTO. Conclusion: The aforementioned results suggest that BRTO performed using EO as the sclerosant induces pulmonary function disorders. The effect was found to depend on the total amount of EO injected. Therefore, careful respiratory monitoring seems necessary in patients undergoing BRTO, particularly those in whom large volumes of the sclerosant are used.     

Long‐term results of balloon‐occluded retrograde transvenous obliteration for gastric fundal varices: Hepatic deterioration links to portosystemic shunt syndrome

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.’