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.     

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.     

Successful Treatment of Mesenteric Varices After Living Donor Liver Transplantation with Retrograde Transvenous Obliteration Via an Abdominal Wall Vein

Balloon-occluded retrograde transvenous obliteration is an established treatment for gastric varices; it has been used more rarely to treat mesenteric varices. We report a 12-year-old girl who had received a living donor liver transplant and suffered melena due to ruptured mesenteric varices. We addressed treatment of the mesenteric varices by retrograde transvenous obliteration of an abdominal wall collateral vein detected by superior mesenteric arteriography.     

Successful treatment of mesenteric varices with balloon-occluded retrograde transvenous obliteration via an abdominal wall vein

Balloon-occluded retrograde transvenous obliteration (BRTO) is an established therapy for gastric varices, but it has been used less frequently for mesenteric varices. This report describes the successful management of mesenteric varices with BRTO performed via an abdominal wall collateral vein detected on contrast medium-enhanced computed tomography.     

B-RTO对食管胃底静脉瘤的栓塞硬化治疗

目的　探讨B -RTO(经静脉逆行性球囊阻塞硬化法 )对食管胃底静脉瘤的栓塞硬化治疗作用。方法　对 11例患食管胃底静脉瘤病人施行了B -RTO。入路为右侧大腿静脉 ,用气囊导管闭塞胃肾短路后向食管胃底静脉瘤内注入硬化剂 (氨基乙醇油酸盐 ) ,并留管 1h ,随后造影 ,以后行CT及内窥镜检查。结果　 11例中 9例静脉瘤在随访期间明显缩小或消失 ,未发生破裂出血。少数病人食管静脉瘤较前明显 ,经内窥镜下注入硬化剂后明显缓解。结论　B -RTO对治疗食管胃底静脉瘤有显著疗效 ,可起到预防及治疗食管胃底静脉瘤破裂的作用     

Balloon-occluded retrograde transvenous obliteration of complex gastric varices assisted by temporary balloon occlusion of the splenic artery

Six cases of gastric varices with multiple afferent veins, in which balloon-occluded venography of the draining vein showed insufficient filling of gastric varices with contrast medium, were treated by balloon-occluded retrograde transvenous obliteration (BRTO) and temporary balloon occlusion of the splenic artery. The gastric varices were completely filled with sclerosant in all but one patient. No procedure-related complications were encountered. Computed tomography (CT) after the procedure showed complete thrombosis of the varices in five patients and partial thrombosis in one patient. Temporary balloon occlusion of the splenic artery is a useful additional technique for complete obliteration of gastric varices in selected cases.     

Bleeding Duodenal Varices Successfully Treated with Balloon-Occluded Retrograde Transvenous Obliteration (B-RTO) Assisted by CT During Arterial Portography

A 60-year-old woman with massive hemorrhage from duodenal varices was transferred to our hospital for the purpose of transcatheter intervention. Although digital subtraction arterial portography could not depict the entire pathway of collateral circulation, the efferent route of the duodenal varices was clearly demonstrated on subsequent CT during arterial portography. Balloon-occluded retrograde transvenous obliteration (B-RTO) of the varices was performed via the efferent vein and achieved complete thrombosis of the varices.     

Successful Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Varix Mainly Draining into the Pericardiophrenic Vein

Two cases of gastric varices were treated by balloon-occluded retrograde transvenous obliteration via the pericardiophrenic vein at our hospital, and both were successful. One case developed left hydrothorax. Gastric varices did not bled and esophageal varices were not aggravated in both cases for 24–30 months thereafter. These outcomes indicate the feasibility of balloon-occluded retrograde transvenous obliteration via the pericardiophrenic vein.     

Balloon-occluded antegrade transvenous obliteration of rectal varices: A case report

Patients with liver cirrhosis frequently experience rectal variceal bleeding subsequent to portal hypertension. Unlike gastroesophageal variceal bleeding, a well-established guideline does not exist in terms of management of bleeding rectal varices. A 75-year-old male with non-alcoholic-steatohepatitis induced cirrhosis presented with a 3-day history of severe rectorrhagia. Considering patient''s clinical history, TIPS was not performed and thus, a novel endovascular technique termed balloon-occluded antegrade transvenous obliteration was considered. Under conscious sedation, an occlusion was made through balloon catheter by sclerotic agents including air/sodium tetradecyl sulfate/Lipiodol. After the procedure, and in the 6 months follow up period the patient''s hemodynamic status was stable and he recovered without any serious complications. Balloon-occluded antegrade transvenous obliteration is a feasible and safe modality for treating rectal varices bleeding and could be used as an alternative approach in patients with contraindications to traditional treatments.     

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.     

Should balloon-occluded retrograde transvenous obliteration be the first-line interventional radiologic treatment for bleeding duodenal varices? A case report and review of the literature

We report a 78-year-old woman who presented with repeated tarry stools, and having lower duodenal variceal bleeding caused by portal hypertension. Endoscopic therapy had been attempted, but was impossible because the endoscope could not be inserted into the lower duodenum. Thus, the lower duodenal variceal bleeding was treated with balloon-occluded retrograde transvenous obliteration in combination with embolization using microcoils. Complete hemostasis was achieved without complications, and neither the recurrence of varices nor rebleeding has occurred for the last 3 years. A review of the English-language literature reveals only 11 such cases. The world literature is reviewed.     

Efficacy and Safety of Balloon-Occluded Retrograde Transvenous Obliteration with Sodium Tetradecyl Sulfate Liquid Sclerotherapy

Objective

To evaluate the efficacy and safety of balloon-occluded retrograde transvenous obliteration (BRTO) with sodium tetradecyl sulfate (STS) liquid sclerotherapy of gastric varices.

Materials and Methods

Between February 2012 and August 2014, STS liquid sclerotherapy was performed in 17 consecutive patients (male:female = 8:9; mean age 58.6 years, range 44–86 years) with gastric varices. Retrograde venography was performed after occlusion of the gastrorenal shunt using a balloon catheter and embolization of collateral draining veins using coils or gelfoam pledgets, to evaluate the anatomy of the gastric varices. We prepared 2% liquid STS by mixing 3% STS and contrast media in a ratio of 2:1. A 2% STS solution was injected into the gastric varices until minimal filling of the afferent portal vein branch was observed (mean 19.9 mL, range 6–33 mL). Patients were followed up using computed tomography (CT) or endoscopy.

Results

Technical success was achieved in 16 of 17 patients (94.1%). The procedure failed in one patient because the shunt could not be occluded due to the large diameter of gastrorenal shunt. Complete obliteration of gastric varices was observed in 15 of 16 patients (93.8%) with follow-up CT or endoscopy. There was no rebleeding after the procedure. There was no procedure-related mortality.

Conclusion

BRTO using STS liquid can be a safe and useful treatment option in patients with gastric varices.     

Foam sclerotherapy using polidocanol for balloon-occluded retrograde transvenous obliteration (BRTO)

Purpose  

To evaluate the clinical safety and effectiveness of foam sclerotherapy using polidocanol for the treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration (BRTO).     

Retrograde–Antegrade Accelerated Trap Obliteration: A Modified Approach to Transvenous Eradication of Gastric Varices

This series presents a hybrid technique for obliteration of gastric varices (GVs) termed retrograde–antegrade accelerated trap obliteration that employs sclerosant agent instillation under concurrent inflow and outflow vessel occlusion with coils or plugs. Six patients (mean age, 56 y) with GVs were treated in 2014 and 2015. Technical success rate was 100%. Five patients completed 30-day follow-up. There were no procedure-related complications, and clinical success rate was 100%, with no bleeding recurrence over a mean follow-up of 298 days ± 178. GV obliteration rate was 100% (n = 4) at a mean of 157 days ± 158. This limited experience suggests that the described technique represents a viable approach to GV obliteration.     

Balloon Occlusion Retrograde Transvenous Obliteration of Gastric Varices in Two Non-Cirrhotic Patients with Portal Vein Thrombosis

This report describes two non-cirrhotic patients with portal vein thrombosis who underwent successful balloon occlusion retrograde transvenous obliteration (BRTO) of gastric varices with a satisfactory response and no complications. One patient was a 35-year-old female with a history of Crohn''s disease, status post-total abdominal colectomy, and portal vein and mesenteric vein thrombosis. The other patient was a 51-year-old female with necrotizing pancreatitis, portal vein thrombosis, and gastric varices. The BRTO procedure was a useful treatment for gastric varices in non-cirrhotic patients with portal vein thrombosis in the presence of a gastrorenal shunt.     

Application of Balloon-Occluded Retrograde Transvenous Obliteration to Gastric Varices Complicating Refractory Ascites

We report two cases of gastric varices complicated by massive ascites that disappeared after balloon-occluded retrograde transvenous obliteration (B-RTO). The first patient had progressive gastric varices that continued to enlarge even after three episodes of esophagogastric variceal bleeding, and the second patient was admitted to our hospital because of the bleeding from gastric varices. After B-RTO procedures in both patients, significant improvement of the ascites, hepatic function reserve, and hypoalbuminemia was observed. Although further experience is needed, our experience points to the likelihood of the amelioration of ascites after B-RTO.     

Infusion of 50% glucose solution before injection of ethanolamine oleate during balloon-occluded retrograde transvenous obliteration

The feasibility of infusion of 50% glucose solution before balloon-occluded retrograde transvenous obliteration (BRTO) to occlude collateral vessels draining gastric varices other than gastrorenal shunt was evaluated. In five patients with such collateral vessels, 50% glucose solution was infused from the balloon catheter inflated within the gastrorenal shunt. The degree of collateral vessels had decreased when BRTO was carried out so that sclerotic agents sufficiently occupied the gastric varices in all patients. In three patients, embolization of collateral vessels with coils was unnecessary. There were no complications. In conclusion, retrograde infusion of 50% glucose solution assists in effectively carrying out BRTO.     

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。     

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.