"Downgrading" of gastric varices with multiple collateral veins in balloon-occluded retrograde transvenous obliteration

The efficacy of a "downgrading" method for treatment of gastric varices (GVs) was evaluated in 15 patients who had undergone balloon-occluded retrograde transvenous obliteration (B-RTO) of GVs with multiple collateral veins. Downgrading in this study was meant to transform high-grade GVs into GVs with a low-grade architecture more amenable to treatment. Success was defined as gastrorenal shunt occlusion at the proximal site with a 6-F balloon catheter advanced over a microcatheter and without opacification of large collateral vessels. Thirteen of 15 patients with grade 3/4 GVs had their GVs successfully downgraded. The procedure is thought to be safe and effective in the initial B-RTO procedure.     

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).     

Transportal intravariceal sclerotherapy with N-butyl-2-cyanoacrylate for gastric varices

Four patients with gastric varices without catheterizable draining veins through a systemic vein were treated with transportal intravariceal sclerotherapy with n-butyl-2-cyanoacrylate (NBCA). In all patients, the gastric varices were successfully obliterated with 2-5 mL of NBCA-lipiodol mixture injected via a microcatheter introduced into the varices with transhepatic or transileocolic portal venous access. No complications related to the procedure were encountered. Follow-up gastroendoscopy showed disappearance (n = 3) or marked decrease (n = 1) of the varices. Neither recurrent gastric varices nor variceal bleeding were observed during the follow-up period (6-46 months). Transportal intravariceal sclerotherapy is useful for obliteration of gastric varices in selected cases.     

Percutaneous transhepatic portography. III. Relationships between portosystemic collaterals and portal pressure in cirrhosis.

The relationships among collateral veins, gastroesophageal varices, extrahepatic shunting, and free portal pressure were studied by percutaneous transhepatic portography in 57 patients with cirrhosis of the liver. The size of esophageal varices was related to the size of the coronary and short gastric veins and to the portal pressure. The size of gastric varices was related to cephalad collaterals from the spleen and splenic vein, but not to portal pressure. Portosystemic shunting was associated with collaterals in the lower abdomen, but not with varices or portal pressure.     

多层螺旋CT门静脉成像对门脉高压侧支循环血管的研究

目的:评价多层螺旋CT门静脉成像(MDCTP)在门脉高压侧支循环血管显示中的价值。方法:31例经临床检查确诊的门静脉高压患者行MDCTP检查,采用MIP、MPR、VR等重建技术进行图像后处理,获得门静脉系统及侧支血管图像,两名医师分别判断侧支血管显示情况。结果:MDCTP不仅显示肝内门静脉3~4级分支,还显示了整个门脉侧支血管系统。31例患者中,胃左静脉曲张28例,食管或食管旁静脉曲张27例,脾静脉曲张21例,胃短/胃后静脉曲张7例,脾-肾分流血管1例,脐静脉曲张伴腹壁静脉曲张2例,门静脉栓塞4例,肠系膜上静脉血管闭塞2例。结论:MDCTP能显示门静脉高压侧支血管开放的部位、范围及程度,有助于对门脉高压患者治疗方案的选择,是一种有重要临床价值的无创性门脉检查方法。     

胃静脉曲张的CT表现（附15例报告）

本文对经手术或胃镜证实为胃静脉曲张的１５例患者的ＣＴ检查进行了回顾性分析，描述了胃静脉曲张的ＣＴ表现及其特点。胃静脉曲张特征性ＣＴ表现为注射造影剂后增厚的胃壁内可见条状或管状致密影，本组９例强化，７例显示特征性表现。ＣＴ检查还可以确定其原发疾病，脾血管和门静脉扩张程度，以及腹腔内侧支循环情况。     

MDCTP对肝硬化门脉高压侧支循环血管的显示价值

目的:评价16排螺旋CT门静脉血管成像(MDCTP)技术在显示肝硬化门脉高压侧支循环血管方面的应用价值。方法:对38例临床诊断肝硬化门脉高压的患者行上腹部MDCTP检查。采用MIP、MPR、VR等三维重组技术进行图像后处理,获得门静脉系统及侧支循环血管图像。结果:38例中显示食管胃底粘膜下静脉曲张31例,食管旁静脉曲张10例;胃左静脉曲张29例,胃短静脉曲张26例;脐静脉与腹壁静脉曲张7例;脾-肾或胃-肾分流6例;腹膜后分流2例。结论:MDCTP能显示肝硬化患者门-体侧支循环开放部位、范围及程度,有重要的临床应用价值。     

Use of a catheter with a large side hole for selective catheterization of the inferior phrenic artery

The authors report the use of a catheter with a large side hole in the catheterization of the right inferior phrenic artery (IPA) arising from the proximal portion of the celiac trunk. A 5-F catheter with a side hole on either the top or the right side of the superior portion near the tip was used in five patients with hepatocellular carcinoma fed by the right IPA, which could not be selected by a conventional coaxial technique. In all patients, a 3-F microcatheter was successfully advanced into the right IPA through the side hole of this catheter introduced into the celiac artery or the common hepatic artery.     

Percutaneous Transportal Sclerotherapy with N-Butyl-2-Cyanoacrylate for Gastric Varices: Technique and Clinical Efficacy

Objective

This study was deigned to evaluate the technique and clinical efficacy of the use of percutaneous transportal sclerotherapy with N-butyl-2-cyanoacrylate (NBCA) for patients with gastric varices.

Materials and Methods

Seven patients were treated by transportal sclerotherapy with the use of NBCA. For transportal sclerotherapy, portal vein catheterization was performed with a 6-Fr sheath by the transhepatic approach. A 5-Fr catheter was introduced into the afferent gastric vein and a microcatheter was advanced through the 5-Fr catheter into the varices. NBCA was injected through the microcatheter in the varices by use of the continuous single-column injection technique. After the procedure, postcontrast computed tomography (CT) was performed on the next day and then every six months. Gastroendoscopy was performed at one week, three months, and then every six months after the procedure.

Results

The technical success rate of the procedure was 88%. In six patients, gastric varices were successfully obliterated with 1-8 mL (mean, 5.4 mL) of a NBCA-Lipiodol mixture injected via a microcatheter. No complications related to the procedure were encountered. As seen on the follow-up endoscopy and CT imaging performed after six months, the presence of gastric varcies was not seen in any of the patients after treatment with the NBCA-Lipiodol mixture and the use of microcoils. Recurrence of gastric varices was not observed during the follow-up period. Worsening of esophageal varices occurred in four patients after transportal sclerotherapy. The serum albumin level increased, the ammonia level decreased and the prothrombin time increased at six months after the procedure (p < 0.05).

Conclusion

Percutaneous transportal sclerotherapy with NBCA is useful to obliterate gastric varices if it is not possible to perform balloon-occluded retrograde transvenous obliteration.     

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.     

肝硬化门静脉高压侧枝血管的多层螺旋CT表现

目的用多层螺旋CT(MSCT)统计、分析肝硬化门静脉高压患者的侧枝循环表现。方法收集203例肝硬化门静脉高压患者MSCT上腹部检查的完整资料。结果共发现门静脉侧枝或异常血管612处:食管下段静脉曲张175处,食管旁静脉曲张49处(其中伴假肿瘤征13处),胃底静脉曲张119处,胃冠状静脉曲张105处,胃肾静脉分流34处,脾肾静脉分流15处,椎旁静脉丛曲张16处,脐静脉再通48处,副脐静脉再通22处,脐静脉、副脐静脉同时再通4处,腹壁静脉丛曲张呈蛇头征12处,门静脉海绵样变8处,门静脉右后支瘤样扩张并与下腔静脉分流4处,胃左静脉直接入肝与门静脉左支相连1处。结论MSCT可较好地显示各类门静脉高压侧枝,了解这些异常表现有助于作出正确诊断,避免误诊,对临床选择治疗方法有重要的意义。     

Recognition of splenic vein occlusion.

Radiologic findings and medical records of 27 patients with angiographic documentation of splenic vein occlusion were reviewed. The most common causes were pancreatic carcinoma, pancreatitis, and malignant lymphoma. Radiographic findings which suggest splenic vein occlusion are gastric varices without esophageal varices and collateral veins in the left upper abdomen during the vascular phase of rapid sequence pyelography. Additional features may be associated with the underlying disease, such as pancreatic calcification and upper abdominal mass lesions. The diagnosis is usually confirmed by high dose celiac or splenic angiography. Examination of the stomach with barium for the detection of gastric varices is more sensitive than has been previusly recognized; features which suggest them are described. Isolated gastric varices may be a clue to isolated splenic vein occlusion and its underlying causes.     

Percutaneous transhepatic obliteration of gastroesophageal varices: some technical aspects.

Two cases of bleeding from gastroesophageal varices treated by variceal obliteration illustrate multiple routes of variceal supply, and alert embolizing angiographers to the presence of spontaneous portosystemic shunts which should be kept open. In one case, variceal obliteration required embolization of the left gastric vein and a transhepatic collateral originating from the left hepatic portal branch and contributing substantially to variceal filling. A second patient with a relatively large spontaneous splenorenal shunt had recurrent variceal bleeding two months after a successful embolization of the coronary vein and a short gastric vein. A repeat study revealed the recurrent varices were supplied by enlarged right gastric and gastroepiploic veins. Superior mesenteric venography was necessary for their visualization.     

Long-term results of balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy

PURPOSE: To evaluate the long-term results of balloon-occluded retrograde transvenous obliteration (B-RTO) for the treatment of gastric varices (GV) and hepatic encephalopathy. MATERIALS AND METHODS: A total of 43 patients who had undergone B-RTO were evaluated, 32 with GV, two with hepatic encephalopathy, and nine with both. All but one had been consecutively followed up with gastrointestinal endoscopy for more than 1 year (3-60 months; mean, 30.44 months). Collateral veins of gastric varices were graded using balloon-occluded retrograde left adrenal venography. The relation of both worsening of esophageal varices (EV) and improved Child-Pugh score after B-RTO to the grades of collateral vein development was analyzed. The relapse-free survival and the prognostic factors for survival after B-RTO were also assessed. RESULTS: GV disappeared or decreased markedly in size, and hepatic encephalopathy was completely cured in all patients. Improvement in Child-Pugh score was observed in 21 patient (50.0%) 6 months after B-RTO, but in only 11 patients (25.6%) 1 year after B-RTO. Worsening of EV was seen in eight patients and was related to a worsened grade of collateral veins. Cumulative relapse-free survival rate was 90.8% at 1 year and 87.4% at 3 years after B-RTO. The most significant prognostic factor was Child-Pugh classification (relative risk: 4.16) CONCLUSION: B-RTO is a safe and effective treatment for patients with GV and hepatic encephalopathy. The most important prognostic factors are the extent of Child-Pugh classification.     

Collateral pathways of the left gastric vein in portal hypertension

Since June 1974, 347 percutaneous transhepatic portal venographic studies were performed on 246 patients with portal hypertension who had had bleeding gastroesophageal varices. Of 234 patients in whom left gastric veins (LGV) (coronary) were demonstrated, 177 (75.6%) had a single LGV and 57 (24.4%) had multiple left gastric veins (21.8% had two LGVs, 2.1% had three LGVs, and 0.5% had five LGVs). Of 193 patients undergoing selective left gastric venography, spontaneous portosystemic communications to the left renal vein were found in 55, to the inferior vena cava in two, to the inferior pulmonary veins in five, to the pericardiophrenic vein in eight, to the right inferior phrenic vein in three, and to the left intercostal veins in one. Interportal communications with the left gastric vein and varices occurred from the left portal vein in 13, from the gastroepiploic vein in one, and from a superior mesenteric vein branch in one. The predominant drainage of esophageal varices was to the azygos vein in 78 of 155 patients, to the hemiazygos vein in 13, and to multiple small unnamed veins in the mediastinum in 57. Opacified varices did not extend above the level of the azygos vein arch in 71 of 130 patients; however, 59 continued cephalad to the azygos arch and drained through more superior veins of the thorax. Knowledge of the anatomy and incidence of each of these portosystemic or interportal venous communications is important to properly treat bleeding esophageal varices by surgery or angiographic embolization.     

Balloon-occluded retrograde transvenous obliteration (B-RTO) for portal hypertension

We reviewed the current techniques and published results of balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices (GV) and hepatic encephalopathy. The portal hemodynamics of gastric varices were classified into three types according to their feeding vessels, and the development of collateral veins under balloon occlusion of gastro-renal shunt was classified into five grades. The main draining veins of gastric varices were gastro-renal and gastro-inferior phrenic shunts. Preprocedural diagnosis of portal hemodynamics is important in selecting the technique for B-RTO. The rate of disappearance or marked reduction of GV was 98%, and the rate of recurrence of GV was 2%. Hepatic encephalopathy due to gastro-renal shunt improved markedly. In contrast, esophageal varices were aggravated at rates of 10% to 62.5% by the post-procedural elevation of portal pressure. Common adverse effects were hemoglobinuria, abdominal pain, and low-grade fever, but ascites and pleural effusion were also reported. Severe complications such as cardiogenic shock, atrial fibrillation, and pulmonary embolism were reported. We await technical improvements and further indications for this procedure.     

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.     

Three-dimensional portography using multislice helical CT is clinically useful for management of gastric fundic varices

OBJECTIVE: This study seeks to evaluate three-dimensional (3D) helical CT portography as a tool for examining patients with gastric fundic varices. SUBJECTS AND METHODS: We compared 3D helical CT portography and conventional angiographic portography in 30 consecutive patients with gastric fundic varices. We assessed whether 3D helical CT portography is useful in selecting patients and in evaluating the results of balloon-occluded retrograde transvenous obliteration. RESULTS: Three-dimensional helical CT portography simultaneously depicted second or third branches of the intrahepatic portal vein and provided images of entire portosystemic collaterals. On 3D helical CT portography, gastric fundic varices were seen in 30 patients (100%), left gastric veins in 19 (63%), posterior gastric veins or short gastric veins in 28 (93%), gastrorenal shunts in 27 (90%), paraumbilical veins in three (10%), and inferior phrenic veins in two patients (7%). Findings of 3D helical CT portography and conventional angiographic portography were in close agreement. However, in four patients, posterior gastric veins or short gastric veins were not seen on conventional angiographic portography images of the spleen, but they were clearly revealed on 3D helical CT portography. Treatment was successful in all patients except one. Three-dimensional helical CT portography could easily evaluate therapeutic results. CONCLUSION: Three-dimensional helical CT portography proved so effective that it can be considered a less invasive alternative than conventional angiographic portography in assessing portosystemic collaterals. CT portography is useful in selecting candidates from patients with gastric fundic varices for retrograde transvenous obliteration and also in evaluating therapeutic results.     

Microcatheter placement through a side hole created in a 5-F catheter into proximal subclavian arterial branches causing hemoptysis

Five patients with moderate to massive hemoptysis who had a bronchial artery of anomalous origin or a nonbronchial systemic artery originating from the proximal subclavian artery underwent microcatheter placement through a created side hole of a 5-F catheter. All patients had pulmonary tuberculosis and had undergone bronchial artery embolization for hemoptysis. The side holes were made in the lesser (n = 2) or greater curvature sides (n = 3) of 5-F nonbraided Headhunter catheters. A microcatheter was passed through the side hole of the 5-F catheter into the target artery for embolization. Polyvinyl alcohol particles were used as the embolic material. The technical success rate was 100%, and immediate control of hemoptysis was achieved in all patients without complication.     

肝硬化患者CT门静脉血管成像中门静脉侧支血管的表现

目的 分析肝硬化患者在16排螺旋CT门静脉血管成像(CTPV)上门静脉侧支血管的表现.方法 对36例经临床、肝功能和影像学检查诊断为肝硬化门静脉高压的患者行腹部CTPV检查,经图像后处理,获得门静脉系统及侧支血管三维重建图像.结果 CTPV可以直观地显示门静脉系统及整个门静脉侧支循环系统.36例病例中显示胃左静脉曲张29例(80.6%),食管下段静脉曲张18例(50.0%),胃短/W后静脉曲张15例(41.7%),食管旁静脉曲张9例(25.0%),胃-肾/脾-肾分流8例(22.2%),门静脉海绵样变7例(19.4%),脐静脉与腹壁静脉曲张6例(16.7%),椎旁静脉分流4例(11.1%).结论 CTPV能很好地显示肝硬化患者门脉高压侧支循环的开放部位、范围及严重程度,对判断病情、选择治疗方案及估计预后有重要的临床应用价值.