The Role of Divided Injections of a Sclerotic Agent over Two Days in Balloon-Occluded Retrograde Transvenous Obliteration for Large Gastric Varices

OBJECTIVE: To determine the safety and usefulness of a two-tiered approach to balloon-occluded retrograde transvenous obliteration (B-RTO) as a treatment for large gastric varices after portal hypertension. MATERIALS AND METHODS: 50 patients were studied who underwent B-RTO for gastric varices between October 2004 and October 2011 in our institution. The B-RTO procedure was performed from the right femoral vein and the B-RTO catheter was retained until the following morning. Distribution of sclerotic agents in the gastric varices on fluoroscopy was evaluated in all patients on days 1 and 2. When distribution of sclerotic agents in the gastric varices on day 1 had been none or very scanty even though the volume of the sclerotic agent infused was above the acceptable level, a second infusion was administered on day 2. When distribution was satisfactory, the B-RTO catheter was removed. RESULTS: In 8 (16%) patients, little or no sclerotic agent infused on day 1 was distributed in the gastric varices. However, on day 2, sclerotic agents were distributed in all gastric varices. Mean volume of ethanolamine oleate-iopamidol infused on day 1 was 24.6 mL and was 19.4 mL on day 2. Gastric varices were well obliterated with no recurrence. Complications caused by the sclerotic agent such as pulmonary edema or renal insufficiencies were not seen. CONCLUSION: When gastric varices are very large, a strategy involving thrombosis of only the drainage vein on the first day followed by infusing the sclerotic agent on the following day might be effective and feasible.

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.

The Clinical Results of Balloon-Occluded Retrograde Transvenous Obliteration in Treatment of Gastric Varices Compared with Transjugular Intrahepatic Portosystemic Shunt

PURPOSE: To compare the clinical results of BRTO in the gastric varices with those of TIPS. MATERIALS AND METHODS: From January 2004 to March 2006, eight patients who had been followed up for more than 1 month after BRTO were enrolled in this study. This study compared the clinical efficacy of BRTO with that of TIPS in 13 patients who had undergone TIPS from January 2000 to March 2006. The change in laboratory parameters before and after each procedure and the incidence of rebleeding, encephalopathy, asictes and varices were analyzed after each procedure. Results:In the BRTO group, the level of albumin increased, and the levels of ammonia and the Child-Pugh score decreased. The TIPS group showed no improvement in the liver function. In the BRTO group, the gastric varices were eradicated in 7 patients. Gastric variceal rebleeding and encephalopathy did not occur. However, the esophageal varices worsened in 6 patients. In the TIPS group, rebleeding (n=4), encephalopathy (n=7) and a worsening of the gastric (n=5) or esophageal varices (n=2) occurred. CONCLUSION: BRTO improves the metabolic activity of the liver and has a lower incidence of encephalopathy. Hence, BRTO is a good alternative to TIPS in the gastric varices accompanied by a gastrorenal shunt although a treatment for a worsening of the esophageal varices may be needed after BRTO.

The Short-Term Effects of Balloon-Occluded Retrograde Transvenous Obliteration, for Treating Gastric Variceal Bleeding, on Portal Hypertensive Changes: a CT Evaluation

OBJECTIVE: We wanted to evaluate the short-term effects of balloon-occluded retrograde transvenous obliteration (BRTO) for treating gastric variceal bleeding, in terms of the portal hypertensive changes, by comparing CT scans. MATERIALS AND METHODS: We enrolled 27 patients who underwent BRTO for gastric variceal bleeding and they had CT scans performed just before and after BRTO. The pre- and post-procedural CT scans were retrospectively compared by two radiologists working in consensus to evaluate the short-term effects of BRTO on the subsequent portal hypertensive changes, including ascites, splenomegaly, portosystemic collaterals (other than gastrorenal shunt), the gall bladder (GB) edema and the intestinal wall edema. Statistical differences were analyzed using the Wilcoxon signed rank test and the paired t-test. RESULTS: Following BRTO, ascites developed or was aggravated in 22 (82%) of 27 patients and it was improved in two patients; the median spleen volumes increased from 438.2 cm3 to 580.8 cm3, and based on a 15% volume change cut-off value, splenic enlargement occurred in 15 (56%) of the 27 patients. The development of new collaterals or worsening of existing collaterals was not observed in any patient. GB wall edema developed or was aggravated in four of 23 patients and this disappeared or improved in five; intestinal wall edema developed or was aggravated in nine of 27 patients, and this disappeared or improved in five. Statistically, we found significant differences for ascites and the splenic volumes before and after BRTO (p = 0.001 and p < 0.001, respectively) CONCLUSION: Some portal hypertensive changes, including ascites and splenomegaly, can be aggravated shortly after BRTO.

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.

Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Variceal Bleeding patient

PURPOSE: To evaluate the technical feasibility and clinical efficacy of balloon-occluded retrograde transvenous obliteration (BRTO) in the treatment of gastric variceal bleeding. MATERIALS AND METHODS: Between September 2001 and March 2002, ten patients with gastric variceal bleeding and gastrorenal shunt, underwent BRTO. Three of the ten also had hepatic encephalopathy. To evaluate the gastrorenal shunt and exclude portal vein thrombosis, all patients underwent pre-procedural CT scanning. An occlusion balloon catheter was inserted from the right internal jugular vein and on ballooning was wedged into the left adrenal vein. A sclerosing agent (5% ethanolamine oleate-lipiodol mixture) was injected until the varices were completely filled. In four patients, the collateral veins seen at balloon-occluded adrenal venography were embolized with coils prior to sclerotherapy. Post-procedural follow-up CT (n=3) or endoscopy (n=8) was performed 1-4 weeks later, and both before and after the procedure, hepatic function was also monitored. RESULTS: Treatment was successful in nine cases: the failure involed rupture of the occlusion balloon during inflation, and a transjugular intrahepatic portosystemic shunt was performed. The cessation of bleeding was confirmed endoscopically or clinically; in three patients, follow-up CT showed complete obliteration of the varices. Hepatic function improved in eight patients, but three weeks after the procedure, one expired due to progressive infiltrative hepatoma. The clinical symptoms of the three patients with hepatic encephalopathy showed remarkable improvement. CONCLUSION: Although more extensive studies and long-term follow up are needed to overcome the limitations of our study, we believe that BRTO is a technically feasible and clinically effective treatment for gastric varices and hepatic encephalopathy.

The Change of Portal Hemodynamics before and after Transjugular Intrahepatic Portosystemic Shunt according to Variceal Type: Gastric and Esophageal varix

PURPOSE: To investigate the changes occurring in portal hemodynamics in patients with esophageal and gastric varices, according to variceal type, before and after TIPS. MATERIALS AND METHODS: Between January 1994 and June 1999, we evaluated 22 of 44 patients who had undergone TIPS and endoscopy on admission. In these 22, hepatic venous and main portal venous pressure were measured. On the basis of endoscpic findings, the esophageal and gastric varices were classified as one of three types. Changes in portal hemodynamics in relation to the diameter of the portal vein, mean portosystemic gradient before and after TIPS, delta MPSG, and the presence of hepatic encephalopathy and gastrorenal shunt were all evaluated. RESULTS: Endoscopy indicated that there were ten Type-I cases, nine Type-II, and three Type-III. The diameter of the main portal vein was 14.95 +/-1.79 mm in Type I cases, and 13.35 +/-1.59 mm in Type II. Before TIPS, main portal venous pressure was 31.40 +/-6.79 mmHg (Type I) and 22.80 +/-4.26 mmHg (Type II), and the mean portosystemic gradient was 16.10 +/-7.0 mmHg (Type I), and 11.20 +/-5.36 mmHg (Type II). After TIPS, the pressure readings were 25.70 +/-7.60 mmHg (Type I) and 17.80 +/-6.52 mmHg (Type II), while those relating to were 10.80 +/-4.94 mmHg (Type I) and 5.25 +/-3.67 mmHg (Type II). delta MPSG was 6.04 +/-2.98 mmHg (Type I) and 5.91 +/-3.98 mmHg (Type II). Angiography revealed that the gastrorenal shunt was Type I in 10% of cases, Type II in 77%, and Type III in 33%. Hepatic encephalopathy after TIPS occured in three Type-I cases, three-Type- II, and two Type-III. CONCLUSION: The diameter of the main portal vein was significantly smaller, and portal venous pressure and mean portosystemic gradient before and after TIPS significantly lower in patients with dominant gastric varices than in those with dominant esophageal varices (p<0.05). Gastrorenal shunt was more frequent among patients with dominant gastric varices. No difference in the incidence of hepatic encephalopathy after TIPS was noted between those with dominant gastric varices and those with the esophageal variety.