Balloon-occlusion Retrograde Transvenous Obliteration Using Gadoteridol As an Alternative Contrast Agent in a Patient with Iodine Allergy.

A 70-year-old woman with liver cirrhosis presented with gastric varices and recurrent hepatic encephalopathy. Magnetic resonance imaging (MRI) showed a splenorenal shunt, and balloon-occluded retrograde transvenous obliteration (B-RTO) was indicated but could not be performed due to iodine allergy. We then performed B-RTO using gadoteridol, an MRI contrast medium, instead of iodine contrast and successfully occluded the shunt vessel. After the procedure, hepatic encephalopathy did not recur, and the size of the gastric varices was reduced. This experience may aid in the management of iodine-allergic patients requiring interventional radiological treatment.

An Adult Case of Congenital Extrahepatic Portosystemic Shunt Successfully Treated with Balloon-occluded Retrograde Transvenous Obliteration.

A 42-year-old woman visited our hospital due to syncope. Contrast-enhanced CT revealed portosystemic shunt, portal vein hypoplasia, and multiple liver nodules. The histological examination of a liver biopsy specimen exhibited portal vein hypoplasia and revealed that the liver tumor was positive for glutamine synthetase. The patient was therefore diagnosed with congenital extrahepatic portosystemic shunt type II, and with focal nodular hyperplasia (FNH)-like nodules. She had the complication of severe portopulmonary hypertension and underwent complete shunt closure by balloon-occluded retrograde transvenous obliteration (B-RTO). The intrahepatic portal vein was well developed at 1 year after B-RTO, and multiple liver nodules completely regressed. Her pulmonary hypertension also improved.

Usefulness of coil-assisted retrograde transvenous obliteration II (CARTO-II) for the treatment of ascending colonic varix: a case report.

BACKGROUND: Colonic varices are rare among ectopic varices. A previous report demonstrated that once bleeding from colonic varices occurs, it can be fatal. Several treatments for colonic varices exist, including surgical, endoscopic, and endovascular treatments; however, management of colonic varices has not been standardized. For colonic varices, minimally invasive therapies would be desirable. Balloon-occluded retrograde transvenous obliteration (B-RTO) is one of the treatment options for colonic varices to prevent their rupture. Two cases of successful conventional B-RTO for these varices have already been reported. However, B-RTO using coil-assisted retrograde transvenous obliteration II (CARTO-II) procedure for these varices has not been reported. CASE PRESENTATION: A 71-year-old male patient had liver cirrhosis caused by hepatitis C virus infection. A varix was located at the ascending colon, which was coincidentally found on colonic endoscopy. Contrast-enhanced computed tomography (CT) showed that the feeder vein was the ileocolic vein and that the main draining vein was the right renal vein. Physicians concluded that treatment was required to avoid the risk of death from massive bleeding due to varix rupture. However, endoscopic and surgical treatments were difficult due to the anatomical location of the varix and the high risk of operative compilations, respectively. This ascending colonic varix was treated by balloon-occluded retrograde transvenous obliteration (B-RTO) using coil-assisted retrograde transvenous obliteration II (CARTO-II) procedure via the right renal vein. There were no complications during the procedure and no recurrences for 36 months during long-term follow-up. CONCLUSIONS: CARTO-II can be one of the effective treatment techniques for ascending colonic varices.

Selective Balloon-occluded Retrograde Transvenous Obliteration for Gastric Varices.

Objective Balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices (GV) is associated with drawbacks including a postoperative increase in portal pressure and the risk of subsequent worsening of esophageal varices (EV). Selective B-RTO that embolizes only the varices may have the potential to minimize such risks. The aim of this study is to retrospectively compare the postoperative course of patients after selective B-RTO (Group S) and conventional B-RTO (Group B). Methods One hundred four patients treated from January 2007 to April 2012 were classified into Groups S (n=5) and B (n=99). In the univariate analysis, the volume of 5% ethanolamine oleate iopamiodol (EOI) administered at baseline and the GV blood flow on endoscopic ultrasound after B-RTO were considered as covariates. The rates of GV recurrence and EV aggravation was also compared between Groups B and S. Results In Group S, the volume of 5% EOI was significantly lower (Group S vs. Group B: 14.6±5.5 vs. 28.5±16.4 mL; p=0.0012) and the rate of EV aggravation was lower in comparison to Group B (p=0.045). However, in Group S, the rate of complete eradication of GV blood flow was significantly lower (Group S vs. Group B: 0% vs. 89.9%; p<0.001) and the rate of re-treatment for GV was higher in comparison to Group B (Group S vs. Group B: 60% vs. 1.0%; p<0.001). Conclusion Selective B-RTO for GV could minimize the risk of a worsening of EV or reduce the amount of sclerosants; however, the rate of recurrence was high in comparison to conventional B-RTO.

A case of colonic varices complicated by alcoholic cirrhosis treated using balloon-occluded retrograde transvenous obliteration.

A 44-year-old man with cirrhosis arising from alcohol abuse manifested melena caused by the rupture of esophageal varices. He received endoscopic variceal ligation for the initial hemostasis, followed by endoscopic injection sclerotherapy as an additional consolidation therapy. A CT examination performed at the time of admission revealed collateral veins developing around the ascending colon, in which the feeding and draining vessels were identified as the superior mesenteric vein and the right testicular vein, respectively. Moreover, large nodular varices were observed in the ascending colon during a colonoscopy. To prevent the rupture of the colonic varices, balloon-occluded retrograde transvenous obliteration (B-RTO) was performed through the right testicular vein using a microballoon catheter. A CT examination performed 4 days after the B-RTO procedure revealed the disappearance of blood flow with thrombosis formation in both the colonic varices and the feeding vein. The varices in the ascending colon had completely disappeared when examined during a colonoscopy performed 4 months after the B-RTO procedure. B-RTO is a useful and minimally invasive procedure for the treatment of colonic varices to prevent bleeding.

A case of liver cirrhosis with bleeding from stomal varices successfully treated using balloon-occluded retrograde transvenous obliteration.

A 66-year-old male patient with liver cirrhosis because of alcohol intake underwent a Hartmann's procedure for rectal cancer. Four months later, bleeding from the sigmoid stoma occurred and persisted for 2 months. A colonoscopic examination revealed bleeding from stomal varices. Three-dimensional computed tomography (CT) imaging demonstrated the inferior mesenteric vein and left superficial epigastric vein as the feeding and drainage vessels, respectively. Balloon-occluded retrograde transvenous obliteration (B-RTO) through the left epigastric vein was performed using a microballoon catheter inserted from the right femoral vein according to the Seldinger method. A CT examination performed 2 days after the B-RTO procedure revealed that the blood flow had disappeared, with thrombosis formation in both the stomal varices and the feeding vein. No recurrent bleeding from the stoma occurred. B-RTO using a microballoon catheter is useful as a therapeutic procedure for stomal varices to prevent bleeding, since the procedure can be performed with minimal invasion using the Seldinger method.

Portal response related to shunt occlusion by balloon-occluded retrograde transvenous obliteration may determine the prognosis of cirrhosis.

AIM: To determine the prognostic effect of portal hemodynamic responses after balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices (GV) in cirrhosis patients. METHODS: This retrospective study consisted of 37 cirrhosis patients (aged 62.5 ± 9.7 years) with medium- or large-grade GV treated with B-RTO. Portal hemodynamic response was assessed by the changes in flow volume in the portal trunk (PFV, mL/min) before and after the treatment. Group I showed increased PFV and group II showed no increase in PFV. The median observation period was 49.8 months (range, 4.7-150.3 months). RESULTS: All patients showed complete embolization of GV without any recurrence. There were 30 patients in group I and 7 patients in group II (decreased PFV in 6 and unchanged PFV in 1). The PFV at baseline was significantly lower in the former (583.5 ± 232.0 mL/min) than in the latter (880.7 ± 345.9 mL/min; P = 0.009). The survival rate was significantly lower in group II (83.3% at 1 year and 66.7% at 3 years) than in group I (96.7% at 1 year, 81.5% at 3 years, and 61.8% at 5 years; P = 0.012). The incidence of deterioration of the esophageal varices was 18/30 (60%) in group I and 5/7 (71.4%; P = 0.687) in group II. Multivariate analysis identified only no increase in portal response (hazard ratio, 8.086; P = 0.005) as an independent factor for poor prognosis. CONCLUSION: Balloon-occluded retrograde transvenous obliteration for GV may result in a poor prognosis when portal hemodynamics shows no increase in portal response.

Long-term outcome of 154 patients receiving balloon-occluded retrograde transvenous obliteration for gastric fundal varices.

BACKGROUND AND AIM: This study aims to clarify the long-term outcome of therapeutic strategies including balloon-occluded retrograde transvenous obliteration (B-RTO) for patients with gastric fundal varices. METHODS: The subjects were 154 patients with gastric fundal varices fulfilling the criteria for receiving B-RTO. In patients showing variceal bleeding, endoscopic therapies and/or balloon tamponade was performed to achieve hemostasis. B-RTO was accomplished with injection of 5% ethanolamine oleate through a standard balloon catheter except for patients with atypical varices, in whom a microballoon catheter was used to occlude drainage vessels other than a gastrorenal shunt. In patients complicated with esophageal varices at baseline, endoscopic therapies were performed following B-RTO. RESULTS: Balloon-occluded retrograde transvenous obliteration was performed successfully in 147 patients (95%), including 15 patients using a microballoon catheter. Complete variceal obliteration was achieved in all patients. Additional endoscopic therapies for esophageal varices were performed in 31 patients. Gastric varices did not recur in any of these patients. The cumulative survival rates at 1, 3, and 5 years after B-RTO were 91%, 76%, and 72%, respectively. Child-Pugh scores and hepatocellular carcinoma complication were identified as prognostic factors associated with survival rates. The cumulative exacerbation rates of esophageal varices at 1, 3, and 5 years were 13%, 20%, and 27%, respectively, and rupture developed in six patients, which were successfully treated with endoscopic therapies. CONCLUSIONS: Therapeutic strategies including B-RTO with a microballoon catheter were useful to achieve a favorable outcome in patients with gastric fundal varices especially in those manifesting Child-Pugh class-A liver damage and/or those without hepatocellular carcinoma complication.

Long-term outcome of patients with gastric varices treated by balloon-occluded retrograde transvenous obliteration.

BACKGROUND AND AIM: To assess the short- and long-term outcome of patients with gastric varices (GV) after balloon-occluded retrograde transvenous obliteration (B-RTO) by comparing bleeding cases with prophylactic cases. METHODS: Consecutive 100 patients with GV treated by B-RTO were enrolled in this retrospective cohort study. We compared the technical success, complications, and survival rates between bleeding and prophylactic cases. RESULTS: Of 100 patients, 61 patients were bleeding cases and 39 patients were prophylactic cases. Technical success was achieved in 95% of bleeding case and in 100% of prophylactic case, with no significant difference between these groups (overall technical success rate, 97%). The survival rates at 5 and 10 years were 50% and 22% in bleeding case, and 49% and 36% in prophylactic case, respectively. There was also no significant difference (P = 0.420). By multivariate analysis, survival rates correlated significantly with liver function (hazard ratio 2.371, 95% CI 1.457-3.860, P = 0.001) and hepatocellular carcinoma development (HR 4.782, 95% CI 2.331-9.810, P < 0.001). The aggravating rates of esophageal varices (EV) were 21%, 50%, and 54% at 12, 60, and 120 months after B-RTO. By multivariate analysis, aggravating rates significantly correlated with EV existing before B-RTO (HR 18.114, 95% CI 2.463-133.219, P = 0.004). CONCLUSION: B-RTO for GV could provide the high rate of complete obliteration and favorable long-term prognosis even in bleeding cases as well as prophylactic cases. Management of EV after B-RTO, especially in coexisting case of GV and EV, would be warranted.

Balloon-occluded retrograde transvenous obliteration using a microballoon catheter for intractable gastric fundal varices.

BACKGROUND AND AIM: Balloon-occluded retrograde transvenous obliteration (B-RTO) is recognized as the standard therapy for patients with gastric fundal varices in Japan; however, the procedure is difficult when drainage veins other than the gastrorenal shunt developed. The efficacy and safety of B-RTO using a microballoon catheter for such patients were evaluated. METHODS: The subjects were 99 patients with gastric fundal varices who fulfilled the criteria for receiving endoscopic and/or interventional therapies. Among these, 95 patients underwent B-RTO. Of the 95 patients, 14 were treated with the use of microballoon catheters, including nine in whom the left inferior phrenic vein was found as a secondary drainage vein in addition to the gastrorenal shunt, and five in whom a gastrorenal shunt was absent. The B-RTO procedure performed using a microballoon catheter inserted through the left inferior phrenic vein in 13 patients, and through the pericardiophrenic vein in one patient. RESULTS: The B-RTO procedure using microballoon catheters was successful in 13 of the 14 patients (93%), while in the remaining one patient, multiple drainage veins were visualized on venography. Complete obliteration of the varices was achieved in all the 13 patients by injection of 5% ethanolamine oleate iopamidol at a median volume of 25 mL (range, 11 to 40 mL) through the catheters. None of the patients showed injuries of the drainage veins or any systemic complications. CONCLUSIONS: B-RTO using a microballoon catheter is useful for the treatment of gastric fundal varices in which drainage veins other than the gastrorenal shunt developed.

EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: a multicenter study (with videos).

BACKGROUND: Therapy of gastric varices (GV) is still challenging. Cyanoacrylate (CYA) injection is the recommended treatment for bleeding GV, but has a known adverse event rate, which could be reduced if EUS is used for guidance. Otherwise, EUS-guided coil application (ECA) may be an alternative. OBJECTIVES: To compare CYA and ECA embolization of feeding GV for feasibility, safety, and applicability. DESIGN: Retrospective analysis of a prospectively maintained database. SETTING: Multicenter study, tertiary referral centers. PATIENTS AND INTERVENTIONS: Thirty consecutive patients with localized GV who received either CYA injection or ECA were included with follow-up for 6 months after treatment. RESULTS: There were 11 patients in the coil group and 19 patients in the CYA group. The GV obliteration rate was 94.7% CYA versus 90.9% ECA; mean number of endoscopy sessions was 1.4 ± 0.1 (range 1-3). Adverse events occurred in 12 of 30 patients (40%) (CYA, 11/19 [57.9%]; ECA, 1/11 [9.1%]; P < .01); only 3 were symptomatic, and an additional 9 (CYA group) had glue embolism on a CT scan but was asymptomatic. No further adverse events occurred during follow-up. Six patients (20%) died unrelated to the procedures or bleeding. LIMITATIONS: Nonrandomized; EUS expertise necessary. CONCLUSIONS: EUS-guided therapy for GV by using CYA or ECA is effective in localized GV. ECA required fewer endoscopies and tended to have fewer adverse events compared with CYA injection. Larger comparative studies are needed to prove these data.

Obliteration of gastric varices improves the arrival time of ultrasound contrast agents in hepatic artery and vein.

BACKGROUND AND AIM: Liver cirrhosis (LC) is accompanied by hepatic arterializations, intrahepatic shunts, and hyperdynamic circulations. These changes shorten the arrival time (AT) of ultrasound contrast agents to the hepatic vein (HV). Whether treatment of gastric fundal varices (GVs) by balloon-occluded transvenous obliteration (B-RTO) improves the AT in LC patients was prospectively investigated. METHODS: A total of 32 LC patients with GVs and 10 normal controls (NCs) were enrolled. This study was approved by the clinical research ethics committee. Images of hepatic artery (HA), portal vein (PV), and HV were monitored after an injection of a contrast agent using quantification software. The AT before and after B-RTO in LC patients and that in NCs were compared. RESULTS: All GVs were treated effectively, and indocyanine green retention rate was improved (P < 0.0001). The mean values of the HA, PV, and HV ATs in the NCs were 21.9 ± 3.3, 28.2 ± 2.0, and 40.5 ± 2.1 s, respectively. Those in LC patients were 17.4 ± 4.4, 21.9 ± 5.6, and 26.3 ± 6.7, respectively, which were shorter than those in NCs (P < 0.01, P < 0.002, P < 0.0001, respectively). However, these ATs were significantly prolonged 1 week after B-RTO, with mean values of 18.7 ± 4.8, 23.8 ± 6.0, and 30.0 ± 7.2 s (P = 0.043, P < 0.01, P < 0.001). CONCLUSION: Obliteration of GVs shifted the AT in LC patients to the normalization, raising the possibility of improvement of arterialization and intrahepatic shunt.

Usefulness of multi-detector row computed tomography for management of duodenal varices by emergency balloon-occluded retrograde transvenous obliteration.

Ectopic varices outside the gastroesophageal region are less common in patients with portal hypertension and liver cirrhosis. Among ectopic varices, bleeding from duodenal varices is often massive and fatal. Several reports have recently described various treatment options for duodenal varices including interventional radiology. It is necessary to thoroughly investigate variceal hemodynamics before conducting interventional radiology. We report a case of bleeding duodenal varices treated successfully with balloon-occluded retrograde transvenous obliteration (B-RTO) after investigating the hemodynamics of the duodenal varices with multi-detector row computed tomography (MDCT). MDCT easily identified the duodenal varices together with the afferent and efferent vessels. Our case suggests the usefulness of MDCT before B-RTO for investigating the hemodynamics and vascular anatomy of the duodenal varices and selection of the most appropriate therapy.

Short- and long-term clinical outcome after balloon-occluded retrograde transvenous obliteration: is pretreatment portal flow direction a predictive factor?

PURPOSE: To determine whether pretreatment portal flow direction can predict different clinical manifestations or prognosis after balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices. METHODS: The subjects were 103 cirrhotic patients with medium- or large-grade gastric varices treated by B-RTO. Short- and long-term clinical outcomes were compared among patients with forward portal flow (F group) and those with reversed or to-and-fro portal flow (R group) on color Doppler sonography before B-RTO. RESULTS: Deterioration of liver function reserve 1 year after B-RTO was more frequent in the R group (34.7 %) than in the F group (11.1 %, p = 0.0251). Thrombotic disorders within 1 year after B-RTO were also more frequent in the R group (20.7 %) than in the F group (2.7 %, p = 0.0079). There was no significant difference in cumulative survival rate of Child class A patients between the two groups. In Child class B or class C patients, however, the cumulative survival rate was poorer in the R group (68.7, 30.5, and 30.5 % at 1, 5, and 9 years, respectively) than in the F group (94.9, 58.8, and 37.8 % and 1, 5, and 9 years, respectively; p = 0.0097). CONCLUSIONS: Hemodynamic assessment of portal flow direction is important before B-RTO, and care should be taken to manage thrombotic disorders in the perioperative period in patients with reversed portal flow after B-RTO. Another treatment option might be preferred for gastric varices in Child classes B and C patients with reversed portal flow instead of B-RTO, which may have a poor prognosis.

A case of gastric varices with gastropericardiac shunt successfully treated by balloon-occluded retrograde transvenous obliteration via the pericardiophrenic vein using a microballoon catheter.

Gastric fundal varices developed in a 72-year-old female patient with liver cirrhosis due to hepatitis C virus infection after endoscopic injection sclerotherapy for esophageal varices. Three-dimensional computed tomography (CT) imaging demonstrated that gastrorenal shunts were absent as the drainage vessels of the varices, and the blood flows drained mainly into the pericardiophrenic vein. Balloon-occluded retrograde transvenous obliteration (B-RTO) was performed using a microballoon catheter to prevent bleeding from the gastric varices. The left inferior phrenic vein detectable as the second drainage vessel by venography was embolized with metallic coils and ethanolamine oleate solution was injected into the varices following occlusion of blood flow with a microballoon located in the pericardiophrenic vein. CT examination performed 7 days following B-RTO therapy revealed that the blood flow had disappeared with thrombus formation in the varices. B-RTO therapy with a microballoon catheter may be a useful therapy for gastric fundal varices even in cases without gastrorenal shunts, if the main drainage vessels are determined.

A case of liver cirrhosis due to hepatits C virus infection complicating giant anorectal varices treated with balloon-occluded retrograde transvenous obliteration.

A 73-year-old man with liver cirrhosis due to hepatitis C virus infection was admitted to our hospital because of massive bleeding from external varices. Colonoscopic examination revealed that giant anorectal varices had developed between the anus and rectal ampulla, and had ruptured at the perianal site. On three-dimensional computed tomography imaging, the feeding and drainage vessels of the varices were identified as the inferior mesenteric vein and right inferior hemorrhoidal vein, respectively. Endoscopic therapies were not employed for the bleeding varices, because the blood flow volume of the feeding vessel was extremely large. Balloon-occluded retrograde transvenous obliteration (B-RTO) was therefore carried out through the drainage vessels. The variceal blood flow disappeared after B-RTO therapy, and the varices decreased in size with thrombus formation verified by colonoscopy. Bleeding from the external varices also ceased. B-RTO therapy may be an effective approach for giant anorectal varices presenting as a complication in liver cirrhosis patients in whom the main drainage vessels can be determined.

Therapeutic Efficacy of Balloon-Occluded Retrograde Transvenous Obliteration in the Treatment of Gastric Varices in Cirrhotic Patients with Gastrorenal Shunt / 대한소화기학회지

BACKGROUND/AIMS: Rupture of gastric varices was one of the most dreadful complications of cirrhosis. Recently, a new interventional procedure, balloon-occluded retrograde transvenous obliteration (B-RTO) was introduced for the treatment of gastric variceal bleeding. This study was performed to evaluate the therapeutic efficacy of B-RTO in the treatment of gastric varices with gastro-renal shunts. METHODS: From March 2000 to June 2003, we performed B-RTO in 17 patients with gastric varices and gastrorenal shunts. All patients had history or high risk factors of gastric variceal bleeding. For the evaluation of therapeutic efficacy, we performed esophagogastroduodenoscopy (EGD) and computed tomography (CT) at 1, 6 and 12 months after B-RTO. Successful B-RTO was judged by combined CT findings and EGD findings (disappearance of gastric varices or markedly reduced gastric variceal size or bleeding risk) during follow-up periods (1-14 months, mean:6.18). We analyzed the clinical factors related to clinical success of B-RTO. RESULTS: Technical success were achieved in all patients except one (94.1%). Gastric varices were disappeared or decreased after B-RTO in 13 patients (81.2%). Complications related to procedure included transient hematuria (n=5), puncture site oozing (n=1) and partial splenic infarction (n=1), and all were conservatively managed. During the follow up periods, neither significant hepatic nor renal functional damages occurred. Statistically, no significant factors related with B-RTO success. CONCLUSIONS: B-RTO is effective and safe in the management of gastric varices in cirrhotic patients with gastrorenal shunt.