Coexistence of "extra-gastric afferent-efferent direct connection" with gastric varices: CT evaluation and clinical significance

Transvenous obliteration of gastric varices

Gastric varices on the background of portal hypertension occur less frequently than esophageal varices but they develop at lower portal pressure and are associated with more massive bleedings and higher mortality rate. Balloon-occluded retrograde transvenous obliteration (BRTO) has been well documented as an effective therapy for gastric varices caused by portal hypertension. However, BRTO requires long-term, higher-level post-procedural monitoring and can have complications related to balloon rupture and adverse effects of sclerosing agents. Several modified BRTO techniques have been developed, including vascular plug-assisted retrograde transvenous obliteration, coil-assisted retrograde transvenous obliteration, and balloon-occluded antegrade transvenous obliteration. This article provides an overview of BRTO various and modified BRTO techniques.

Difference between type 2 gastroesophageal varices and isolated fundic varices in clinical profiles and portosystemic collaterals

BACKGROUND

There is significant heterogeneity between gastroesophageal varices (GOV2) and isolated gastric varices (IGV1). The data on the difference between GOV2 and IGV1 are limited.

AIM

To determine the etiology, clinical profiles, endoscopic findings, imaging signs, portosystemic collaterals in patients with GOV2 and IGV1.

METHODS

Medical records of 252 patients with gastric fundal varices were retrospectively collected, and computed tomography images were analyzed.

RESULTS

Significant differences in routine blood examination, Child–Pugh classification and MELD scores were found between GOV2 and IGV1. The incidence of peptic ulcers in patients with IGV1 (26.55%) was higher than that of GOV2 (11.01%), while portal hypertensive gastropathy was more commonly found in patients with GOV2 (22.02%) than in those with IGV1 (3.54%). Typical radiological signs of cirrhotic liver were more commonly observed in patients with GOV2 than in those with IGV1. In patients with GOV2, the main afferent vessels were via the left gastric vein (LGV) (97.94%) and short gastric vein (SGV) (39.18%). In patients with IGV1, the main afferent vessels were via the LGV (75.61%), SGV (63.41%) and posterior gastric vein (PGV) (43.90%). In IGV1 patients with pancreatic diseases, spleno-gastromental-superior mesenteric shunt (48.15%) was a major collateral vessel. In patients with fundic varices, the sizes of gastric/esophageal varices were positively correlated with afferent vessels (LGVs and PGVs) and efferent vessels (gastrorenal shunts). The size of the esophageal varices was negatively correlated with gastrorenal shunts in GOV2 patients.

CONCLUSION

Significant heterogeneity in the etiology and vascular changes between GOV2 and IGV1 is useful in making therapeutic decisions.

Conventional versus selective balloon-occluded retrograde transvenous obliteration of gastric varices

Background

Balloon-occluded retrograde transvenous obliteration (BRTO) is a well-established interventional radiological technique for treatment of isolated gastric varices (GV). The aim of this study is to compare outcome after different BRTO techniques, i.e., conventional, selective and superselective techniques.

Fifty-nine consecutive patients underwent BRTO as a primary prophylactic treatment for GV were retrospectively categorized into group A (38 patients underwent conventional BRTO) and group B (21 patients underwent selective or superselective BRTO). Group B was sub-grouped into group B1 (11 patients underwent selective BRTO) and group B2 (10 patients underwent superselective BRTO).

Results

Median volume of ethanol amine oleate iopamidol (EOI) was significantly higher in group A than in group B2 (14.8 Vs 7.4 ml, p = 0.03). Complete GV thrombosis was significantly lower in group B2 (50%) than in A (89.5%, p = 0.01) and B1 (100%, p = 0.01). GV bleeding rate after BRTO was significantly higher in group B2 than in group A (20% vs 0%, p = 0.04). GV recurrence rate was not significantly different between group A and B (p = 0.5) or between group A, B1 and B2 (p = 0.1). Cumulative ascites exacerbation rate was significantly higher in group A than B (p = 0.005), B1 (p = 0.03), and B2 (p = 0.03). Cumulative esophageal varices (Es.V) aggravation rate was significantly higher in group A than B (p = 0.001), B1 (p = 0.01), and B2 (p = 0.03). Volume of EOI was a significant risk factor for ascites exacerbation (p = 0.008) while shunt occlusion and pre-existing partial portal vein thrombosis were significant risk factors for Es.V aggravation (p = 0.01 and 0.03, respectively).

Conclusion

Selective and super-selective techniques had a lower ascites exacerbation, and Es.V aggravation rates than conventional technique. However, superselective BRTO had a lower GV complete thrombosis and higher GV bleeding rates after BRTO than other techniques.