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Wu R, Kokabi N, Adler JM, Bhave AD, Morris CS, Saad WE, Majdalany DS, Majdalany BS. Paradoxical Cerebral Embolization during Transjugular Intrahepatic Portosystemic Shunt Creation and Variceal Sclerotherapy. Semin Intervent Radiol 2024; 41:220-225. [PMID: 38993595 PMCID: PMC11236452 DOI: 10.1055/s-0044-1786539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Affiliation(s)
- Richard Wu
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Nima Kokabi
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Jonah M. Adler
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Anant D. Bhave
- Division of Interventional Radiology, Department of Radiology, University of Vermont Medical Center, Burlington, Vermont
| | - Christopher S. Morris
- Division of Interventional Radiology, Department of Radiology, University of Vermont Medical Center, Burlington, Vermont
| | - Wael E. Saad
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Utah Hospital, Salt Lake City, Utah
| | | | - Bill S. Majdalany
- Division of Interventional Radiology, Department of Radiology, University of Vermont Medical Center, Burlington, Vermont
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Lee EW, Eghtesad B, Garcia-Tsao G, Haskal ZJ, Hernandez-Gea V, Jalaeian H, Kalva SP, Mohanty A, Thabut D, Abraldes JG. AASLD Practice Guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage. Hepatology 2024; 79:224-250. [PMID: 37390489 DOI: 10.1097/hep.0000000000000530] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023]
Affiliation(s)
- Edward Wolfgang Lee
- Department of Radiology and Surgery, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Bijan Eghtesad
- Department of General Surgery, Digestive Disease and Surgery Institute Cleveland Clinic, Cleveland, Ohio, USA
| | - Guadalupe Garcia-Tsao
- Yale University School of Medicine, Department of Internal Medicine, Section of Digestive Diseases, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging/Interventional Radiology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Universitat de Barcelona (UB). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Hamed Jalaeian
- Department of Interventional Radiology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | | | - Arpan Mohanty
- Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Dominique Thabut
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'Hépato-gastroentérologie, Paris, France
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
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Tamura Y, Asaoka Y, Takeuchi A, Matsumoto K, Miura R, Abe K, Arizumi T, Yamamoto M, Kodashima S, Kondo H, Yamamoto T, Tanaka A. Long-Term Prognosis and Related Factors in Patients with Cirrhosis Treated with Balloon-Occluded Retrograde Transvenous Obliteration. Dig Dis 2023; 41:789-797. [PMID: 37385227 DOI: 10.1159/000530781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/11/2023] [Indexed: 07/01/2023]
Abstract
INTRODUCTION Balloon-occluded retrograde transvenous obliteration (BRTO) was developed as an effective treatment for gastric varices in patients with cirrhosis. Because liver fibrosis in these patients is assumed to be advanced, their prognosis is expected to be poor. In this study, we investigated the prognosis and characteristics of the patients. METHODS We enrolled 55 consecutive patients with liver cirrhosis treated with BRTO between 2009 and 2021 at our department. To evaluate factors related to variceal recurrence and long-term prognosis, survival analysis was performed on 45 patients, excluding those who died within 1 month, had an unknown prognosis, or whose treatments were converted to other treatments. RESULTS During a mean follow-up period of 2.3 years, esophageal varices recurred in 10 patients and could be treated endoscopically. Non-alcoholic steatohepatitis (NASH) was related to the variceal recurrence (hazard ratio [HR] = 4.27, 95% CI: 1.17-15.5, p = 0.028). The survival rate after the procedure at 1, 3, and 5 years was 94.2%, 74.0%, and 63.5%, respectively, and 10 patients died of hepatocellular carcinoma (n = 6), liver failure (n = 1), sepsis (n = 1), and unknown reasons (n = 2). The estimated glomerular filtration rate (eGFR) level was proved to be a significant poor prognostic factor (HR = 0.96, 95% CI: 0.93-0.99, p = 0.023). The comorbid hypertension (HTN) was the main cause of low eGFR, and HTN was also significantly related to survival (HR = 6.18, 95% CI: 1.57-24.3, p = 0.009). Most of the patients with HTN were treated with calcium channel blocker and/or angiotensin receptor blocker. CONCLUSION The clinical course of patients with cirrhosis treated with BRTO was dependent on the metabolic factors including renal function, comorbid HTN, and NASH.
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Affiliation(s)
- Yamato Tamura
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yoshinari Asaoka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Akihito Takeuchi
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Kosuke Matsumoto
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Ryo Miura
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Koichiro Abe
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Toshihiko Arizumi
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Masayoshi Yamamoto
- Department of Radiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Shinya Kodashima
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Hiroshi Kondo
- Department of Radiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Takatsugu Yamamoto
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
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Gaba RC, Pandhi MB, Niemeyer MM, Shah KY, Lipnik AJ. Combined Transjugular Intrahepatic Portosystemic Shunt Creation plus Transvenous Obliteration for Treatment of Gastric Varices: Initial Technical and Safety Outcomes from a Single-Center Prospective Pilot Study. J Vasc Interv Radiol 2022; 33:1432-1435.e2. [PMID: 35964882 DOI: 10.1016/j.jvir.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/25/2022] [Accepted: 08/07/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Ron C Gaba
- Department of Radiology, University of Illinois College of Medicine, 1740 West Taylor Street, MC 931, Chicago, IL 60612.
| | - Mithil B Pandhi
- Department of Radiology, University of Illinois College of Medicine, 1740 West Taylor Street, MC 931, Chicago, IL 60612
| | - Matthew M Niemeyer
- Department of Radiology, University of Illinois College of Medicine, 1740 West Taylor Street, MC 931, Chicago, IL 60612
| | - Ketan Y Shah
- Department of Radiology, University of Illinois College of Medicine, 1740 West Taylor Street, MC 931, Chicago, IL 60612
| | - Andrew J Lipnik
- Department of Radiology, University of Illinois College of Medicine, 1740 West Taylor Street, MC 931, Chicago, IL 60612
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Fujisaki H, Fukami Y, Arikawa T, Saito T, Osawa T, Komatsu S, Kaneko K, Kurokawa T, Nonami T, Sano T. Long-term results of laparoscopic Hassab's procedure for esophagogastric varices with portal hypertension. Asian J Endosc Surg 2022; 15:505-512. [PMID: 35132809 DOI: 10.1111/ases.13038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/29/2021] [Accepted: 01/22/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Recent reports have shown laparoscopic gastric devascularization and splenectomy (Hassab's procedure) to be a safe and effective treatment for esophagogastric varices with portal hypertension. However, the long-term postoperative results remain unclear. METHODS Between 2009 and 2015, 17 patients with portal hypertension and esophagogastric varices underwent laparoscopic Hassab's procedure at our institution. Two patients were lost to long-term follow-up (at least 2 years) and excluded. The remaining 15 patients' data and endoscopic findings were retrospectively reviewed. RESULTS The median postoperative follow-up period was 56 months. The median spleen volume, operation time, blood loss, and length of postoperative hospital stay were 651 (320-1,265) mL, 305 (275-547) minutes, 347 (24-1,131) mL, and 20 (8-41) days, respectively. According to the endoscopic findings 1 year after surgery, the esophagogastric varices disappeared in three patients and improved in 12 patients. The median platelet count was significantly higher 1 year after surgery (19.7 × 104 /dL) than before surgery (5.5 × 104 /dL) (P < .001) and remained stable 2 years after surgery. Two patients died of liver disease. The remaining 13 patients, with a median postoperative follow-up of 57 months, were alive without bleeding from esophagogastric varices. CONCLUSION Laparoscopic Hassab's procedure is a feasible treatment for esophagogastric varices with portal hypertension in terms of both short- and long-term results.
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Affiliation(s)
- Hiroyuki Fujisaki
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Yasuyuki Fukami
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Takashi Arikawa
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Takuya Saito
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Takaaki Osawa
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Shunichiro Komatsu
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Kenitiro Kaneko
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Tsuyoshi Kurokawa
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Toshiaki Nonami
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
| | - Tsuyoshi Sano
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Nagakute, Japan
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Diaz-Soto MP, Garcia-Tsao G. Management of varices and variceal hemorrhage in liver cirrhosis: a recent update. Therap Adv Gastroenterol 2022; 15:17562848221101712. [PMID: 35757384 PMCID: PMC9218432 DOI: 10.1177/17562848221101712] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/03/2022] [Indexed: 02/04/2023] Open
Abstract
Cirrhosis consists of two main stages: compensated (asymptomatic) and decompensated, the latter with a higher mortality. Variceal hemorrhage, together with ascites or encephalopathy, or both, are events that define cirrhosis decompensation and are driven by portal hypertension. The approach and management of patients with compensated cirrhosis has been mostly focused on preventing variceal hemorrhage in those who have high-risk varices on endoscopy. Recent studies suggest a paradigm shift aimed at preventing all decompensating events, not only variceal hemorrhage, in patients with cirrhosis and clinically significant portal hypertension identified via noninvasive measures such as liver stiffness and platelet count. In these patients, nonselective beta-blockers have been shown to prevent ascites (the most common decompensating event) and variceal growth. Variceal hemorrhage has a high mortality rate and even though advances in diagnostic approach and standard of care over the past decades have led to a decrease in mortality, it is still high with a 6-week mortality rate of 15-20%. Survival has improved with the preemptive placement of the transjugular intrahepatic portosystemic shunt in patients at high risk of failing standard therapy. In this review, we provide an overview of the pathophysiology and bases for therapy of portal hypertension and varices, the diagnostic approach and management of compensated cirrhosis with clinically significant portal hypertension, and the management of acute variceal hemorrhage as well as prevention strategies for variceal hemorrhage recurrence.
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Abstract
Acute variceal bleeding is the major cause of mortality in patients with cirrhosis. The standard medical and endoscopic treatment has reduced the mortality of variceal bleeding from 50% to 10-20%. The refractory variceal bleed is either because of failure to control the bleed or failure of secondary prophylaxis. The patients refractory to standard medical therapy need further interventions. The rescue therapies include balloon tamponade, self-expanding metal stents (SEMS) placement, shunt procedures, including transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), and endoscopic ultrasound (EUS) guided coiling. In cases where endoscopic variceal ligation (EVL) has failed and the variceal bleeding continues, temporary measures like balloon tamponade can be used to achieve hemostasis and as a bridge to definitive measures. SEMS being in use for refractory bleed is preferred over balloon tamponade due to the reduced complication rate. The shunting procedures are highly effective in reducing portal pressure and represent the gold standard for uncontrolled variceal bleeding. The surgical shunts, as well as nonshunt surgeries such as devascularization have become less popular with the increasing use of minimally invasive techniques like TIPS. TIPS have high success rates in controlling refractory variceal bleeding. The mortality rate is greater in high-risk patients undergoing salvage TIPS, and hence, pre-emptive TIPS should be considered in these patients. BRTO is an interventional radiologic procedure used in the management of bleeding gastric and ectopic varices. The availability of gastrorenal or splenorenal shunts is required for the BRTO procedure, which helps to reach and obliterate the cardiofundal varices through the femoral or jugular vein approach. The EUS guided coiling and glue injection have shown promising results, and further randomized controlled trials are required to establish their efficacy for refractory variceal bleeding.
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Key Words
- BAATO, balloon-assisted antegrade transvenous obliteration
- BRTO
- BRTO, balloonoccluded retrograde transvenous obliteration
- DIPS, direct intrahepatic portacaval shunt
- EUS guided coiling
- EUS, endoscopic ultrasound
- EVL, endsocopic variceal ligation
- HVPG, hepatic venous pressure gradient
- PARTO, plug-assisted retrograde transvenous obliteration
- PTFE, polytetrafluoroethylene
- PVT, portal vein thrombosis
- TIPS, transjugular intrahepatic portosystemic shunt
- TIPSS
- portal hypertension
- refractory variceal bleed
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Vaz K, Efthymiou M, Vaughan R, Testro AG, Lew HB, Pu LZCT, Chandran S. Unpacking the challenge of gastric varices: A review on indication, timing and modality of therapy. World J Hepatol 2021; 13:868-878. [PMID: 34552693 PMCID: PMC8422918 DOI: 10.4254/wjh.v13.i8.868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/09/2021] [Accepted: 07/29/2021] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal bleeding from oesophageal or gastric varices is an important medical condition in patients with portal hypertension. Despite the emergence of a number of novel endoscopic and radiologic therapies for oesophagogastric varices, controversy exists regarding the indication, timing and modality of therapy. The aim of this review is to provide a concise and practical evidence-based overview of these issues.
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Affiliation(s)
- Karl Vaz
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Marios Efthymiou
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- University of Melbourne, Parkville 3052, Victoria, Australia
| | - Rhys Vaughan
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- University of Melbourne, Parkville 3052, Victoria, Australia
| | - Adam G Testro
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Hin-Boon Lew
- Department of Radiology, Austin Health, Heidelberg 3084, Victoria, Australia
| | | | - Sujievvan Chandran
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- University of Melbourne, Parkville 3052, Victoria, Australia
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Shah KY, Ren A, Simpson RO, Kloster ML, Mikolajczyk A, Bui JT, Lipnik AJ, Niemeyer MM, Ray CE, Gaba RC. Combined Transjugular Intrahepatic Portosystemic Shunt Plus Variceal Obliteration versus Transjugular Intrahepatic Portosystemic Shunt Alone for the Management of Gastric Varices: Comparative Single-Center Clinical Outcomes. J Vasc Interv Radiol 2021; 32:282-291.e1. [PMID: 33485506 DOI: 10.1016/j.jvir.2020.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/11/2020] [Accepted: 10/11/2020] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To compare the safety and clinical outcomes of combined transjugular intrahepatic portosystemic shunt (TIPS) plus variceal obliteration to those of TIPS alone for the treatment of gastric varices (GVs). MATERIALS AND METHODS A single-center, retrospective study of 40 patients with bleeding or high-risk GVs between 2008 and 2019 was performed. The patients were treated with combined therapy (n = 18) or TIPS alone (n = 22). There were no significant differences in age, sex, model for end-stage liver disease score, or GV type between the groups. The primary outcomes were the rates of GV eradication and rebleeding. The secondary outcomes included portal hypertensive complications and hepatic encephalopathy. RESULTS The mean follow-up period was 15.4 months for the combined therapy group and 22.9 months for the TIPS group (P = .32). After combined therapy, there was a higher rate of GV eradication (92% vs 47%, P = .01) and a trend toward a lower rate of GV rebleeding (0% vs 23%, P = .056). The estimated rebleeding rates were 0% versus 5% at 3 months, 0% versus 11% at 6 months, 0% versus 18% at 1 year, and 0% versus 38% at 2 years after combined therapy and TIPS, respectively (P = .077). There was no difference in ascites (13% vs 11%, P = .63), hepatic encephalopathy (47% vs 55%, P = .44), or esophageal variceal bleeding (0% vs 0%, P > .999) after the procedure between the groups. CONCLUSIONS The GV eradication rate is significantly higher after combined therapy, with no associated increase in portal hypertensive complications. This translates to a clinically meaningful trend toward a reduction in GV rebleeding. The value of a combined treatment strategy should be prospectively studied in a larger cohort to determine the optimal management of GVs.
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Affiliation(s)
- Ketan Y Shah
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL, 60612.
| | - Albert Ren
- University of Illinois College of Medicine, Chicago, IL
| | | | | | - Adam Mikolajczyk
- Department of Medicine, University of Illinois Health, Chicago, IL
| | - James T Bui
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL, 60612
| | - Andrew J Lipnik
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL, 60612
| | - Matthew M Niemeyer
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL, 60612
| | - Charles E Ray
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL, 60612
| | - Ron C Gaba
- Department of Radiology, University of Illinois at Chicago, 1740 West Taylor Street, MC 931, Chicago, IL, 60612
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Ahmed R, Kiyosue H, Mori H, Abdelaziz S, Othman M, Abdel-Aal S, Maruno M, Matsumoto S. Conventional versus selective balloon-occluded retrograde transvenous obliteration of gastric varices. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00228-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
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Philips CA, Ahamed R, Rajesh S, George T, Mohanan M, Augustine P. Beyond the scope and the glue: update on evaluation and management of gastric varices. BMC Gastroenterol 2020; 20:361. [PMID: 33126847 PMCID: PMC7602314 DOI: 10.1186/s12876-020-01513-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/23/2020] [Indexed: 02/08/2023] Open
Abstract
Gastric varices are encountered less frequently than esophageal varices. Nonetheless, gastric variceal bleeding is more severe and associated with worse outcomes. Conventionally, gastric varices have been described based on the location and extent and endoscopic treatments offered based on these descriptions. With improved understanding of portal hypertension and the dynamic physiology of collateral circulation, gastric variceal classification has been refined to include inflow and outflow based hemodynamic pathways. These have led to an improvement in the management of gastric variceal disease through newer modalities of treatment such as endoscopic ultrasound-guided glue-coiling combination therapy and the emergence of highly effective endovascular treatments such as shunt and variceal complex embolization with or without transjugular intrahepatic portosystemic shunt (TIPS) placement in patients who are deemed ‘difficult’ to manage the traditional way. Furthermore, the decisions regarding TIPS and additional endovascular procedures in patients with gastric variceal bleeding have changed after the emergence of ‘portal hypertension theories’ of proximity, throughput, and recruitment. The hemodynamic classification, grounded on novel theories and its cognizance, can help in identifying patients at baseline, in whom conventional treatment could fail. In this exhaustive review, we discuss the conventional and hemodynamic diagnosis of gastric varices concerning new classifications; explore and illustrate new ‘portal hypertension theories’ of gastric variceal disease and corresponding management and shed light on current evidence-based treatments through a ‘new’ algorithmic approach, established on hemodynamic physiology of gastric varices.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Laboratory, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India.
| | - Rizwan Ahamed
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Meera Mohanan
- Anaesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Philip Augustine
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
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12
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The combination of balloon-assisted antegrade transvenous obliteration and transjugular intrahepatic portosystemic shunt for the management of cardiofundal varices hemorrhage. Eur J Gastroenterol Hepatol 2020; 32:656-662. [PMID: 32175982 PMCID: PMC7147412 DOI: 10.1097/meg.0000000000001705] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES In this study, we propose a modified balloon-occluded retrograde transvenous obliteration (BRTO) strategy - balloon-assisted antegrade transvenous obliteration (BAATO), and explore the feasibility, efficacy and safety of BAATO combined with transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of cardiofundal varices (GOV2 or IGV1) hemorrhage. MATERIALS AND METHODS In this retrospective cohort study, 15 patients with cardiofundal varices hemorrhage who received BAATO combined with TIPS procedures, from August 2017 to September 2019 in our center, were enrolled. They consisted of seven patients with GOV2 and eight patients with IGV1. The clinical efficacy and safety of BAATO + TIPS procedures were assessed by comparing the clinical symptoms, laboratory and imaging examinations before and after treatment. RESULTS The technical success rate of BAATO + TIPS procedure was 100%. After the procedure, clinical symptoms were improved and complete regression of gastric varices (GVs) was observed in all patients, besides, the control efficiency of ascites and PVT which were 77.8 and 87.5%, respectively. No patient died or had a rebleeding during the follow up, but grade II hepatic encephalopathy (HE) occurred in two patients (13.3%) and shunt dysfunction was discovered in one patient (6.7%). CONCLUSION For the treatment of GVs, the new technique BAATO is feasible, safe and effective, and it may be a more convenient and economical method than conventional BRTO. In addition, the combination of BAATO and TIPS may play a positive role in achieving hemostasis and improving the complications of portal hypertension such as ascites and PVT.
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Kim CY, Pinchot JW, Ahmed O, Braun AR, Cash BD, Feig BW, Kalva SP, Knavel Koepsel EM, Scheidt MJ, Schramm K, Sella DM, Weiss CR, Hohenwalter EJ. ACR Appropriateness Criteria® Radiologic Management of Gastric Varices. J Am Coll Radiol 2020; 17:S239-S254. [PMID: 32370968 DOI: 10.1016/j.jacr.2020.01.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 12/13/2022]
Abstract
Hemorrhage, resulting from gastric varies, can be challenging to treat, given the various precipitating etiologies. A wide variety of treatment options exist for managing the diverse range of the underlying disease processes. While cirrhosis is the most common cause for gastric variceal bleeding, occlusion of the portal or splenic vein in noncirrhotic states results in a markedly different treatment paradigm. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Charles Y Kim
- Duke University Medical Center, Durham, North Carolina.
| | | | | | - Aaron R Braun
- St Elizabeth Regional Medical Center, Lincoln, Nebraska
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Barry W Feig
- The University of Texas MD Anderson Cancer Center, Houston, Texas; American College of Surgeons
| | | | | | | | - Kristofer Schramm
- University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
| | | | | | - Eric J Hohenwalter
- Specialty Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
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14
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Al-Khazraji A, Curry MP. The current knowledge about the therapeutic use of endoscopic sclerotherapy and endoscopic tissue adhesives in variceal bleeding. Expert Rev Gastroenterol Hepatol 2019; 13:893-897. [PMID: 31389265 DOI: 10.1080/17474124.2019.1652092] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: The most recent guidelines vary in their approach to the management of variceal bleeding especially with the use of endoscopic sclerotherapy (ES) and endoscopic tissue adhesive (ETA). This review highlights their clinical use for variceal bleeding from different guidelines perspectives. Areas covered: A comprehensive literature review of three major guidelines including the American Association for the Study of Liver Diseases (AASLD) 2017, United Kingdom (UK) guidelines 2015 and Baveno VI Consensus workshop guidelines in 2015 on the use of ES and ETA in variceal bleeding. Expert opinion: While endoscopic band ligation (EBL) completely replaced endoscopic sclerotherapy (ES) for esophageal varices. There is a valuable use of endoscopic sclerotherapy (ES) and endoscopic tissue adhesive (ETA) especially for patients with gastroesophageal varices (GOV2) and isolated gastric varices (IGV2). The current standard of care heading toward portosystemic shunting with Trans-jugular-Intrahepatic Portosystemic Shunt (TIPS) and balloon retrograde transvenous obliteration (BRTO). However, recent advancement in endoscopic ultrasound (EUS) allowing direct injection of sclerosant and tissue adhesive into the varix bringing promising results in achieving hemostasis and lowering the risk of complications. Also, ES and ETA have great clinical value in achieving hemostasis for isolated (ectopic) varices and stomal varices.
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Affiliation(s)
- Ahmed Al-Khazraji
- Department of Gastroenterology & Hepatology, Transplant Liver Center, Harvard School of Medicine, Beth Israel Deaconess Medical Center , Boston , MA , USA
| | - Michael P Curry
- Department of Gastroenterology & Hepatology, Transplant Liver Center, Harvard School of Medicine, Beth Israel Deaconess Medical Center , Boston , MA , USA
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15
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Comparison of transjugular intrahepatic portosystemic shunt for treatment of variceal bleeding in patients with cirrhosis with or without spontaneous portosystemic shunt. Eur J Gastroenterol Hepatol 2019; 31:853-858. [PMID: 30633039 DOI: 10.1097/meg.0000000000001349] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Transjugular intrahepatic portosystemic shunt (TIPS) is an effective intervention for portal hypertensive complications in cirrhosis. Spontaneous portosystemic shunts (SPSSs) may increase the risk of post-TIPS complications and mortality. This study was done to evaluate the safety and efficacy of TIPS for treating variceal bleeding between patients with and without SPSSs. PATIENTS AND METHODS The clinical data of 467 consecutive patients with cirrhosis who received TIPS for variceal bleeding from January 2012 to January 2018 were screened. A total of 33 patients with coexisting SPSSs were included as the SPSS group, and 33 patients without SPSSs were randomly selected as control. The procedure-related complications and long-term outcomes were compared between the two groups. RESULTS Both groups were successfully treated with TIPS. SPSSs were antegradely embolized before TIPS placement. In terms of safety, one patient in the SPSS group experienced an asymptomatic pulmonary embolism, and another patient experienced serious gastric ulcer bleeding. Overall, 23 (70.0%) patients in the SPSS group and 16 (51.5%) patients in the control group experienced different mild complications (P=0.131). During a median follow-up of more than 2 years, the rebleeding rates (7.1 vs. 3.7% at 1 year, P=0.508), overt hepatic encephalopathy occurrence rates (34.4 vs. 39.4% at 2 years, P=0.685), and orthotopic liver transplantation-free survival rates (73.2 vs. 70.7% at 2 years, P=0.557) were not significantly different between the two groups. CONCLUSION TIPS combined with antegrade embolization is safe, effective, and feasible for patients with SPSSs, with safety and long-term outcomes comparable to patients without SPSSs.
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16
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Qiu Z, Wang GS, Gao F. Whole-course management of interventional treatment in liver cancer patients with portal hypertension. J Interv Med 2019; 2:52-54. [PMID: 34805872 PMCID: PMC8562174 DOI: 10.1016/j.jimed.2019.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Primary liver cancer often occurs in patients with hepatitis and cirrhosis. Some patients have portal hypertension due to cirrhosis, and present with varying degrees of collateral circulation, splenomegaly and hypersplenism, ascites, and liver dysfunction. It often interferes with the treatment of tumors and affects the disease prognosis. There are internationally recognized guidelines for interventional treatment of liver cancer and portal hypertension which will not be repeated in this paper. This paper focuses on how to treat portal hypertension and intervene with tumors in the treatment of liver cancer to optimize the management of patients with liver cancer and portal hypertension. We propose that the Interventional Management Mode of Liver Cancer with Portal Hypertension can improve the treatment of liver cancer patients with portal hypertension.
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Affiliation(s)
| | | | - Fei Gao
- Corresponding author. State Key Laboratory of Oncology in Southern China, Department ofMedical Imaging and Interventional Radiology, Cancer Center, Sun Yat-sen University, Guangzhou, 510060, Guangdong Province, PR China.
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17
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Ahmed R, Kiyosue H, Maruno M, Matsumoto S, Mori H. Coexistence of "extra-gastric afferent-efferent direct connection" with gastric varices: CT evaluation and clinical significance. Abdom Radiol (NY) 2019; 44:2699-2707. [PMID: 31030246 DOI: 10.1007/s00261-019-02033-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE To evaluate the prevalence of extra-gastric direct connection between afferent and efferent veins of gastric varices (GVs) (i.e., EAEDC) and its clinical significance during balloon-occluded retrograde transvenous obliteration (BRTO). MATERIALS AND METHODS 57 patients who underwent BRTO for GVs obliteration were retrospectively enrolled in this study. Pre-procedural CT images were reviewed for the presence of EAEDC. Patients were categorized into group A (patients with EAEDC) and group B (Patients with no detectable EAEDC). Intraprocedural images were reviewed to see if EAEDCs could be seen and if additional techniques were used to preserve or occlude them. Post-procedural CT images were reviewed for GVs obliteration, portal/splenic vein thrombosis, EAEDC patency, and ascites exacerbation. Post-procedural esophageal varices aggravation was evaluated by upper endoscopy. RESULTS 39 EAEDCs were identified in CT images of 35 patients (i.e., group A = 61.4%). Among them, only 20 EAEDCs were visualized during BRTO. In the remaining 22 patients, EAEDC was not identified in CT images or during BRTO (i.e., group B = 38.6%). There was no statistically significant difference between group A and B regarding post-BRTO GVs obliteration and portal/splenic vein thrombosis. Use of additional techniques to preserve EAEDC patency had significantly reduced the incidence of ascites and esophageal varices exacerbation (p = 0.036 and 0.028, respectively). In patients with EAEDC diameter ≥ 5 mm, EAEDC preservation or obliteration by coils or balloon had significantly reduced the injected sclerosant volume (p = 0.003). CONCLUSION CT is very useful for EAEDC detection. EAEDC preservation may decrease the incidence of post-BRTO ascites and esophageal varices exacerbation.
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Affiliation(s)
- Ramy Ahmed
- Department of Radiology, Faculty of Medicine, Assuit University, Assuit, 71515, Egypt.
- Department of Radiology, Faculty of Medicine, Oita University, Oita, Japan.
| | - Hiro Kiyosue
- Department of Radiology, Faculty of Medicine, Oita University, Oita, Japan
| | - Miyuki Maruno
- Department of Radiology, Faculty of Medicine, Oita University, Oita, Japan
| | - Shunro Matsumoto
- Department of Radiology, Faculty of Medicine, Oita University, Oita, Japan
| | - Hiromu Mori
- Department of Radiology, Faculty of Medicine, Oita University, Oita, Japan
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18
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Transjugular intrahepatic portosystemic shunt as a bridge to liver transplant: Current state and future directions. Transplant Rev (Orlando) 2018; 33:64-71. [PMID: 30477811 DOI: 10.1016/j.trre.2018.10.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/27/2018] [Accepted: 10/29/2018] [Indexed: 02/07/2023]
Abstract
Liver transplantation is one of the mainstays of treatment for liver failure due to severe chronic liver disease. Bridging therapies, such as placement of a transjugular intrahepatic portosystemic shunt (TIPS), are frequently employed to control complications of portal hypertension such as ascites, hydrothorax, and variceal bleeding, and thereby reduce morbidity in patients awaiting transplant. There is no significant difference seen in either graft survival or patient survival between those receiving TIPS pre-transplant and those who do not, although those receiving TIPS placement on average have a longer waiting time on the transplant waitlist. Locoregional therapies, such as thermal ablation or chemoembolization, can be efficacious in patients with HCC and pre-existing TIPS; however there is a risk for increased adverse events in patients receiving these therapies who have TIPS compared to those who do not. In summary, TIPS is a safe, effective treatment that can be used to ameliorate the complications that are sequelae of portal hypertension. While it does not appear to improve survival post-transplant, TIPS placement pre-transplant may increase survival time to transplant, thus improving overall survival as well as quality of life.
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19
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Lipnik AJ, Pandhi MB, Khabbaz RC, Gaba RC. Endovascular Treatment for Variceal Hemorrhage: TIPS, BRTO, and Combined Approaches. Semin Intervent Radiol 2018; 35:169-184. [PMID: 30087520 DOI: 10.1055/s-0038-1660795] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Variceal hemorrhage is a feared complication of portal hypertension, with high rates of morbidity and mortality. Optimal management requires a thoughtful, multidisciplinary approach. In cases of refractory or recurrent esophageal hemorrhage, endovascular approaches such as transjugular intrahepatic portosystemic shunt (TIPS) have a well-defined role. For hemorrhage related to gastric varices, the optimal treatment remains to be established; however, there is increasing adoption of balloon-occluded retrograde transvenous obliteration (BRTO). This article will review the concept, history, patient selection, basic technique, and outcomes for TIPS, BRTO, and combined TIPS + BRTO procedures for variceal hemorrhage.
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Affiliation(s)
- Andrew J Lipnik
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | - Mithil B Pandhi
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | - Ramzy C Khabbaz
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
| | - Ron C Gaba
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois
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20
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Minowa K, Komatsu S, Takashina K, Tanaka S, Kumano T, Imura K, Shimomura K, Ikeda J, Taniguchi F, Ueshima Y, Lee T, Ikeda E, Otsuji E, Shioaki Y. Ectopic gastrointestinal variceal bleeding with portal hypertension. World J Gastrointest Surg 2017; 9:288-292. [PMID: 29359035 PMCID: PMC5752964 DOI: 10.4240/wjgs.v9.i12.288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 10/07/2017] [Accepted: 11/12/2017] [Indexed: 02/07/2023] Open
Abstract
Massive gastrointestinal bleeding from gastrointestinal varices is one of the most serious complications in patients with portal hypertension. However, if no bleeding point can be detected by endoscopy in the predilection sites of gastrointestinal varices, such as the esophagus and stomach, ectopic gastrointestinal variceal bleeding should be considered as a differential diagnosis. Herein, we report a case of ectopic ileal variceal bleeding in a 57-year-old woman, which was successfully diagnosed by multi-detector row CT (MDCT) and angiography and treated by segmental ileum resection. To date, there have been no consensus for the treatment of ectopic ileal variceal bleeding. This review was designed to clarify the clinical characteristics of patients with ectopic ileal variceal and discuss possible treatment strategies. From the PubMed database and our own database, we reviewed 21 consecutive cases of ileal variceal bleeding diagnosed from 1982 to 2017. MDCT and angiography is useful for the rapid examination and surgical resection of an affected lesion and is a safe and effective treatment strategy to avoid further bleeding.
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Affiliation(s)
- Keita Minowa
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
- Emergency and Critical Care Center, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Shuhei Komatsu
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Kenichiro Takashina
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
- Emergency and Critical Care Center, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Sachie Tanaka
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Tatsuya Kumano
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Kenichiro Imura
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Katsumi Shimomura
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Jun Ikeda
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Fumihiro Taniguchi
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Yasuo Ueshima
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Tecchuu Lee
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Eito Ikeda
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Eigo Otsuji
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Yasuhiro Shioaki
- Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, Higashiyama-ku, Kyoto 605-0981, Japan
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21
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Storace M, Martin JG, Shah J, Bercu Z. CTA As an Adjuvant Tool for Acute Intra-abdominal or Gastrointestinal Bleeding. Tech Vasc Interv Radiol 2017; 20:248-257. [DOI: 10.1053/j.tvir.2017.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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22
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Two-year outcomes of balloon-occluded retrograde transvenous obliteration of gastric varices in liver transplant recipients: A multi-institutional study. Diagn Interv Imaging 2017; 98:801-808. [DOI: 10.1016/j.diii.2017.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 03/14/2017] [Accepted: 03/16/2017] [Indexed: 01/01/2023]
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23
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Single-Session Percutaneous Endovascular Mesocaval Shunt Creation and Balloon-Occluded Retrograde Transvenous Obliteration for the Treatment of Gastric Varices. Ann Vasc Surg 2017; 46:371.e1-371.e6. [PMID: 28893712 DOI: 10.1016/j.avsg.2017.08.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 08/21/2017] [Accepted: 08/30/2017] [Indexed: 01/03/2023]
Abstract
In the setting of portal hypertension, the body responds by creating portosystemic venous shunts, which may lead to the development of varices. Endoscopic treatment of these varices is often warranted to prevent catastrophic bleeding. During the course of variceal treatment, 1 or more portosystemic shunts may be sacrificed, which may acutely exacerbate portal hypertension and reduce systemic venous return. This report describes percutaneous creation of a mesocaval shunt and balloon-occluded retrograde transvenous obliteration (BRTO) in a patient with cavernous transformation of the portal vein. The patient had previously undergone an unsuccessful attempt at transjugular intrahepatic portosystemic shunt (TIPS) creation with postoperative bleeding requiring splenectomy. As TIPS was not feasible, creation of a percutaneous mesocaval shunt provided an alternate pathway for portosystemic decompression, facilitating safe treatment of gastric varices with BRTO via a gastrorenal shunt. These procedures were performed simultaneously to reduce the risk of variceal bleeding from acute changes in portal venous pressures and redirect blood flow through the shunt to maintain patency. This is the first reported case of combined mesocaval shunt placement and BRTO in a single session.
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24
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Abstract
Probiotics contain microorganisms, most of which are bacteria similar to the beneficial bacteria that occur naturally in the human gut. Probiotics have been widely studied in a variety of gastrointestinal diseases. The most-studied species include Lactobacillus, Bifidobacterium, and Saccharomyces. However, a lack of clear guidelines on when to use probiotics and the most effective probiotic for different gastrointestinal conditions may be confusing for family physicians and their patients. Probiotics have an important role in the maintenance of immunologic equilibrium in the gastrointestinal tract through the direct interaction with immune cells. Probiotic effectiveness can be species-, dose-, and disease-specific, and the duration of therapy depends on the clinical indication. There is high-quality evidence that probiotics are effective for acute infectious diarrhea, antibiotic-associated diarrhea, Clostridium difficile- associated diarrhea, hepatic encephalopathy, ulcerative colitis, irritable bowel syndrome, functional gastrointestinal disorders, and necrotizing enterocolitis. Conversely, there is evidence that probiotics are not effective for acute pancreatitis and Crohn disease. Probiotics are safe for infants, children, adults, and older patients, but caution is advised in immunologically vulnerable populations.
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Affiliation(s)
- Thad Wilkins
- Medical College of Georgia at Augusta University, Augusta, GA, USA
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25
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Wang Q, Lv Y, Chen H, Shao J, Han G. Use of 8-mm Covered TIPS: Is "Losses without Gains" the End of the Story? Radiology 2017; 284:604. [PMID: 28723295 DOI: 10.1148/radiol.2017170468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Qiuhe Wang
- Department of Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 15 West Changle Rd, Xi'an 710032, China
| | - Yong Lv
- Department of Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 15 West Changle Rd, Xi'an 710032, China
| | - Hui Chen
- Department of Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 15 West Changle Rd, Xi'an 710032, China
| | - Jing Shao
- Department of Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 15 West Changle Rd, Xi'an 710032, China
| | - Guohong Han
- Department of Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 15 West Changle Rd, Xi'an 710032, China
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26
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Spengler EK, Hunsicker LG, Zarei S, Zimmerman MB, Voigt MD. Transjugular intrahepatic portosystemic shunt does not independently increase risk of death in high model for end stage liver disease patients. Hepatol Commun 2017; 1:460-468. [PMID: 29404473 PMCID: PMC5721420 DOI: 10.1002/hep4.1053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 04/14/2017] [Accepted: 04/22/2017] [Indexed: 12/15/2022] Open
Abstract
Physicians often exclude patients with a model for end-stage liver disease (MELD) score ≥ 18 from a transjugular intrahepatic portosystemic shunt (TIPS) procedure due to the concern for higher risk of death. We aimed to determine if TIPS increased the risk of death in these patients. We analyzed the interaction between TIPS and MELD in 106 patients with TIPS and 79 with intractable ascites without TIPS. We performed Cox proportional hazard regression, including both TIPS and MELD as time-dependent covariates together with their interaction, to calculate the impact of TIPS on the risk of death associated with a high MELD score. We found a negative interaction between a high MELD score and a history of TIPS, with potentially important effect sizes. Patients with MELD scores ≥18 had a 51% lower incremental risk of death (lower risk than would be expected from the combined independent risks of MELD and needing/receiving TIPS) associated with TIPS than patients with MELD scores <18 (hazard ratio for TIPS, 0.49; 95% confidence interval, 0.10-2.45) in the first 6 months following TIPS. There was an 80% lower incremental risk of death among patients with a MELD score ≥18 (hazard ratio for TIPS, 0.20; 95% confidence interval, 0.03-1.23) 6 months after the TIPS procedure. Conclusion: Risk of death is associated with underlying disease severity as shown by the MELD score and the need for TIPS, and both history of TIPS and high MELD score independently increased the risk of mortality. However, the risk of death after TIPS was progressively lower than expected as the MELD score increased. (Hepatology Communications 2017;1:460-468).
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Affiliation(s)
- Erin K Spengler
- Division of Gastroenterology and Hepatology Department of Internal Medicine, The University of Iowa Hospitals and Clinics Iowa City IA.,University of Wisconsin, School of Medicine and Public Health Madison WI
| | - Lawrence G Hunsicker
- Division of Nephrology Department of Internal Medicine, The University of Iowa Hospitals and Clinics Iowa City IA
| | - Sanam Zarei
- Carver College of Medicine The University of Iowa Hospitals and Clinics Iowa City IA
| | - M Bridget Zimmerman
- Department of Biostatistics The University of Iowa Hospitals and Clinics Iowa City IA
| | - Michael D Voigt
- Division of Gastroenterology and Hepatology Department of Internal Medicine, The University of Iowa Hospitals and Clinics Iowa City IA
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27
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Kim SK, Sauk S, Guevara CJ. Transjugular intrahepatic portosystemic shunts versus balloon-occluded retrograde transvenous obliteration for the management of gastric varices: Treatment algorithm according to clinical manifestations. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii150030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Seung Kwon Kim
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO, USA
| | - Steven Sauk
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO, USA
| | - Carlos J. Guevara
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO, USA
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28
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Hansing CE, Marquardt JP, Sutton DM, York JD. Balloon-Occluded Retrograde Transvenous Obliteration of a Gastric Vascular Malformation: An Innovative Approach to Treatment of a Rare Condition. Cardiovasc Intervent Radiol 2016; 40:310-314. [DOI: 10.1007/s00270-016-1470-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 09/19/2016] [Indexed: 11/28/2022]
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29
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Madoff DC, Gaba RC, Weber CN, Clark TWI, Saad WE. Portal Venous Interventions: State of the Art. Radiology 2016; 278:333-53. [PMID: 26789601 DOI: 10.1148/radiol.2015141858] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In recent decades, there have been numerous advances in the management of liver cancer, cirrhosis, and diabetes mellitus. Although these diseases are wide ranging in their clinical manifestations, each can potentially be treated by exploiting the blood flow dynamics within the portal venous system, and in some cases, adding cellular therapies. To aid in the management of these disease states, minimally invasive transcatheter portal venous interventions have been developed to improve the safety of major hepatic resection, to reduce the untoward effects of sequelae from end-stage liver disease, and to minimize the requirement of exogenously administered insulin for patients with diabetes mellitus. This state of the art review therefore provides an overview of the most recent data and strategies for utilization of preoperative portal vein embolization, transjugular intrahepatic portosystemic shunt placement, balloon retrograde transvenous obliteration, and islet cell transplantation.
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Affiliation(s)
- David C Madoff
- From the Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 E 68th St, P-518, New York, NY 10065 (D.C.M.); Department of Radiology, Interventional Radiology Section, University of Illinois Hospital, Chicago, Ill (R.C.G.); Department of Radiology, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa (C.N.W., T.W.I.C.); and Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, Ann Arbor, Mich (W.E.S.)
| | - Ron C Gaba
- From the Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 E 68th St, P-518, New York, NY 10065 (D.C.M.); Department of Radiology, Interventional Radiology Section, University of Illinois Hospital, Chicago, Ill (R.C.G.); Department of Radiology, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa (C.N.W., T.W.I.C.); and Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, Ann Arbor, Mich (W.E.S.)
| | - Charles N Weber
- From the Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 E 68th St, P-518, New York, NY 10065 (D.C.M.); Department of Radiology, Interventional Radiology Section, University of Illinois Hospital, Chicago, Ill (R.C.G.); Department of Radiology, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa (C.N.W., T.W.I.C.); and Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, Ann Arbor, Mich (W.E.S.)
| | - Timothy W I Clark
- From the Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 E 68th St, P-518, New York, NY 10065 (D.C.M.); Department of Radiology, Interventional Radiology Section, University of Illinois Hospital, Chicago, Ill (R.C.G.); Department of Radiology, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa (C.N.W., T.W.I.C.); and Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, Ann Arbor, Mich (W.E.S.)
| | - Wael E Saad
- From the Department of Radiology, Division of Interventional Radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, 525 E 68th St, P-518, New York, NY 10065 (D.C.M.); Department of Radiology, Interventional Radiology Section, University of Illinois Hospital, Chicago, Ill (R.C.G.); Department of Radiology, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa (C.N.W., T.W.I.C.); and Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Medical Center, Ann Arbor, Mich (W.E.S.)
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Lakhoo J, Bui JT, Lokken RP, Ray CE, Gaba RC. Transjugular Intrahepatic Portosystemic Shunt Creation and Variceal Coil or Plug Embolization Ineffectively Attain Gastric Variceal Decompression or Occlusion: Results of a 26-Patient Retrospective Study. J Vasc Interv Radiol 2016; 27:1001-11. [PMID: 27106732 DOI: 10.1016/j.jvir.2016.02.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 02/09/2016] [Accepted: 02/13/2016] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To assess the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation with or without variceal coil and/or plug embolization in decompressing or occluding gastric varices (GVs). MATERIALS AND METHODS In this retrospective study, 78 patients with GV bleeding who underwent TIPS creation with or without embolotherapy with metallic coils and/or plugs from 1999 to 2014 were identified. Individuals who had a bare-metal TIPS and/or lacked post-TIPS imaging or endoscopic follow-up were excluded. The final cohort included 26 patients (16 men; median age, 54 y; median Model for End-stage Liver Disease score, 16). Variceal types, supplying vessels, and postprocedure GV patency on cross-sectional imaging or endoscopy were assessed. The primary study outcome measure was GV patency rate as a surrogate for efficacy of TIPS creation with or without embolization. RESULTS GVs included gastroesophageal varix types 1 (n = 10) and 2 (n = 2), isolated GV types 1 (n = 4) and 2 (n = 2), and unspecified (n = 8). TIPS creation resulted in a median final portosystemic pressure gradient of 7 mm Hg. Multiple GV-supplying vessels (left/posterior/short gastric veins) were present in 65% of patients (n = 17). Embolization was performed in 69% (n = 18). Thirteen, four, and nine patients had imaging, endoscopic, or both imaging/endoscopic follow-up. GV patency rate was 65% (n = 17; 61%/75% with/without embolization) at a median of 128.5 days (range, 1-1,295 d) after TIPS creation. Incidence of recurrent bleeding was 27% (n = 7), and the 90-day mortality rate was 15% (n = 4). CONCLUSIONS In this study, most GVs showed persistent patency despite TIPS decompression and variceal embolization, and the incidence of recurrent bleeding was high. The findings suggest suboptimal efficacy for GVs, and indicate a need for study of alternative or adjunctive approaches to GV treatment, such as chemical obliteration.
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Affiliation(s)
- Janesh Lakhoo
- University of Illinois College of Medicine, University of Illinois Hospital and Health Sciences System, 1740 W. Taylor St., MC 931, Chicago, IL 60612
| | - James T Bui
- Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, 1740 W. Taylor St., MC 931, Chicago, IL 60612
| | - R Peter Lokken
- Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, 1740 W. Taylor St., MC 931, Chicago, IL 60612
| | - Charles E Ray
- Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, 1740 W. Taylor St., MC 931, Chicago, IL 60612
| | - Ron C Gaba
- Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, 1740 W. Taylor St., MC 931, Chicago, IL 60612.
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Chang MY, Kim MD, Kim T, Shin W, Shin M, Kim GM, Won JY, Park SI, Lee DY. Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Variceal Hemorrhage. Korean J Radiol 2016; 17:230-8. [PMID: 26957908 PMCID: PMC4781762 DOI: 10.3348/kjr.2016.17.2.230] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 12/28/2015] [Indexed: 02/06/2023] Open
Abstract
Objective To evaluate the feasibility, safety, and clinical outcomes of plug-assisted retrograde transvenous obliteration (PARTO) to treat gastric variceal hemorrhage in patients with portal hypertension. Materials and Methods From May 2012 to June 2014, 19 patients (11 men and 8 women, median age; 61, with history of gastric variceal hemorrhage; 17, active bleeding; 2) who underwent PARTO using a vascular plug and a gelfoam pledget were retrospectively analyzed. Clinical and laboratory data were examined to evaluate primary (technical and clinical success, complications) and secondary (worsening of esophageal varix [EV], change in liver function) end points. Median follow-up duration was 11 months, from 6.5 to 18 months. The Wilcoxon signed-rank test was used to compare laboratory data before and after the procedure. Results Technical success (complete occlusion of the efferent shunt and complete filling of gastric varix [GV] with a gelfoam slurry) was achieved in 18 of 19 (94.7%) patients. The embolic materials could not reach the GV in 1 patient who had endoscopic glue injection before our procedure. The clinical success rate (no recurrence of gastric variceal bleeding) was the same because the technically failed patient showed recurrent bleeding later. Acute complications included fever (n = 2), fever and hypotension (n = 2; one diagnosed adrenal insufficiency), and transient microscopic hematuria (n = 3). Ten patients underwent follow-up endoscopy; all exhibited GV improvement, except 2 without endoscopic change. Five patients exhibited aggravated EV, and 2 of them had a bleeding event. Laboratory findings were significantly improved after PARTO. Conclusion PARTO is technically feasible, safe, and effective for gastric variceal hemorrhage in patients with portal hypertension.
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Affiliation(s)
- Min-Yung Chang
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Man-Deuk Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Taehwan Kim
- Department of Radiology, National Health Insurance Serivce Ilsan Hospital, Goyang 10444, Korea
| | - Wonseon Shin
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Minwoo Shin
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Gyoung Min Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Jong Yun Won
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Sung Il Park
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Do Yun Lee
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
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Gaba RC. Transjugular Intrahepatic Portosystemic Shunt Creation With Embolization or Obliteration for Variceal Bleeding. Tech Vasc Interv Radiol 2016; 19:21-35. [DOI: 10.1053/j.tvir.2016.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Abstract
PURPOSE OF REVIEW Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are two types of upper gastrointestinal bleeding that may present similarly, but are managed very differently. This article reviews the pathogenesis and guidelines in management of both of these conditions with emphasis on recent advances in the field. RECENT FINDINGS Off-label use of Hemospray has been shown in several case series to be useful in managing acute bleeding from PHG. Balloon-occluded retrograde transvenous obliteration presents an alternative approach for this condition. Radiofrequency ablation may be an alternative therapy to argon plasma coagulation in the endoscopic treatment of GAVE, as it consists of fewer sessions and has been shown to decrease gastrointestinal blood loss. SUMMARY The treatment options for PHG and GAVE are constantly evolving and expanding. In this review, we present the latest approaches in the gastroenterologist's arsenal to deal with these conditions.
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Garcia MC, Ahlenstiel G, Mahajan H, van der Poorten D. Small bowel varices secondary to chronic superior mesenteric vein thrombosis in a patient with heterozygous Factor V Leiden mutation: a case report. J Med Case Rep 2015; 9:210. [PMID: 26423996 PMCID: PMC4589920 DOI: 10.1186/s13256-015-0705-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 09/02/2015] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Bleeding ectopic small bowel varices pose a clinical dilemma for the physician, given their diagnostic obscurity and the lack of evidence-based medicine to guide therapy. They often occur in the context of portal hypertension, secondary to either liver disease or extrahepatic causes. Rarely is their presence associated with chronic superior mesenteric vein thrombosis and hereditary coagulopathies. CASE PRESENTATION A 74-year-old white woman, with a heterozygous Factor V Leiden mutation and no underlying liver disease or portal hypertension, presented over the course of 13 months for recurrent episodes of melena and per rectal bleeding. An initial endoscopy showed a clean-based chronic gastric ulcer, while colonoscopies showed multiple, non-bleeding angioectasias which were treated with argon plasma coagulation. Subsequent video capsule endoscopy and double balloon enteroscopy revealed red wale marks overlying engorged submucosal veins in her distal ileum, consistent with ectopic varices. A chronic superior mesenteric vein thrombus, found via computed tomography venogram, was the cause of the ileal varices. She underwent curative surgical resection of the affected bowel, with no re-bleeding episodes 17 months post-surgery, despite needing lifelong anticoagulation for recurrent venous thromboembolisms. CONCLUSIONS Clinicians should consider ectopic varices in patients who present with obscure gastrointestinal bleeding, even in the absence of portal hypertension or liver disease. In those with a known thrombophilia, patients should be screened for splanchnic thrombosis, which may precipitate ectopic varices.
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Affiliation(s)
- Maria C Garcia
- Sydney Medical School, Westmead Clinical School, University of Sydney, Sydney, NSW, Australia.
| | - Golo Ahlenstiel
- Department of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Westmead, NSW, Australia.
| | - Hema Mahajan
- Department of Anatomical Pathology, Westmead Hospital, Westmead, NSW, Australia.
| | - David van der Poorten
- Department of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Westmead, NSW, Australia.
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Siramolpiwat S. Transjugular intrahepatic portosystemic shunts and portal hypertension-related complications. World J Gastroenterol 2014; 20:16996-17010. [PMID: 25493012 PMCID: PMC4258568 DOI: 10.3748/wjg.v20.i45.16996] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 07/09/2014] [Accepted: 08/28/2014] [Indexed: 02/06/2023] Open
Abstract
Portal hypertension (PH) plays an important role in the natural history of cirrhosis, and is associated with several clinical consequences. The introduction of transjugular intrahepatic portosystemic shunts (TIPS) in the 1980s has been regarded as a major technical advance in the management of the PH-related complications. At present, polytetrafluoroethylene-covered stents are the preferred option over traditional bare metal stents. TIPS is currently indicated as a salvage therapy in patients with bleeding esophageal varices who fail standard treatment. Recently, applying TIPS early (within 72 h after admission) has been shown to be an effective and life-saving treatment in those with high-risk variceal bleeding. In addition, TIPS is recommended as the second-line treatment for secondary prophylaxis. For bleeding gastric varices, applying TIPS was able to achieve hemostasis in more than 90% of patients. More trials are needed to clarify the efficacy of TIPS compared with other treatment modalities, including cyanoacrylate injection and balloon retrograde transvenous obliteration of gastric varices. TIPS should also be considered in bleeding ectopic varices and refractory portal hypertensive gastropathy. In patients with refractory ascites, there is growing evidence that TIPS not only results in better control of ascites, but also improves long-term survival in appropriately selected candidates. In addition, TIPS is a promising treatment for refractory hepatic hydrothorax. However, the role of TIPS in the treatment of hepatorenal and hepatopulmonary syndrome is not well defined. The advantage of TIPS is offset by a risk of developing hepatic encephalopathy, the most relevant post-procedural complication. Emerging data are addressing the determination the optimal time and patient selection for TIPS placement aiming at improving long-term treatment outcome. This review is aimed at summarizing the published data regarding the application of TIPS in the management of complications related to PH.
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Parekh PJ, Buerlein RC, Shams R, Vingan H, Johnson DA. Evaluation of gastrointestinal bleeding: Update of current radiologic strategies. World J Gastrointest Pharmacol Ther 2014; 5:200-208. [PMID: 25374760 PMCID: PMC4218949 DOI: 10.4292/wjgpt.v5.i4.200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 06/10/2014] [Accepted: 09/24/2014] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal bleeding (GIB) is a common presentation with significant associated morbidity and mortality, the prevalence of which continues to rise with the ever-increasing aging population. Initial evaluation includes an esophagoduodeonscopy and/or colonoscopy, which may fail to reveal a source. Such cases prove to be a dilemma and require collaboration between gastroenterology and radiology in deciding the most appropriate approach. Recently, there have been a number of radiologic advances in the approach to GIB. The purpose of this review is to provide an evidence-based update on the most current radiologic modalities available and an algorithmic approach to GIB.
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Abstract
Bleeding from gastric varices is a major complication of portal hypertension. Although less common than bleeding associated with esophageal varices, gastric variceal bleeding has a higher mortality. From an endovascular perspective,transjugular intrahepatic portosystemic shunts (TIPS) to decompress the portal circulation and/or balloon-occluded retrograde transvenous obliteration (BRTO) are utilized to address bleeding gastric varices. Until recently, there was a clear medical cultural divide between the strategy of decompressing the portal circulation (TIPS creation, for example) and transvenous obliteration for the management of gastric varices. However, the practice of BRTO is gaining acceptance in the United States and its practice is spreading rapidly. Recently, the American College of Radiology has identified BRTO to be a viable alternative to TIPS in particular anatomical and clinical scenarios. However, the anatomical and clinical applications of BRTO were not defined beyond the conservative approach of resorting to BRTO in non-TIPS candidates. The article discusses the outcomes of BRTO and TIPS for the management of gastric varices individually or in combination. Definitions, endovascular technical concepts and contemporary vascular classifications of gastric variceal systems are described in order to help grasp the complexity of the hemodynamic pathology and hopefully help define the pathology better for future reporting and lay the ground for more defined stratification of patients not only based on comorbidity and hepatic reserve but on anatomy and hemodynamic classifications.
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Bercu ZL, Fischman AM. Outcomes of transjugular intrahepatic portosystemic shunts for ascites. Semin Intervent Radiol 2014; 31:248-51. [PMID: 25177085 DOI: 10.1055/s-0034-1382792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Refractory ascites represents a devastating complication of portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) is an efficacious option for patients for whom transplant is not an immediate option. Techniques to optimize the hepatic venous pressure gradient and the use of covered stents have reduced rates of hepatic encephalopathy and stent occlusion, respectively. Patients with a Model for End-Stage Liver Disease score less than 15, serum creatinine less than 2 mg/dL, and serum bilirubin less than 2 mg/dL are particularly suited for TIPS placement. TIPS is also effective for hepatic hydrothorax and for massive ascites in the posttransplant setting, although future investigations are necessary to elucidate risk factors and establish the effect on transplant-free survival.
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Affiliation(s)
- Zachary L Bercu
- Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Aaron M Fischman
- Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
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Saad WE. Combining Transjugular Intrahepatic Portosystemic Shunt with Balloon-Occluded Retrograde Transvenous Obliteration or Augmenting TIPS with Variceal Embolization for the Management of Gastric Varices: An Evolving Middle Ground? Semin Intervent Radiol 2014; 31:266-8. [PMID: 25177089 DOI: 10.1055/s-0034-1382796] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The American College of Radiology Appropriateness Criteria Committee on interventional radiology has recently recognized balloon-occluded retrograde transvenous obliteration (BRTO) as a viable alternative to transjugular intrahepatic portosystemic shunt (TIPS) in certain anatomic and clinical scenarios for the management of gastric varices. However, it did not define these particular scenarios where BRTO would be a viable alternative. With the increased practice of BRTO in the United States, a debate ensues in the United States and Europe whether BRTO or TIPS should be the primary endovascular procedure of choice for gastric varices. From a conservative standpoint, BRTO is reserved for patients who are not TIPS candidates, while other institutions leave the decision to operator preference and "favorable anatomy" for either procedure. To add to the debate, there is a heightened interest in the improved efficacy of variceal embolization (metallic/bland embolization) concurrent with TIPS compared with TIPS without embolization, and a recent article describing a combination of TIPS and BRTO that demonstrated impressive results superior to BRTO or TIPS alone. This article discusses the most recent outcomes of TIPS and embolization of gastric varices as well as combining BRTO and TIPS.
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Affiliation(s)
- Wael E Saad
- Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan
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40
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Abstract
Although often considered together, gastric and ectopic varices represent complications of a heterogeneous group of underlying diseases. Commonly, these are known to arise in patients with cirrhosis secondary to portal hypertension; however, they also arise in patients with noncirrhotic portal hypertension, most often secondary to venous thrombosis of the portal venous system. One of the key initial assessments is to define the underlying condition leading to the formation of these portal-collateral pathways to guide management. In the authors' experience, these patients can be grouped into distinct although sometimes overlapping conditions, which can provide a helpful conceptual basis of management.
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Affiliation(s)
- Zachary Henry
- Division of Gastroenterology and Hepatology, University of Virginia Health System, PO Box 800708, Charlottesville, VA 22908-0708, USA
| | - Dushant Uppal
- Division of Gastroenterology and Hepatology, University of Virginia Health System, PO Box 800708, Charlottesville, VA 22908-0708, USA
| | - Wael Saad
- Division of Vascular and Interventional Radiology, University of Virginia Health System, PO Box 800170, Charlottesville, VA 22908, USA
| | - Stephen Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia Health System, PO Box 800708, Charlottesville, VA 22908-0708, USA.
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Factors associated with aggravation of esophageal varices after B-RTO for gastric varices. Cardiovasc Intervent Radiol 2013; 37:1243-50. [PMID: 24322305 PMCID: PMC4156781 DOI: 10.1007/s00270-013-0809-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 11/10/2013] [Indexed: 12/15/2022]
Abstract
PURPOSE To retrospectively evaluate risk factors for aggravation of esophageal varices (EV) within 1 year after balloon-occluded retrograde transvenous obliteration (B-RTO) of gastric varices (GV) and to clarify suitable timing for upper endoscopy to detect EV aggravation after B-RTO. METHODS Participants included 67 patients who underwent B-RTO for GV between January 2006 and December 2010. Whether EV aggravation occurred within 1 year was evaluated, and the time interval from B-RTO to aggravation was calculated. Factors potentially associated with EV aggravation were analyzed. RESULTS B-RTO was successfully performed in all patients. EV aggravation at 1 year after B-RTO was found in 38 patients (56.7 %). Multivariate logistic regression analysis showed that total bilirubin (T-bil) (P = 0.032) and hepatic venous pressure gradient (HVPG) (P = 0.011) were significant independent risk factors for EV aggravation after B-RTO. Cutoff values of T-bil and HVPG yielding maximal combined sensitivity and specificity for EV aggravation were 1.6 mg/dL and 13 mmHg, respectively. The patients with T-bil ≥ 1.6 mg/dL or HVPG ≥ 13 mmHg had a median aggravation time of 5.1 months. All five patients with ruptured EV belonged to this group. In contrast, patients with T-bil < 1.6 mg/dL and HVPG < 13 mmHg had a median aggravation time of 21 months. CONCLUSION T-bil and HVPG were significant independent risk factors for EV aggravation after B-RTO. The patients with T-bil ≥ 1.6 mg/dL or HVPG ≥ 13 mmHg require careful follow-up evaluation, including endoscopy.
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Balloon-occluded retrograde transvenous obliteration of gastric varices. Cardiovasc Intervent Radiol 2013; 37:299-315. [PMID: 24091750 DOI: 10.1007/s00270-013-0715-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 06/28/2013] [Indexed: 02/07/2023]
Abstract
Balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices is an image-guided transcatheter procedure used to treat gastric varices with sclerosants rather than decompression of the portal venous system. The history of its development, relevant portal venous, and systemic venous anatomic considerations, techniques, indications, and early results will be reviewed. In addition, the status of the practice of BRTO in the United States will be discussed.
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