Evaluation of gastric fundic and oesophageal varices by 64-row multidetector computed tomography before and after transjugular intrahepatic portosystemic shunt with concurrent left gastric vein embolization

Multimodal Ultrasound Model Based on the Left Gastric Vein in B-Viral Cirrhosis: Noninvasive Prediction of Esophageal Varices

OBJECTIVES:

To establish and verify a simple noninvasive model based on the left gastric vein (LGV) to predict the grade of esophageal varices (EV) and high-risk EV (HEV), to facilitate clinical follow-up and timely treatment.

METHODS:

We enrolled 320 patients with B-viral cirrhosis. All patients underwent endoscopy, laboratory tests, liver and spleen stiffness (SS), and ultrasonography. HEV were analyzed using the χ² test/t test and logistic regression in the univariate and multivariate analyses, respectively. EV grades were analyzed using the variance/rank-sum test and logistic regression. A prediction model was derived from the multivariate predictors.

RESULTS:

In the training set, multivariate analysis showed that the independent factors of different EV grades were SS, LGV diameter, and platelet count (PLT). We developed the LGV diameter-SS to PLT ratio index (LSPI) and LGV diameter/PLT models without SS. The area under the receiver operating characteristic curve of the LSPI for diagnosis of small EV, medium EV, large EV, and HEV was 0.897, 0.899, 0.853, and 0.954, respectively, and that of the LGV/PLT was 0.882, 0.890, 0.837, and 0.942, respectively. For the diagnosis of HEV, the negative predictive value was 94.07% when LSPI < 19.8 and the positive predictive value was 91.49% when LSPI > 23.0. The negative predictive value was 95.92% when LGV/PLT < 5.15, and the positive predictive value was 86.27% when LGV/PLT > 7.40. The predicted values showed similar accuracy in the validation set.

DISCUSSION:

Under appropriate conditions, the LSPI was an accurate method to detect the grade of EV and HEV. Alternatively, the LGV/PLT may also be useful in diagnosing the varices when condition limited.

The presence of spontaneous portosystemic shunts increases the risk of complications after transjugular intrahepatic portosystemic shunt (TIPS) placement

PURPOSE

The goal of this study was to identify clinical and imaging variables that are associated with an unfavorable outcome during the 30 days following transjugular intrahepatic portosystemic shunt (TIPS) placement.

MATERIAL AND METHODS

Fifty-four consecutive patients with liver cirrhosis (Child-Pugh 6-13, Model for End-stage Liver Disease 7-26) underwent TIPS placement for refractory ascites (n=25), recurrent or uncontrolled variceal bleeding (n=23) or both (n=6). Clinical, biological and imaging variables including type of stent (covered n=40; bare-stent n=14), presence of spontaneous portosystemic shunt (n=31), and variations in portosystemic pressure gradient were recorded. Early severe complication was defined as the occurrence of overt hepatic encephalopathy or death within the 30days following TIPS placement.

RESULTS

Sixteen patients (30%) presented with early severe complication after TIPS placement. Child-Pugh score was independently associated with complication (HR=1.52, P<0.001). Among the imaging variables, opacification of spontaneous portosystemic shunt during TIPS placement but before its creation was associated with an increased risk of early complication (P=0.04). The other imaging variables were not associated with occurrence of complication.

CONCLUSION

Identification of spontaneous portosystemic shunt during TIPS placement reflects the presence of varices and is associated with an increased risk of early severe complication.

Three-dimensional Doppler ultrasonographic evaluation of hemodynamic changes in the left gastric vein of patients after esophageal variceal ligation

AIM: To determine the hemodynamic effects of endoscopic variceal band ligation (EVL) on the left gastric vein (LGV) using three-dimensional Doppler ultrasonography (TD-DUS).

METHODS: One hundred and ten patients with pathologically confirmed cirrhosis, portal hypertension and esophageal varices who underwent esophageal variceal ligation at our hospital from January 2009 to December 2012 were divided into either a non-hemorrhage group (n = 50) or a hemorrhage group (n = 60). TD-DUS measurements of hemodynamic indexes of the LGV including vein diameter, mean blood flow velocity, blood flow and blood flow were performed.

RESULTS: Before and after EBL, LGV diameter, mean flow velocity, and blood flow were significantly higher in the hemorrhage group than in the non-hemorrhage group (t = 3.2, 2.8; 4.7, 6.0; 3.6, 3.8, all P < 0.01). After EVL treatment, hemodynamic indexes were significantly reduced in both groups. The direction of blood flow of the left gastric vein to the liver (4.55% vs 70.91%), from the liver (87.27% vs 19.09%), and bidirectional blood flow (8.18% vs 10%) differed significantly between before and after treatment. There was also a significant difference between the two groups (χ² = 16.82, P < 0.01).

CONCLUSION: EVL can reduce hemodynamic indexes (LGV diameter, mean blood flow velocity and blood flow) of the LGV.

MDCT angiography to evaluate the therapeutic effect of PTVE for esophageal varices

AIM: To evaluate the role of multi-detector row computed tomography (MDCT) angiography for assessing the therapeutic effects of percutaneous transhepatic variceal embolization (PTVE) for esophageal varices (EVs).

METHODS: The subjects of this prospective study were 156 patients who underwent PTVE with cyanoacrylate for EVs. Patients were divided into three groups according to the filling range of cyanoacrylate in EVs and their feeding vessels: (1) group A, complete obliteration, with at least 3 cm of the lower EVs and peri-/EVs, as well as the adventitial plexus of the gastric cardia and fundus filled with cyanoacrylate; (2) group B, partial obliteration of varices surrounding the gastric cardia and fundus, with their feeding vessels being obliterated with cyanoacrylate, but without reaching lower EVs; and (3) group C, trunk obliteration, with the main branch of the left gastric vein being filled with cyanoacrylate, but without reaching varices surrounding the gastric cardia or fundus. We performed chart reviews and a prospective follow-up using MDCT images, angiography, and gastrointestinal endoscopy.

RESULTS: The median follow-up period was 34 mo. The rate of eradication of varices for all patients was 56.4% (88/156) and the rate of relapse was 31.3% (41/131). The rates of variceal eradication at 1, 3, and 5 years after PTVE were 90.2%, 84.1% and 81.7%, respectively, for the complete group; 61.2%, 49% and 42.9%, respectively, for the partial group; with no varices disappearing in the trunk group. The relapse-free rates at 1, 3 and 5 years after PTVE were 91.5%, 86.6% and 81.7%, respectively, for the complete group; 71.1%, 55.6% and 51.1%, respectively, for the partial group; and all EVs recurred in the trunk group. Kaplan-Meier analysis showed P values of 0.000 and 0.000, and odds ratios of 3.824 and 3.603 for the rates of variceal eradication and relapse free rates, respectively. Cyanoacrylate in EVs disappeared with time, but those in the EVs and other feeding vessels remained permanently in the vessels without a decrease with time, which is important for the continued obliteration of the feeding vessels and prevention of EV relapse.

CONCLUSION: MDCT provides excellent visualization of cyanoacrylate obliteration in EV and their feeding veins after PTVE. It confirms that PTVE is effective for treating EVs.