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Kim HC, Miyayama S, Lee EW, Lim DY, Chung JW, Jae HJ, Choi JW. Interventional Radiology for Bleeding Ectopic Varices: Individualized Approach Based on Vascular Anatomy. Radiographics 2024; 44:e230140. [PMID: 38990775 DOI: 10.1148/rg.230140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
Ectopic varices are rare but potentially life-threatening conditions usually resulting from a combination of global portal hypertension and local occlusive components. As imaging, innovative devices, and interventional radiologic techniques evolve and are more widely adopted, interventional radiology is becoming essential in the management of ectopic varices. The interventional radiologist starts by diagnosing the underlying causes of portal hypertension and evaluating the afferent and efferent veins of ectopic varices with CT. If decompensated portal hypertension is causing ectopic varices, placement of a transjugular intrahepatic portosystemic shunt is considered the first-line treatment, although this treatment alone may not be effective in managing ectopic variceal bleeding because it may not sufficiently resolve focal mesenteric venous obstruction causing ectopic varices. Therefore, additional variceal embolization should be considered after placement of a transjugular intrahepatic portosystemic shunt. Retrograde transvenous obliteration can serve as a definitive treatment when the efferent vein connected to the systemic vein is accessible. Antegrade transvenous obliteration is a vital component of interventional radiologic management of ectopic varices because ectopic varices often exhibit complex anatomy and commonly lack catheterizable portosystemic shunts. Superficial veins of the portal venous system such as recanalized umbilical veins may provide safe access for antegrade transvenous obliteration. Given the absence of consensus and guidelines, a multidisciplinary team approach is essential for the individualized management of ectopic varices. Interventional radiologists must be knowledgeable about the anatomy and hemodynamic characteristics of ectopic varices based on CT images and be prepared to consider appropriate options for each specific situation. ©RSNA, 2024 Supplemental material is available for this article.
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Affiliation(s)
- Hyo-Cheol Kim
- From the Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea (H.C.K., J.W. Chung., H.J.J., J.W. Choi); Department of Diagnostic Radiology, Fukui-ken Saiseikai Hospital, Fukui, Japan (S.M.); Department of Radiology, Division of Interventional Radiology and Department of Surgery, Division of Liver and Pancreas Transplantation, University of California at Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles, Calif (E.W.L.); and Department of Diagnostic Radiology, Changi General Hospital, Singapore (D.Y.L.)
| | - Shiro Miyayama
- From the Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea (H.C.K., J.W. Chung., H.J.J., J.W. Choi); Department of Diagnostic Radiology, Fukui-ken Saiseikai Hospital, Fukui, Japan (S.M.); Department of Radiology, Division of Interventional Radiology and Department of Surgery, Division of Liver and Pancreas Transplantation, University of California at Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles, Calif (E.W.L.); and Department of Diagnostic Radiology, Changi General Hospital, Singapore (D.Y.L.)
| | - Edward Wolfgang Lee
- From the Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea (H.C.K., J.W. Chung., H.J.J., J.W. Choi); Department of Diagnostic Radiology, Fukui-ken Saiseikai Hospital, Fukui, Japan (S.M.); Department of Radiology, Division of Interventional Radiology and Department of Surgery, Division of Liver and Pancreas Transplantation, University of California at Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles, Calif (E.W.L.); and Department of Diagnostic Radiology, Changi General Hospital, Singapore (D.Y.L.)
| | - David Yurui Lim
- From the Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea (H.C.K., J.W. Chung., H.J.J., J.W. Choi); Department of Diagnostic Radiology, Fukui-ken Saiseikai Hospital, Fukui, Japan (S.M.); Department of Radiology, Division of Interventional Radiology and Department of Surgery, Division of Liver and Pancreas Transplantation, University of California at Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles, Calif (E.W.L.); and Department of Diagnostic Radiology, Changi General Hospital, Singapore (D.Y.L.)
| | - Jin Wook Chung
- From the Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea (H.C.K., J.W. Chung., H.J.J., J.W. Choi); Department of Diagnostic Radiology, Fukui-ken Saiseikai Hospital, Fukui, Japan (S.M.); Department of Radiology, Division of Interventional Radiology and Department of Surgery, Division of Liver and Pancreas Transplantation, University of California at Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles, Calif (E.W.L.); and Department of Diagnostic Radiology, Changi General Hospital, Singapore (D.Y.L.)
| | - Hwan Jun Jae
- From the Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea (H.C.K., J.W. Chung., H.J.J., J.W. Choi); Department of Diagnostic Radiology, Fukui-ken Saiseikai Hospital, Fukui, Japan (S.M.); Department of Radiology, Division of Interventional Radiology and Department of Surgery, Division of Liver and Pancreas Transplantation, University of California at Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles, Calif (E.W.L.); and Department of Diagnostic Radiology, Changi General Hospital, Singapore (D.Y.L.)
| | - Jin Woo Choi
- From the Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea (H.C.K., J.W. Chung., H.J.J., J.W. Choi); Department of Diagnostic Radiology, Fukui-ken Saiseikai Hospital, Fukui, Japan (S.M.); Department of Radiology, Division of Interventional Radiology and Department of Surgery, Division of Liver and Pancreas Transplantation, University of California at Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles, Calif (E.W.L.); and Department of Diagnostic Radiology, Changi General Hospital, Singapore (D.Y.L.)
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Sasaki F, Jogo A, Yamamoto A, Kageyama K, Tashiro A, Mitsuyama Y, Oura T, Matsushita K, Asano K, Terayama E, Ozaki M, Sakai Y, Harada S, Murai K, Nakano M, Kita R, Kaminou T, Miki Y. Percutaneous transhepatic sclerotherapy for ascending colonic varices due to left-sided portal hypertension. Radiol Case Rep 2024; 19:2669-2673. [PMID: 38645961 PMCID: PMC11033108 DOI: 10.1016/j.radcr.2024.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/11/2024] [Accepted: 03/13/2024] [Indexed: 04/23/2024] Open
Abstract
Left-sided portal hypertension (LSPH) causes varices and splenomegaly due to splenic vein issues. Colonic varices are rare and lack standardized treatment. We report the successful treatment of colonic varices caused by LSPH, by addressing both the afferent and efferent veins. A 70-year-old man with distal cholangiocarcinoma had surgery without splenic vein resection, leading to proximal splenic vein stenosis and varices at multiple locations. Percutaneous transhepatic splenic venography revealed that collateral veins flowed into the ascending colonic varices and returned to the portal vein. Complete thrombosis of the varices was achieved by injecting sclerosants and placing coils in both the afferent and efferent veins. The procedure was safe and effective, with no variceal recurrence. This approach provides a minimally invasive option for treating colonic varices associated with LSPH.
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Affiliation(s)
- Fumi Sasaki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Akane Tashiro
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Yasuhito Mitsuyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Tatsushi Oura
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Kazuki Matsushita
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Kazuo Asano
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Eisaku Terayama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Masanori Ozaki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Yuki Sakai
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Shohei Harada
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Kazuki Murai
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Mariko Nakano
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Ryuichi Kita
- Department of Gastroenterology, Red Cross Osaka Hospital, 5-30 Fudegasakicho, Tennoji-ku, Osaka, 543-8555, Japan
| | - Toshio Kaminou
- Advanced Imaging and Minimally Invasive Therapy Center, Tsukazaki Hospital, 68-1, Waku, Aboshi-ku, Himeji, Hyogo 671-1227, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
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Hassan N, Zulqarnain M, Bader A, Hassan M, Mohamed I, Brown T, Jadhav K, Ghoz H. A Case of Coil-Assisted Retrograde Transvenous Obliteration to Treat Colonic Varices. Cureus 2024; 16:e63850. [PMID: 39099951 PMCID: PMC11297617 DOI: 10.7759/cureus.63850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2024] [Indexed: 08/06/2024] Open
Abstract
Colonic variceal bleeding is a rare cause of lower gastrointestinal (GI) bleeding, which carries a high mortality rate. Due to limited data, the optimal management of colonic variceal bleeding is not known. Coil-assisted retrograde transvenous obliteration (CARTO) has been shown to be very effective in managing non-esophageal variceal bleeding, but only a few cases demonstrate its effectiveness in treating colonic variceal bleeding. Here we present a case of colonic variceal bleeding treated with CARTO in order to expand on the limited body of evidence showing its efficacy in effectively treating this rare cause of life-threatening GI bleeding.
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Affiliation(s)
- Noor Hassan
- Internal Medicine, University of Missouri Kansas City School of Medicine, Kansas City, USA
| | - Mir Zulqarnain
- Gastroenterology and Hepatology, University of Missouri Kansas City School of Medicine, Kansas City, USA
| | - Abbas Bader
- Internal Medicine, University of Missouri Kansas City School of Medicine, Kansas City, USA
| | - Maaz Hassan
- Radiology, University of Kansas School of Medicine, Kansas City, USA
| | - Islam Mohamed
- Internal Medicine, University of Missouri Kansas City School of Medicine, Kansas City, USA
| | - Travis Brown
- Interventional Radiology, University of Missouri Kansas City School of Medicine, Kansas City, USA
| | - Kavita Jadhav
- Internal Medicine, University of Missouri Kansas City School of Medicine, Kansas City, USA
| | - Hassan Ghoz
- Gastroenterology and Hepatology, University of Missouri Kansas City School of Medicine, Kansas City, USA
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Yasin ALF, Kassamali RH, Khader M, Almokdad O, Barah AR, Omar A. Acute Colonic Variceal Bleeding in a Cirrhotic Patient Treated by Modified Balloon-occluded Retrograde Transvenous Obliteration: A Case Report. JOURNAL OF GASTROINTESTINAL AND ABDOMINAL RADIOLOGY 2022. [DOI: 10.1055/s-0042-1750137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AbstractColonic varices are an uncommon type of ectopic varices that can occur due to underlying liver cirrhosis and portal hypertension. They form a very rare cause of lower gastrointestinal bleeding that can result in massive hemorrhage. We present a 38-year-old woman with a background of ulcerative colitis complicated by primary sclerosing cholangitis-induced liver cirrhosis presenting with fresh rectal bleeding. The colonoscopy failed to identify the source of bleeding. Then, computed tomography scan showed multiple dilated tortuous venous collaterals around the descending colon that extended into the colonic submucosa and drained via the left ovarian vein representing colonic varices. She underwent balloon-occluded retrograde transvenous obliteration (BRTO), which successfully embolized these varices with no significant complications. Despite there being no established management guidelines for colonic variceal bleeding, BRTO is a minimally invasive procedure that can be considered as good option for the treatment of these varices, especially when other alternatives are not applicable.
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Affiliation(s)
- Ahmad L. F. Yasin
- Department of Diagnostic and Interventional Radiology, Hamad Medical Corporation, Doha, Qatar
| | - Rahil Hussein Kassamali
- Department of Diagnostic and Interventional Radiology, Hamad Medical Corporation, Doha, Qatar
| | - Mohammad Khader
- Department of Diagnostic and Interventional Radiology, Hamad Medical Corporation, Doha, Qatar
| | - Omran Almokdad
- Department of Diagnostic and Interventional Radiology, Hamad Medical Corporation, Doha, Qatar
| | - Ali Raza Barah
- Department of Diagnostic and Interventional Radiology, Hamad Medical Corporation, Doha, Qatar
| | - Ahmad Omar
- Department of Diagnostic and Interventional Radiology, Hamad Medical Corporation, Doha, Qatar
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