The short-term effects of balloon-occluded retrograde transvenous obliteration, for treating gastric variceal bleeding, on portal hypertensive changes: a CT evaluation

Enlargement of the Spleen Index Is a Predictor of the Occurrence of Esophageal Varices and Hepatocellular Carcinoma after Administering Direct-acting Antiviral Agents

Objective Direct-acting antiviral agents (DAAs) can eliminate hepatitis C virus at a high rate, although the long-term incidence of portal hypertension and hepatocellular carcinoma (HCC) has not yet been elucidated. In this observational study, we clarified the predictors associated with the incidence of esophageal varices (EVs) and HCC after DAAs treatment based on ultrasound findings and blood examinations. Methods A total of 78 patients treated with DAAs were enrolled in this study. The primary endpoint was to identify the predictors associated with EVs and HCC occurrence using univariate and multivariate analyses. Secondary endpoints were to extract the cutoff values for EVs and HCC occurrence and clarify the changes in liver stiffness (LS), spleen stiffness (SS), spleen index (SI), portal venous flow volume (PVF), and blood examination at 12 weeks after the end of DAAs treatment. Results The mean observation period was 1,402±546 days. SI change (SI after DAAs-SI before DAAs) was a predictor of EVs occurrence in multivariate analysis (p=0.045). The treatment history of HCC, albumin value before DAAs, and SI change were predictors of HCC occurrence in multivariate analysis (p=0.002, p=0.032, and p=0.009, respectively). LS, SS, PVF, SI, and liver function significantly improved after DAAs treatment. Conclusion Portal hypertension seems to improve after DAAs treatment over a long period. Patients with splenomegaly deterioration after DAAs treatment need to be carefully monitored for the occurrence of EVs and HCC.

Endoscopic N-butyl-2-cyanoacrylate and ethanolamine oleate injection is equivalent to balloon-occluded retrograde transvenous obliteration for preventing gastric variceal bleeding

OBJECTIVES

Endoscopic injection sclerotherapy (EIS) is effective for temporary hemostasis, but EIS and balloon-occluded retrograde transvenous obliteration (BRTO) have been reported as effective for secondary prophylaxis of gastric varices (GV) bleeding. This study retrospectively compared EIS and BRTO in patients with GV in terms of the efficacy for secondary prevention of GV bleeding and effects on liver function.

METHODS

From our database of patients with GV who underwent EIS or BRTO between February 2011 and April 2020, a total of 42 patients with GV were retrospectively enrolled. The primary endpoint was the bleeding rate from GV, which was compared between EIS and BRTO groups. Secondary endpoints were liver function after treatment and rebleeding rate from EV, compared between EIS and BRTO groups. Rebleeding rates from GV and EV and liver function after treatment were also compared between EIS-ethanolamine oleate (EO)/histoacryl (HA) and EIS-HA groups.

RESULTS

Technical success was achieved for all EIS cases, but two cases were unsuccessful in the BRTO group and underwent additional EIS. No significant differences in bleeding rates or endoscopic findings for GV improvement were seen between EIS and BRTO groups. Liver function also showed no significant difference in the amount of change after treatment between groups.

CONCLUSION

EIS therapy appears effective for GV in terms of preventing GV rebleeding and effects on liver function after treatment. EIS appears to represent an effective treatment for GV.

Liver and spleen stiffness on ultrasound elastography are predictors of the occurrence of esophagogastric varices after balloon-occluded retrograde transvenous obliteration

BACKGROUND

Balloon-occluded retrograde transvenous obliteration (BRTO) is an effective treatment for gastric varices, but predictors associated with overall survival rate (OS) and occurrence of esophagogastric varices (EGV) have not yet been clarified. In this study, we clarified these predictors by performing ultrasound elastography and blood tests at various time points.

METHODS

A total of 34 patients were enrolled. The primary endpoint was to identify predictors associated with OS and EGV occurrence by univariate and multivariate analyses. Secondary endpoints were to extract the cutoff values for OS and EGV occurrence, and to clarify chronological changes in liver stiffness (LS), spleen stiffness (SS), spleen index (SI), and portal vein flow volume (PVF). Time points were set as before BRTO (Bf), and 1 day (D1), 7 days (D7), 1 month (1M), 3 months (3M), and 6 months (6M) after BRTO.

RESULTS

Albumin-bilirubin score Bf, fibrin-4 index change 6M, and branched chain amino acids tyrosine molar ratio (BTR) 1M were predictors of OS on univariate analysis (p = 0.021, 0.033, and 0.019, respectively) but were not extracted by multivariate analysis. The factors of LS 6M > 19.9 kPa and SS D7 > 21.7 kPa were predictors of the occurrence of EGV on multivariate analysis (p = 0.029 and 0.025, respectively). PVF significantly increased with time after BRTO.

CONCLUSION

Albumin-bilirubin score and BTR had the possibility to associated with OS, and the predictors of reduced occurrence of EGV were LS < 19.9 and SS < 21.7.

Endoscopic Cyanoacrylate Injection Versus Balloon-Occluded Retrograde Transvenous Obliteration for Prevention of Gastric Variceal Bleeding: A Randomized Controlled Trial

BACKGROUND AND AIMS

The optimal treatment for gastric varices (GVs) is a topic that remains open for study. This study compared the efficacy and safety of endoscopic cyanoacrylate injection and balloon-occluded retrograde transvenous obliteration (BRTO) to prevent rebleeding in patients with cirrhosis and GVs after primary hemostasis.

APPROACH AND RESULTS

Patients with cirrhosis and history of bleeding from gastroesophageal varices type 2 or isolated gastric varices type 1 were randomized to cyanoacrylate injection (n = 32) or BRTO treatment (n = 32). Primary outcomes were gastric variceal rebleeding or all-cause rebleeding. Patient characteristics were well balanced between two groups. Mean follow-up time was 27.1 ± 12.0 months in a cyanoacrylate injection group and 27.6 ± 14.3 months in a BRTO group. Probability of gastric variceal rebleeding was higher in the cyanoacrylate injection group than in the BRTO group (P = 0.024). Probability of remaining free of all-cause rebleeding at 1 and 2 years for cyanoacrylate injection versus BRTO was 77% versus 96.3% and 65.2% versus 92.6% (P = 0.004). Survival rates, frequency of complications, and worsening of esophageal varices were similar in both groups. BRTO resulted in fewer hospitalizations, inpatient stays, and lower medical costs.

CONCLUSIONS

BRTO is more effective than cyanoacrylate injection in preventing rebleeding from GVs, with similar frequencies of complications and mortalities.

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

Background

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

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

Results

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

Conclusion

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

The combination of balloon-assisted antegrade transvenous obliteration and transjugular intrahepatic portosystemic shunt for the management of cardiofundal varices hemorrhage

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.

Management Options for Gastric Variceal Hemorrhage

Importance

Varices are one of the main clinical manifestations of cirrhosis and portal hypertension. Gastric varices are less common than esophageal varices but are often associated with poorer prognosis, mainly because of their higher propensity to bleed.

Observations

Currently, treatments used to control and manage gastric variceal bleeding include β-blockers, endoscopic injection sclerotherapy, endoscopic variceal ligation, endoscopic variceal obturation, shunt surgery, transjugular intrahepatic portosystemic shunts, balloon-occluded retrograde transvenous obliteration (BRTO), and modified BRTO. In the past few decades, Western (United States and Europe) interventional radiologists have preferred transjugular intrahepatic portosystemic shunts that aim to decompress the liver and reduce portal pressure. Conversely, Eastern radiologists (Japan and South Korea) have preferred BRTO that directly targets the gastric varices. Over the past 20 years, BRTO has evolved and procedure-related risks have decreased. Owing to its safety and efficiency in treating gastric varices, BRTO is now starting to gain popularity among Western interventional radiologists. In this review, we present a comprehensive literature review of current and emerging management options, including BRTO and modified BRTO, for the treatment of gastric varices in the setting of cirrhosis and portal hypertension.

Conclusions and Relevance

Balloon-occluded retrograde transvenous obliteration has emerged as a safe and effective alternative treatment option for gastric variceal hemorrhage. A proper training, evidence-based consensus and guideline, thorough preprocedural and postprocedural evaluation, and a multidisciplinary team approach with BRTO and modified BRTO are strongly recommended to ensure best patient care.

Balloon Retrograde Transvenous Obliteration Versus Endoscopic Cyanoacrylate in Bleeding Gastric Varices: Comparison of Rebleeding and Mortality with Extended Follow-up

PURPOSE

To assess short- and long-term mortality and rebleeding with endoscopic cyanoacrylate (EC) versus balloon-occluded retrograde transvenous obliteration (BRTO).

MATERIALS AND METHODS

A retrospective cohort comparison was conducted of 90 EC patients and 71 BRTO patients from 1997 through 2015 with portal hypertension who presented due to endoscopically confirmed bleeding cardiofundal gastric varices. Patients underwent either endoscopic intra-varix injection of 4-carbon-n-butyl-2-cyanoacrylate or sclerosis with sodium tetradecyl sulfate with balloon occlusion for primary variceal treatment.

RESULTS

Seventy-one BRTO patients and 90 EC patients, of whom 89% had cirrhosis and 35% were women, were included, with a respective average Model for End-Stage Liver Disease (MELD) score of 13.4 and 14.4, respectively. Mortality at 6 weeks was 14.4% for EC patients and 13.1% for BRTO patients (Kaplan-Meier/Wilcoxon, P = .85). No long-term mortality difference was observed (Cox hazard ratio [HR] = 0.89, P = .64). Also, 5.1% of EC patients and 3.5% of BRTO patients (Kaplan-Meier/Wilcoxon, P = .62) rebled at 6 weeks, but at 1 year, 22.0% of EC patients and 3.5% of BRTO patients had rebled (Kaplan-Meier/Wilcoxon, P < .01). Lower rates of long-term rebleeding were found with BRTO (Cox HR = 0.25, P = .03). No difference was seen in the rate of new portal hypertensive complications (Cox HR = 1.21, P = .464). However, 16/71 patients who underwent BRTO had simultaneous transjugular intrahepatic portosystemic shunt. Age, sex, MELD score, and presence of cirrhosis were the primary predictors of mortality. One death in the EC group and 5 deaths in the BRTO group were deemed to be procedurally related (chi-square, P = .088).

CONCLUSIONS

BRTO is associated with a lower rate of rebleeding but no change in mortality.

Prevention and management of gastroesophageal varices

Bleeding from gastroesophageal varices is a serious complication in patients with liver cirrhosis and portal hypertension. Although there has been significance improvement in the prognosis of variceal bleeding with advancement in diagnostic and therapeutic modalities for its management, mortality rate still remains high. Therefore, appropriate prevention and rapid, effective management of bleeding from gastroesophageal varices is very important. Recently, various studies about management of gastoesophageal varices, including prevention of development and aggravation of varices, prevention of first variceal bleeding, management of acute variceal bleeding, and prevention of variceal rebleeding, have been published. The present article reviews published articles and practice guidelines to present the most optimal management of patients with gastroesophageal varices.

Balloon-occluded retrograde transvenous obliteration as a procedure to improve liver function in patients with decompensated cirrhosis

Aim

Portosystemic shunts aggravate liver function by decreasing portal blood flow. The usefulness of balloon-occluded retrograde transvenous obliteration (B-RTO), a standardized therapeutic procedure for gastric fundal varices (GFV), for the improvement of liver function was evaluated in cirrhotic patients with or without varices.

Methods

The subjects were 161 patients with portosystemic shunts. A balloon catheter was inserted into the shunts, followed by the injection of 5% ethanolamine oleate through the catheter under balloon inflation. The balloon was kept inflated for 6 to 48 h.

Results

B-RTO was performed as a therapy for GFV in 112 patients and for the improvement of liver function in 49 patients. The targets were splenorenal shunts in 104 patients (93.6%) in the former group and 33 patients (67.3%) in the latter group, and the procedures were successfully completed in 109 (97.3%) and 39 (79.6%) patients, respectively. In both groups, the serum albumin levels were increased and the serum ammonia levels were decreased at more than 1 month after the procedures, compared with the baseline levels, whereas significant improvements in the Child-Pugh scores and prothrombin times were only seen in the latter group. In these patients, the portal blood flows evaluated using Doppler ultrasound were increased at 1 week after the procedures, compared with the baseline levels.

Conclusions

B-RTO is a useful therapeutic procedure for improving liver function even in patients without GFV by increasing the portal venous flow with successfully targeted, uncommon portosystemic shunts.

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO): A Novel Method of Control of Bleeding from Post-Glue Ulcer over Gastric Varices. Report of Two Cases and Review of Literature

Bleeding gastric varices (GV) are managed by cyanoacrylate glue injection with transjugular intrahepatic portosystemic shunt (TIPSS) as modality for treatment failure. Ulcer can form at the site of glue injection over GV and it can cause bleeding. Treatment approach for such bleed is not well described. Balloon-occluded retrograde transvenous obliteration (BRTO), TIPSS, and devascularization remain the treatment options in this scenario. BRTO is an endovascular procedure where a balloon catheter is inserted into a draining vein of GV, and the sclerosant can be injected into the varices through the catheter during balloon occlusion. BRTO has the benefit of increasing portal hepatic blood flow and can also be useful in patients who may not tolerate TIPSS. We report two cases where BRTO was done for control of bleeding from ulcers formed over previously injected GV.

Efficacy of combined balloon-occluded retrograde transvenous obliteration and simultaneous endoscopic injection sclerotherapy

OBJECTIVE

We evaluated the efficacy and safety of balloon-occluded retrograde transvenous obliteration (B-RTO) performed using absolute ethanol with iodized oil (ET+LPD) and simultaneous endoscopic injection sclerotherapy (EIS) with cyanoacrylate (CA) for gastric varices (GVs).

METHODS

A total of 16 patients with endoscopically proven high-risk GVs treated using combined B-RTO with ET+LPD and EIS with CA between January 2007 and July 2012 were enrolled.

RESULTS

Twelve cases included GVs involving both the cardia and fundus, two cases included fundal varices and two cases included cardiac varices. In terms of the form of GVs, 10 cases involved F2 lesions and six cases involved F3 lesions. The flow vein was the left gastric vein in 13 cases and the posterior gastric vein in three cases. The drainage route was a splenorenal shunt in all cases. The average dose of ET+LPD was 12.0 mL, while that of CA was 2.45 mL. All complications were transient, and no major complications occurred after the procedures. None of the patients experienced bleeding or recurrence of gastric varices after the combined B-RTO and EIS procedures during an average follow-up period of 38.3 months.

CONCLUSION

Combined B-RTO with ET+LPD and simultaneous EIS with CA is considered to be an effective and safe procedure for treating GVs.

Coil-Assisted Retrograde Transvenous Obliteration (CARTO) for the Treatment of Portal Hypertensive Variceal Bleeding: Preliminary Results

OBJECTIVES:

To describe the technical feasibility, safety, and clinical outcomes of coil-assisted retrograde transvenous obliteration (CARTO) in treating portal hypertensive non-esophageal variceal hemorrhage.

METHODS:

From October 2012 to December 2013, 20 patients who received CARTO for the treatment of portal hypertensive non-esophageal variceal bleeding were retrospectively evaluated. All 20 patients had at least 6-month follow-up. All patients had detachable coils placed to occlude the efferent shunt and retrograde gelfoam embolization to achieve complete thrombosis/obliteration of varices. Technical success, clinical success, rebleeding, and complications were evaluated at follow-up.

RESULTS:

A 100% technical success rate (defined as achieving complete occlusion of efferent shunt with complete thrombosis/obliteration of bleeding varices and/or stopping variceal bleeding) was demonstrated in all 20 patients. Clinical success rate (defined as no variceal rebleeding) was 100%. Follow-up computed tomography after CARTO demonstrated decrease in size with complete thrombosis and disappearance of the varices in all 20 patients. Thirteen out of the 20 had endoscopic confirmation of resolution of varices. Minor post-CARTO complications, including worsening of esophageal varices (not bleeding) and worsening of ascites/hydrothorax, were noted in 5 patients (25%). One patient passed away at 24 days after the CARTO due to systemic and portal venous thrombosis and multi-organ failure. Otherwise, no major complication was noted. No variceal rebleeding was noted in all 20 patients during mean follow-up of 384±154 days.

CONCLUSIONS:

CARTO appears to be a technically feasible and safe alternative to traditional balloon-occluded retrograde transvenous obliteration or transjugular intrahepatic portosystemic shunt, with excellent clinical outcomes in treating portal hypertensive non-esophageal variceal bleeding.

Update on gastric varices

Although less common than oesophageal variceal haemorrhage, gastric variceal bleeding remains a serious complication of portal hypertension, with a high associated mortality. In this review we provide an update on the aetiology, classification and management of gastric varices, including acute bleeding, prevention of rebleeding and primary prophylaxis. We describe the optimum management strategies for gastric varices including drug, endoscopic and radiological therapies, focusing on recent published evidence.

Gastric and ectopic varices

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.

Vascular plug-assisted retrograde transvenous obliteration of portosystemic shunts for refractory hepatic encephalopathy: a case report

While balloon-assisted retrograde transvenous obliteration (BRTO) has been used for two decades in Asia for the management of gastric variceal bleeding, it is still an emerging therapy elsewhere. Given the shunt closure brought about by the procedure, BRTO has also been used for the management of portosystemic encephalopathy with promising results. Modified versions of BRTO have been developed, including plug-assisted retrograde transvenous obliteration (PARTO), where a vascular plug is deployed within a portosystemic shunt. To our knowledge, we present the first North American case of PARTO in the setting of a large splenorenal shunt for the management of portosystemic encephalopathy.

The role of divided injections of a sclerotic agent over two days in balloon-occluded retrograde transvenous obliteration for large gastric varices

Objective

To determine the safety and usefulness of a two-tiered approach to balloon-occluded retrograde transvenous obliteration (B-RTO) as a treatment for large gastric varices after portal hypertension.

Materials and Methods

50 patients were studied who underwent B-RTO for gastric varices between October 2004 and October 2011 in our institution. The B-RTO procedure was performed from the right femoral vein and the B-RTO catheter was retained until the following morning. Distribution of sclerotic agents in the gastric varices on fluoroscopy was evaluated in all patients on days 1 and 2. When distribution of sclerotic agents in the gastric varices on day 1 had been none or very scanty even though the volume of the sclerotic agent infused was above the acceptable level, a second infusion was administered on day 2. When distribution was satisfactory, the B-RTO catheter was removed.

Results

In 8 (16%) patients, little or no sclerotic agent infused on day 1 was distributed in the gastric varices. However, on day 2, sclerotic agents were distributed in all gastric varices. Mean volume of ethanolamine oleate-iopamidol infused on day 1 was 24.6 mL and was 19.4 mL on day 2. Gastric varices were well obliterated with no recurrence. Complications caused by the sclerotic agent such as pulmonary edema or renal insufficiencies were not seen.

Conclusion

When gastric varices are very large, a strategy involving thrombosis of only the drainage vein on the first day followed by infusing the sclerotic agent on the following day might be effective and feasible.

Short-term effects and early complications of balloon-occluded retrograde transvenous obliteration for gastric varices

The short-term effects of balloon-occluded retrograde transvenous obliteration (BRTO) to treat gastric varices were evaluated by using computed tomography (CT) and gastroscopy (GF). The subjects were 77 patients who underwent BRTO to treat gastric varices. The short-term effects of BRTO were investigated with regard to ascites, pleural effusion, venous thrombus, and esophageal varices by comparing the findings of CT and GF performed within one month before and after BRTO. The mean duration of followup was 960.1 days. Ascites and pleural effusion were exacerbated after BRTO in 26 (33.8%) and 31 (40.3%), respectively. A significant difference in ascites exacerbation was noted in patients with hypoalbuminemia and a high Child-Pugh score, and a significant difference in exacerbation of pleural effusion was noted in patients with hypoalbuminemia. Venous thrombus was noted in 7 patients (9.1%). Esophageal varices were exacerbated in 14 (21.2%) of the 66 patients. The 2-year survival rate was 720 days, and significant differences were noted in the Child-Pugh classification and the concomitance of hepatocellular carcinoma (HCC) on multivariate analysis of prognosis-related factors. Conclusion. The frequencies of exacerbation of ascites, pleural effusion, and esophageal varices after BRTO were high but these may not be related to survival.

Gastric varices: is there a role for endoscopic cyanoacrylates, or are we entering the BRTO era?

Bleeding from portal hypertension-related gastric varices arising in the cardiofundal region of the stomach presents a challenge due to the unique underlying vascular anatomy which is sometimes underappreciated in endoscopic classification schemes. They often have dominant tributaries from the splenic vein or splenic hilum and terminate in the left renal vein (spontaneous splenorenal or gastrorenal shunts). This may limit the applicability of a transjugular intrahepatic portosystemic shunt (TIPS), because of the shunt's distance from the hilum of the liver. Endoscopically, the presence of a large systemic outflow track also may influence the performance of different cyanoacrylates. However, this anatomy allows an alternative approach, balloon-occluded retrograde transvenous obliteration (BRTO), which accesses the varix via the outflow pathway. Definitive comparisons between TIPS, endoscopic cyanoacrylate, and BRTO will be challenging because the incidence of this type of varix is insufficient for large trials. Here, I provide a perspective based on existing literature, 15 years of experience with various cyanoacrylates, and 4 years of experience with BRTO.

Medical and endoscopic management of gastric varices

In the past 20 years, our understanding of the pathophysiology and management options among patients with gastric varices (GV) has changed significantly. GV are the most common cause of upper gastrointestinal bleeding in patients with portal hypertension after esophageal varices (EV) and generally have more severe bleeding than EV. In the United States, the majority of GV patients have underlying portal hypertension rather than splenic vein thrombosis. The widely used classifications are the Sarin Endoscopic Classification and the Japanese Vascular Classifications. The former is based on the endoscopic appearance and location of the varices, while the Japanese classification is based on the underlying vascular anatomy. In this article, the authors address the current concepts of classification, epidemiology, pathophysiology, and emerging management options of gastric varices. They describe the stepwise approach to patients with gastric varices, including the different available modalities, and the pearls, pitfalls, and stop-gap measures useful in managing patients with gastric variceal bleed.

Efficacy of balloon-occluded retrograde transvenous obliteration of large spontaneous lienorenal shunt in patients with severe recurrent hepatic encephalopathy with foam sclerotherapy: initial experience

PURPOSE

Balloon-occluded retrograde transvenous obliteration (BRTO) is a widely accepted treatment for gastric varices, but data are limited in regard to its role in the management of hepatic encephalopathy (HE). This study evaluated the efficacy of BRTO with foam sclerotherapy in the management of HE arising as a result of spontaneous large portosystemic shunts.

MATERIALS AND METHODS

Eight sessions of BRTO with sodium tetradecyl sulfate foam were performed in seven patients with cirrhosis complicated by HE. All patients had portosystemic communication (ie, gastro-/lienorenal shunt) on preprocedure computed tomography. Clinical and laboratory parameters including arterial ammonia level were evaluated in all patients before and after the procedure.

RESULTS

Technical success rates were 86% (six of seven) for the first BRTO session and 100% (one of one) for the second. Follow-up imaging revealed complete obliteration of the varices in five of seven patients (71%) and partial obliteration in the remaining two. Immediate clinical improvement of HE was observed in six of seven patients (86%), with postprocedural decrease in arterial ammonia levels; one patient showed delayed improvement. Procedure-related complications (eg, abnormal liver function test results, acute kidney injury with leukocytosis) were encountered in two patients. All patients showed clinical and symptomatic improvement at the time of discharge and during a follow-up of 4 months (with visits at 1 mo and 3 mo later).

CONCLUSIONS

Initial experience suggests that BRTO is an effective procedure in the management of HE arising as a result of large portosystemic shunts.

Duodenal variceal bleeding after balloon-occluded retrograde transverse obliteration: Treatment with transjugular intrahepatic portosystemic shunt

We report a case of duodenal varix bleeding as a long term complication of balloon occluded retrograde transvenous obliteration (BRTO), which was successfully treated with a transjugular intrahepatic portosystemic shunt (TIPS). A 57-year-old man was admitted to the emergency room suffering from melena. He had undergone BRTO to treat gastric varix bleeding 5 mo before admission. Endoscopy and a computed tomography (CT) scan showed complete obliteration of the gastric varix, but the nodular varices in the second portion of the duodenum expanded after BRTO, and spurting blood was seen. TIPS was performed for treatment of duodenal variceal bleeding, because attempts at endoscopic varix ligation were unsuccessful. The postoperative course was uneventful and the patient was discharged without complications. A follow up CT scan obtained 21 mo after TIPS revealed a patent TIPS tract and complete obliteration of duodenal varices, but multinodular hepatocellular carcinoma had developed. He died of hepatic failure 28 mo after TIPS.

Three benefits of microcatheters for retrograde transvenous obliteration of gastric varices

AIM: To evaluate the usefulness of the microcatheter techniques in balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices.

METHODS: Fifty-six patients with gastric varices underwent BRTOs using microcatheters. A balloon catheter was inserted into gastrorenal or gastrocaval shunts. A microcatheter was navigated close to the varices, and sclerosant was injected into the varices through the microcatheter during balloon occlusion. The next morning, thrombosis of the varices was evaluated by contrast enhanced computed tomography (CE-CT). In patients with incomplete thrombosis of the varices, a second BRTO was performed the following day. Patients were followed up with CE-CT and endoscopy.

RESULTS: In all 56 patients, sclerosant was selectively injected through the microcatheter close to the varices. In 9 patients, microcoil embolization of collateral veins was performed using a microcatheter. In 12 patients with incomplete thrombosis of the varices, additional injection of sclerosant was performed through the microcatheter that remained inserted overnight. Complete thrombosis of the varices was achieved in 51 of 56 patients, and the remaining 5 patients showed incomplete thrombosis of the varices. No recurrence of the varices was found in the successful 51 patients after a median follow up time of 10.5 mo. We experienced one case of liver necrosis, and the other complications were transient.

CONCLUSION: The microcatheter techniques are very effective methods for achieving a higher success rate of BRTO procedures.

A case of complete resolution of gastric varices

BACKGROUND

A 49-year-old woman with hepatitis C and peptic ulcer disease presented to the emergency department after an onset of sudden massive hematemesis. She had a history of alcohol abuse, but denied any recent excessive drinking.

INVESTIGATIONS

Physical examination, laboratory investigations including complete blood cell counts and liver function tests, esophagogastroduodenoscopy, abdominal angiography and venography, CT scans of the abdomen and pelvis.

DIAGNOSIS

Gastric variceal hemorrhage, severe portal hypertensive gastropathy, splenic vein thrombosis.

MANAGEMENT

Blood transfusion, splenic artery embolization and balloon-occluded retrograde transvenous obliteration of gastric varices. Immediate postprocedural CT scans of the abdomen, with repeat imaging 30 months later.

Balloon-Occluded Retrograde Transvenous Obliteration of a GastroRenal Shunt using Hydrogel-Coated Coil Embolization

Balloon-retrograde transvenous obliteration (BRTO) can be an appropriate treatment modality for hepatic encephalopathy in the setting of portal-systemic shunting in selected patients. We describe a case of a large gastro-renal shunt that was successfully treated via combined BRTO and expandable hydrogel-coated coil embolization, with an emphasis on technique.