Three benefits of microcatheters for retrograde transvenous obliteration of gastric varices

Prognostic impact of worsening of esophageal varices after balloon-occluded retrograde transvenous obliteration

BACKGROUND AND AIM

Balloon-occluded retrograde transvenous obliteration (BRTO) is widely performed for treating gastric varices (GVs). However, worsening of esophageal varices (EVs) can be observed after BRTO. This study aimed to investigate the impact of EV worsening on prognosis after BRTO.

METHODS

Overall, 258 patients who underwent initial BRTO for GV treatment between January 2004 and May 2019 at 12 institutions were retrospectively registered.

RESULTS

Technical success was achieved in 235 patients (91.1%). Based on the exclusion criteria, 37 patients were excluded, and 198 were evaluated. The cumulative worsening rates of EVs at 1, 2, and 3 years were 39.0%, 59.4%, and 68.4%, respectively. In the univariate Cox proportional hazards model, sex, EV size, history of EV treatment, left gastric vein dilatation, platelet count, aspartate transaminase (AST), alanine aminotransferase (ALT), total bilirubin, albumin, albumin-bilirubin score, prothrombin time-international normalized ratio, fibrosis-4 index, AST to platelet ratio index, and spleen width were significantly associated with worsening of EV after BRTO. Multivariate analysis showed that sex (adjusted hazard ratio [aHR] 1.72; 95% confidence interval [CI] 1.03-2.86; P = 0.04), left gastric vein dilatation (aHR 1.90; 95% CI 1.17-3.10; P = 0.01), ALT (aHR 1.01; 95% CI 1.00-1.03; P = 0.02), albumin (aHR 0.61; 95% CI 0.43-0.87; P < 0.01), and spleen width (aHR 1.02; 95% CI 1.01-1.03; P < 0.01) were independent risk factors for worsening of EV after BRTO. Patients with EV worsening within 1 year after BRTO had a significantly worse prognosis than the other patients (P = 0.007).

CONCLUSIONS

Early worsening of EV after BRTO was associated with poor prognosis after BRTO.

Combination with portosystemic shunt occlusion and antiviral therapy improves prognosis of decompensated cirrhosis

Background and Aim

Portosystemic shunt occlusion using endovascular treatment can transiently improve liver function in patients with decompensated cirrhosis. In recent years, viral hepatitis can be easily controlled. The present study aimed to clarify the safety and efficacy of endovascular treatment in decompensated cirrhotic patients, and to elucidate whether viral treatment improves the prognosis after shunt occlusion.

Methods

Among 98 cirrhotic patients who received portosystemic shunt occlusion from January 2007 to June 2016, we retrospectively analyzed 61 decompensated cirrhotic patients.

Results

Forty‐five patients had viral hepatitis. Recovery rates of liver function to Child A within 6 months in viral hepatitis, non‐viral hepatitis, and overall were 78% (35/45), 81% (13/16), and 79% (48/61), respectively. Recovery rates according to baseline Child‐Pugh score were as follows: score 7, 88% (15/17); score 8, 89% (24/27); score 9, 69% (9/13); and score ≥ 10, 0% (0/4). Three‐year reprogression rates to decompensated cirrhosis for non‐virus, non‐sustained viral negativity (SVN), and SVN groups were 23 100, and 0%, respectively (P < 0.01). Three‐year survival rates for those were 63, 62, and 91%, respectively (P < 0.01). Eight‐year survival rate for SVN group was also 91%. Multivariate analysis revealed age, baseline ammonia level, baseline Child class, and SVN as independent contributors to survival.

Conclusions

SVN in patients with viral hepatitis appears prerequisite to maintaining recovered liver function by shunt occlusion and to improving prognosis. Combination therapy with shunt occlusion and antiviral treatment should be considered as a first‐line treatment for decompensated cirrhotic patients with viral hepatitis and large portosystemic shunt growth.

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.

Evolution of Retrograde Transvenous Obliteration Techniques

Gastric variceal hemorrhage is a life-threatening complication of portal hypertension with a poorer prognosis compared with esophageal variceal hemorrhage. The presence of an infradiaphragmatic portosystemic shunt, often a gastrorenal shunt, allows for treatment with retrograde transvenous obliteration (RTO). RTO is an evolving treatment strategy, which includes balloon-assisted RTO, plug-assisted RTO, and coil-assisted RTO, for both gastric variceal hemorrhage and hepatic encephalopathy. RTO techniques are less invasive than transjugular intrahepatic portosystemic shunt creation, with the benefit of improved hepatic function, but at the expense of increased portal pressure. This article discusses the techniques of RTO, including patient eligibility, as well as technical and clinical outcomes, including adverse events.

Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Variceal Hemorrhage

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.

Advances in treatment of acute esophagogastric variceal bleeding

Acute esophagogastric variceal bleeding is one of life-threatening complications of portal hypertension and the leading cause of death in patients with cirrhosis. How to effectively control bleeding is an important clinical subject, and specific measures include drug therapy, endoscopic therapy, and radiological interventional therapy. This review summarizes the current advances in the treatment of acute esophagogastric variceal bleeding.

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) for Treatment of Gastric Varices: Review and Meta-Analysis

AIM

To perform a systematic review and meta-analysis of the effectiveness and complications of BRTO for gastric varices.

MATERIALS AND METHODS

A systematic review was performed to identify relevant articles. Inclusion criteria were applied to select studies with at least ten patients with acute bleeding or at-risk gastric varices treated with BRTO. Meta-analysis with random effects model was performed to calculate data for immediate technical success, clinical success, and complications.

RESULTS

A total of 1,016 Patients from 24 studies met inclusion criteria. Technical success rate for BRTO was 96.4 % (95 % CI 93.7, 98.3 %; Q = 3,269.26, p < 0.01, I (2) = 99.39 %). Clinical success (defined as no recurrence or rebleed of gastric varices, or complete obliteration of varices on subsequent imaging) rate was 97.3 % (95 % CI 95.2, 98.8 %; Q = 3,105.91, p < 0.01, I (2) = 99.29 %). Major complication rate was 2.6 % (95 % CI 1.1, 4.6 %; Q = 3,348.98, p < 0.01, I (2) = 99.34 %). Esophageal variceal recurrence rate was 33.3 % (95 % CI 24.6, 42.6 %; Q = 7,291.75, p < 0.01, I (2) = 99.74 %).

CONCLUSION

BRTO is safe and efficacious for gastric varices, and current best evidence suggests that BRTO could be considered as therapy for patients with gastric varices.

Emergency balloon-occluded retrograde transvenous obliteration of ruptured gastric varices

AIM: To evaluate the effectiveness and safety of emergency balloon-occluded retrograde transvenous obliteration (BRTO) for ruptured gastric varices.

METHODS: Emergency BRTO was performed in 17 patients with gastric varices and gastrorenal or gastrocaval shunts within 24 h of hematemesis and/or tarry stool. The gastric varices were confirmed by endoscopy, and the gastrorenal or gastrocaval shunts were identified by contrast-enhanced computed tomography (CE-CT). A 6-Fr balloon catheter (Cobra type) was inserted into the gastrorenal shunt via the right internal jugular vein, or into the gastrocaval shunt via the right femoral vein, depending on the varices drainage route. The sclerosant, 5% ethanolamine oleate iopamidol, was injected into the gastric varices through the catheter during balloon occlusion. In patients with incomplete thrombosis of the varices after the first BRTO, a second BRTO was performed the following day. Patients were followed up by endoscopy and CE-CT at 1 d, 1 wk, and 1, 3 and 6 mo after the procedure, and every 6 mo thereafter.

RESULTS: Complete thrombosis of the gastric varices was not achieved with the first BRTO in 7/17 patients because of large gastric varices. These patients underwent a second BRTO on the next day, and additional sclerosant was injected through the catheter. Complete thrombosis which led to disappearance of the varices was achieved in 16/17 patients, while the remaining patient had incomplete thrombosis of the varices. None of the patients experienced rebleeding or recurrence of the gastric varices after a median follow-up of 1130 d (range 8-2739 d). No major complications occurred after the procedure. However, esophageal varices worsened in 5/17 patients after a mean follow-up of 8.6 mo.

CONCLUSION: Emergency BRTO is an effective and safe treatment for ruptured gastric varices.

Treatment of isolated gastric varices by balloon-occluded retrograde transvenous obliteration using lauromacrogol: An analysis of 23 cases

AIM: To evaluate the efficacy and safety of lauromacrogol in treating isolated gastric varices by balloon-occluded retrograde transvenous obliteration (BRTO).

METHODS: The clinical data for 23 patients who were diagnosed with isolated gastric varices with gastrorenal shunt and treated by BRTO using lauromacrogol from November 2009 to September 2012 were retrospectively analyzed. The clinical efficacy, safety and complications of this procedure were evaluated.

RESULTS: The procedure was successful in 21 cases. Hypotension and sinus bradycardia were observed intraoperatively in three cases and disappeared when the balloon was withdrawn. No complications such as ascites and hepatorenal function exacerbation occurred after the operation. Endoscopic examination at 3 mo after the procedure showed that varices disappeared in 13 cases, remarkably decreased in size in 6 cases, and had no significant changes in 2 cases. During 3 to 18 mo of follow-up, no bleeding was observed.

CONCLUSION: BRTO using lauromacrogol is effective and safe in treating isolated gastric varices with gastrorenal shunt.

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.