The long-term outcome of patients with bleeding gastric varices after balloon-occluded retrograde transvenous obliteration

Emergency Plug-Assisted Retrograde Transvenous Obliteration for Active Bleeding from Ruptured Gastric Varices

PURPOSE

To evaluate the safety and effectiveness of emergency plug-assisted retrograde transvenous obliteration (PARTO) for active bleeding from ruptured gastric varices (GVs).

MATERIALS AND METHODS

Twenty-one patients with active bleeding from ruptured GVs were included in this retrospective study. Ten patients (47.6%) showed life-threatening hemorrhage (systolic blood pressure, <90 mm Hg) just before emergency PARTO. All patients underwent emergency PARTO after initial ineffective endoscopic cyanoacrylate injection (n = 9) or because endoscopic injection was not possible (n = 12).

RESULTS

Emergency PARTO was technically successful in all 21 patients. Mean fluoroscopic time was 30.8 minutes (range, 10-62 minutes). There were no procedure-related adverse events. Hemostasis was obtained in 20 (95.2%) of 21 patients immediately after PARTO. In 16 patients who underwent computed tomography (CT), complete thrombosis or obliteration of GVs and portosystemic shunt was observed. With the exception of 1 patient who underwent external transfer, 15 patients died within a mean of 196 days (range, 1-1,111 days), whereas 5 remained alive for a mean of 38.9 months (range, 17.1-74.2 months). Seven died within 30 days due to ischemia-related multiorgan failure (n = 5), hypovolemic shock (n = 1), or rapid progression of hepatocellular carcinoma (HCC) (n = 1). The causes of death in the remaining 9 patients were bleeding from esophageal varices (n = 2), liver failure (n = 2), and rapid progression of HCC (n = 5). The median patient survival time was 47 days (95% confidence interval, 0‒124 days). There was no case of rebleeding or recurrence of GVs.

CONCLUSIONS

Emergency PARTO appears to be a fast, safe, and effective treatment option to stop active bleeding from ruptured GVs; however, survival in this population is modest because of comorbidities and complications of shock.

Analysis of the treatment outcome of duodenal varices: A retrospective case series of 15 patients from a single institution

Background & aims

Duodenal varices (DVs) are a rare type of ectopic varices occurring in portal hypertension, for which no standardized treatment strategy has been established. This retrospective study analyzed the outcomes of DV treatments in 15 patients.

Material and methods

All enrolled patients with DVs were treated at a single institution Hospital between 2011 and 2022. The treatment procedure and outcome were analyzed retrospectively.

Results

Six patients presented with hemorrhagic DVs. Endoscopic variceal ligation was used for initial hemostasis in five bleeding cases. Balloon-occluded retrograde transvenous obliteration was the initial treatment in nine cases, achieving curative obliteration in eight cases. Percutaneous transhepatic variceal obliteration was performed as the initial treatment in three cases for which balloon-occluded retrograde transvenous obliteration was difficult to perform for anatomical reasons, and all cases achieved curative obliterations. Splenectomy was performed as the initial treatment in three patients due to complicating gastroesophageal varices. DVs recurred in two cases with splenectomy after approximately 1 year, but balloon-occluded retrograde transvenous obliteration and percutaneous transhepatic variceal obliteration were curatively applied in each case, and no recurrence has been observed since then. Gastroesophageal varices aggravated after the initial DV treatment in eight of the 15 cases during the observation period, and the cumulative aggravating rate was 58.1% at 4 years.

Conclusion

All 15 cases with DVs were preferably controlled by selecting appropriate treatment based on individual hemodynamics of varices. Because of the relatively high rate of aggravation of gastroesophageal varices, careful long-term follow-up may be important for the treatment of DVs.

Understanding Portosystemic Collateral Anatomy

Portosystemic collateral pathways are a significant concern in interventional radiology, frequently manifesting in patients with cirrhosis or portal vein thrombosis. These pathways can lead to severe clinical complications, including gastrointestinal bleeding, hepatic encephalopathy, and liver failure. A thorough understanding of the anatomy, hemodynamic alterations, and clinical implications of these shunts is crucial for interventional radiologists to provide effective treatment while minimizing risks. This article reviews the clinical presentations associated with portosystemic shunts, explores the anatomical variants and altered flow dynamics, and discusses the latest endovascular treatment strategies to optimize patient outcomes.

Coil or plug-assisted retrograde transvenous obliteration (CARTO/PARTO) for treating portal hypertensive variceal bleeding: A multicenter, real-world 10-year retrospective study

BACKGROUND AND AIMS

Coil-assisted retrograde transvenous obliteration (CARTO) and plug-assisted retrograde transvenous obliteration (PARTO) are well-accepted treatments for gastric variceal bleeding. However, long-term (>2 y) clinical outcomes have yet to be studied. In this study, we investigated long-term clinical outcomes, including overall survival (OS) in 10 years.

APPROACH AND RESULTS

We performed a multinational, multicenter, retrospective study of CARTO/PARTO in gastric varices treatments between May 2012 and July 2024. The primary study outcomes were a long-term OS and prognostic factors of CARTO/PARTO. The secondary outcomes were long-term clinical/technical success, complications, and clinical changes including portal hypertensive symptoms. A total of 311 patients (41% female; 69% CARTO) from 13 centers in 5 countries were included. The cumulative 1-, 3-, 5-, 7-, and 10-year OS rates were 98%, 80%, 68%, 52%, and 33%, respectively, with a median OS of 99 months. Prophylactic CARTO/PARTO showed a better OS than CARTO/PARTO for active bleeding ( p =0.00035). The independent prognostic factors of OS were having high pre-MELD, concurrent HCC, treating GOV2, history of esophageal variceal bleeding, high pre-TBili, and ammonia levels. Notably, a high pre-MELD score >27 had a significantly higher mortality rate (92.6%) than a lower pre-MELD score ( p <0.001). The overall cumulative 1-, 3-, 5-, 7-, and 10-year recurrent gastric varices bleeding rates were 0.9%, 3.2%, 4.0%, 4.5%, and 5.4%, respectively. The overall technical and clinical success rates were 96.5% and 95.3%, respectively, with a 4.5% major complication rate over 10 years.

CONCLUSIONS

CARTO and PARTO have excellent long-term survival and clinical outcomes. However, these are negatively affected by high MELD scores, concomitant HCC, and coexisting esophageal varices.

Hepatic venous pressure gradient after balloon-occluded retrograde transvenous obliteration and liver stiffness measurement predict the prognosis of patients with gastric varices

BACKGROUND

Balloon-occluded retrograde transvenous obliteration (BRTO) is a treatment option for patients with gastric varices (GVs). This study aimed to clarify the clinical significance of portal hypertension estimated by the hepatic venous pressure gradient (HVPG), subsequent exacerbation of esophageal varices (EVs), and prognosis of patients who underwent BRTO for GVs.

METHODS

Thirty-six patients with GVs treated with BRTO were enrolled in this study, and their HVPG was measured before (pre-HVPG) and on the day after BRTO (post-HVPG). After BRTO, patients were followed-up for a median interval of 24.5 (3-140) months. Clinical factors related to EVs exacerbation and prognosis after BRTO were retrospectively analyzed.

RESULTS

Post-HVPG increased compared to pre-HVPG in 21 out of 36 patients (58%), and post-HVPG was overall significantly higher compared to pre-HVPG (P = 0.009). During the observation period, 19 patients (53%) developed EVs exacerbation, and the cumulative EVs exacerbation rates at 1, 3 and 5 years after BRTO were 27%, 67%, and 73%, respectively. Pre-HVPG was not related to EVs exacerbation, although elevation of post-HVPG to ≥ 13 mmHg (P < 0.01) and high level of serum aspartate aminotransferase (P < 0.05) were significant independent risk factors for EVs exacerbation after BRTO. Fourteen patients (38.9%) died during the observation period. An elevated value of liver stiffness measurement (LSM) of ≥ 21 kPa was a significant independent risk factor for poor prognosis after BRTO (P < 0.05).

CONCLUSIONS

HVPG increases after BRTO. HVPG after BRTO has greater predictive ability for subsequent EVs exacerbation than HVPG before BRTO. LSM is a potential prognostic parameter in patients who undergo BRTO.

Balloon-occluded retrograde transvenous obliteration for gastric varices improves hepatic functional reserve in long-term follow-up

Background and Aim

Balloon‐occluded retrograde transvenous obliteration (BRTO) has been widely adopted for the management of gastric fundal varices (GVs). There are a few reports that BRTO leads to the improvement of mid‐term and long‐term hepatic functional reserve (HFR). We retrospectively investigated the long‐term effect on HFR and prognosis among patients who had undergone BRTO for GVs.

Methods

This single‐center, retrospective study included 57successful patients out of 60 patients who underwent BRTO for GVs from December 2005 to September 2018. We examined the indicators of HFR (e.g., encephalopathy and ascites statuses, serum total bilirubin and albumin levels, % prothrombin time, and Child–Pugh and albumin–bilirubin [ALBI] scores) during 3 years of follow‐up after BRTO. We analyzed survival using the Kaplan–Meier method and identified the independent prognostic factors via multivariate analyses.

Results

GVs disappeared in all patients who were successfully treated by BRTO. At 3 years after BRTO, serum albumin levels were significantly elevated (from 3.3 to 4.0 g/dL, P = 0.008), while Child–Pugh and ALBI scores were significantly decreased (from 7.0 to 5.7, P = 0.043, and from −1.94 to −2.60, P = 0.006, respectively). The median survival time among all patients was 2207 days; the survival rates after BRTO were 87.0% at 1 year, 81.8% at 3 years, 67.3% at 5 years, and 44.1% at 10 years. Multivariate analyses revealed that ascites, hepatic encephalopathy, and malignant neoplasms were independently associated with poor prognosis.

Conclusion

BRTO for GVs has a favorable effect on long‐term HFR.

Retrograde transvenous obliteration for the prevention of variceal rebleeding in patients with hepatocellular carcinoma: a multicentre retrospective study

AIM

To evaluate the effectiveness and safety of retrograde transvenous obliteration (RTO) for the prevention of variceal rebleeding variceal rebleeding in patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This multicentre retrospective study enrolled 79 patients with HCC who underwent RTO for the prevention of variceal rebleeding. Successful occlusion of the gastrorenal shunt and obliteration of the gastric varices were achieved in 74 patients, with a technical success rate of 93.7%. Of the remaining 74 patients (mean age, 64.9±10.3 years; 56 men), 66 (90.4%) had gastroesophageal varices and seven (9.6%) had isolated gastric varices. Thirty-two patients (43.8%) underwent balloon-occluded RTO, 40 patients (54.8%) underwent plug-assisted RTO, and one patient (1.4%) underwent coil-assisted RTO. No patients had major procedural complications.

RESULTS

Rebleeding occurred in seven patients (9.6%) during the follow-up period. The 6-week and 1-year actuarial probabilities of patients remaining free of rebleeding were 90.8±3.6% and 88.6±4.1%, respectively. The median survival was 12.6 (95% confidence interval [CI] 8-17.3) months. The 6-week, 1-year, and 3-year actuarial probabilities of survival were 83.2±4.4%, 51.1±6.6%, and 32.7±7%, respectively. New or worsening ascites and oesophageal varices occurred in 12 (16.4%) and 13 patients (17.8%), respectively, during the follow-up period. Overt hepatic encephalopathy occurred in one patient (1.4%) during the follow-up period. The Child-Pugh score remained comparable to that at baseline at 1 and 3 months.

CONCLUSION

RTO was effective and safe in preventing variceal rebleeding in patients with HCC.

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.

Change in Portal Pressure and Clinical Outcome in Cirrhotic Patients with Gastric Varices after Plug-Assisted Retrograde Transvenous Obliteration

Background/Aims

Plug-assisted retrograde transvenous obliteration (PARTO) is widely used to manage gastric varices with a portosystemic shunt. It is not clear whether portal pressure and the incidence of complications increase after PARTO. The aim of this study was to determine the changes in portal pressure and the associated changes in liver function, ascites, hepatic encephalopathy, and especially esophageal varix (EV) after PARTO.

Methods

From March 2012 to February 2018, 54 patients who underwent PARTO were analyzed retrospectively. The parameters collected included liver function and episodes of cirrhotic complications before and at 1 and 6 months after PARTO.

Results

The analysis of 54 patients showed improvement in liver function during the 6-month follow-up period (Model for End-Stage Liver Disease score: change from 11.46±4.35 to 10.33±2.96, p=0.021). Among these 54 patients, 25 patients were evaluated for their hepatic venous pressure gradient (HVPG) before and after PARTO (change from 12.52±3.83 to 14.68±5.03 mm Hg; p<0.001). Twenty-five patients with portal pressure measured before and after PARTO were evaluated for risk factors affecting liver function improvement and EV deterioration. No factor associated with portal pressure was affected by liver function improvement. Post-PARTO portal pressure was a risk factor affecting EV deterioration (HVPG-post: odds ratio, 1.341; 95% confidence interval, 1.017 to 1.767; p=0.037).

Conclusions

The artificial blockade of the portosystemic shunt evidently leads to an increase in HVPG. Liver function was improved over the 6-month follow-up period. Portal pressure after PARTO was a significant risk factor for EV deterioration. Portal pressure measurement is helpful for predicting the patient's clinical outcome.

Retrograde transvenous obliteration for the prevention of variceal rebleeding in patients with portal vein thrombosis: a multicenter study

OBJECTIVES

To evaluate the effectiveness of retrograde transvenous obliteration (RTO) for the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis (PVT).

METHODS

Consecutive cirrhotic patients with PVT who underwent RTO for the prevention of variceal rebleeding between January 2002 and June 2019 were included in this multicenter retrospective study. The primary outcome measure was rebleeding. The secondary outcome measures were survival, other complications of portal hypertension, liver function, and PVT.

RESULTS

Forty-five patients (mean age, 66.0 ± 10.6 years; mean Model for End-Stage Liver Disease (MELD) score, 13.9 ± 5.5) were included. The 1-year actuarial probability of remaining free of rebleeding was 92.8 ± 4.0%. The 6-week, 1-year, and 3-year actuarial probabilities of survival were 79.8 ± 6.0%, 48.8 ± 7.7%, and 46.1 ± 7.9%, respectively. MELD score (hazard ratio (HR), 1.09 (95% confidence interval (CI), 1.01-1.17); p = .013) and ascites (HR, 2.84 (95% CI, 1.24-6.55); p = .014) were identified as significant predictors of survival. The 1-year actuarial probabilities of remaining free of new or worsening ascites and esophageal varices were 81.2 ± 8.7% and 89.2 ± 6.0%, respectively. No patients had overt hepatic encephalopathy during follow-up. MELD score significantly increased by a mean of 3.8 (95% CI, 1.7-6.0) at 3 months (p = .001). PVT had improved in 32.0%, worsened in 12.0%, and remained unchanged in 56.0% of patients at 3 months.

CONCLUSION

RTO may be effective for the prevention of variceal rebleeding in cirrhotic patients with PVT.

KEY POINTS

• Retrograde transvenous obliteration may prevent variceal rebleeding in cirrhotic patients with portal vein thrombosis. • The risks of other complications of portal hypertension may not be high after retrograde transvenous obliteration in cirrhotic patients with portal vein thrombosis. • Portal vein thrombosis may improve in approximately one-third of cirrhotic patients within 3 months after retrograde transvenous obliteration.

Balloon-occluded retrograde transvenous obliteration of colonic varices: a case report

Background

Ectopic varices are uncommon and typically due to underlying liver cirrhosis. They can be located in the duodenum, small intestines, colon or rectum, and may result in massive haemorrhage. While established guidelines exist for the management of oesophageal and gastric variceal bleeding, this is currently lacking for colonic varices.

Beta-blockers, transjugular intrahepatic portosystemic shunt insertion and subtotal colectomy have been reported as management methods. However, there are only two other cases that have reported successfully treating colonic varices using balloon-occluded retrograde transvenous obliteration (BRTO), an endovascular procedure typically performed for gastric varices.

Case presentation

A 55-year-old man with background of alcoholic liver cirrhosis presented with per-rectal bleeding due to caecal varices. Grade 2–3 oesophageal varices were identified on oesophago-gastro-duodenoscopy, and computed tomography showed multiple right para-colic portosystemic collaterals around the hepatic flexure and ascending colon. Colonoscopy confirmed fresh blood in the colon up to the caecum, with a submucosal varix deemed the most likely source of haemorrhage.

As transjugular intrahepatic portosystemic shunt insertion was potentially technically difficult, due to left portal vein thrombosis and a small right portal venous system, he underwent BRTO, which successfully embolised and thrombosed the colonic varices without complications.

Conclusions

Whilst further studies are required to conclude its effectiveness and efficacy, BRTO may be considered a viable solution in managing ectopic, colonic, variceal haemorrhage especially when traditional techniques are unsuccessful or contraindicated.

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.

An Unusual Presentation of Gastric Variceal Hemorrhage

Acute upper gastrointestinal (GI) bleeding is a commonly encountered condition that can potentially be life-threatening. Endoscopy is the diagnostic modality of choice, but it is important to recognize it's shortcomings. We introduce a 61-year-old female who presented with hematemesis and syncope. She had a history of recurrent episodes of hematemesis and hospitalizations for the preceding 18 months, for which multiple endoscopies had been performed but had failed to demonstrate a source. A repeat esophagogastroduodenoscopy (EGD) performed at our facility was unremarkable. A CT scan demonstrated a lobulated mass-like filling defect in the gastric cardia consistent with solitary varix with an abnormal fold pattern. An upper GI follow-through series was performed to better characterize this varix. The patient subsequently underwent balloon-occluded retrograde transvenous obliteration with successful control of the source of bleeding. It is important to keep in mind that EGD while being the gold standard for the diagnosis of varices, has its limitations, and should be augmented with the use of non-traditional diagnostic modalities such as CT scans or radionuclide imaging.

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.

Coexistence of "extra-gastric afferent-efferent direct connection" with gastric varices: CT evaluation and clinical significance

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.

Balloon-Assisted Percutaneous Transhepatic Antegrade Embolization with 2-Octyl Cyanoacrylate for the Treatment of Isolated Gastric Varices with Large Gastrorenal Shunts

Aims

To evaluate the safety and effectiveness of percutaneous transhepatic antegrade embolization (PTAE) with 2-octyl cyanoacrylate assisted with balloon occlusion of the left renal vein or gastrorenal shunts (GRSs) for the treatment of isolated gastric varices (IGVs) with large GRSs.

Methods

Thirty patients with IGVs associated with large GRSs who had underwent PTAE assisted with a balloon to block the opening of the GRS in the left renal vein were retrospectively evaluated and followed up. Clinical and laboratory data were collected to evaluate the technical success of the procedure, complications, changes in the liver function using Child-Pugh scores, worsening of the esophageal varices, the rebleeding rate, and survival. Laboratory data obtained before and after PTAE were compared (paired-sample t-test).

Results

PTAE was technically successful in all 30 patients. No serious complications were observed except for one nonsymptomatic pulmonary embolism. During a mean follow-up of 30 months, rebleeding was observed in 4/30 (13.3%) patients, worsening of esophageal varices was observed in 4/30 (13.3%) patients, and newly developed or aggravated ascites were observed on CT in 3/30 (10%) patients. Significant improvement was observed in Child-Pugh scores (p=0.009) and the international normalized ratio (INR) (p=0.004) at 3 months after PTAE. The cumulative survival rates at 1, 2, 3, and 5 years were 96.3%, 96.3%, 79.9%, and 79.9%, respectively.

Conclusion

Balloon-assisted PTAE with 2-octyl cyanoacrylate is technically feasible, safe, and effective for the treatment of IGV associated with a large GRS.

Liver stiffness measured by transient elastography as predictor of prognoses following portosystemic shunt occlusion

BACKGROUND AND AIM

This study aimed to identify predictors of model for end-stage liver disease sodium score reductions and improvements in vital prognoses following portosystemic shunt occlusion in portal hypertension patients.

METHODS

Seventy cirrhotic patients with major portosystemic shunts and a mean model for end-stage liver disease sodium score of 10.5 underwent balloon-occluded retrograde transvenous obliteration between February 2008 and March 2017. We calculated the scores before and 1 month after shunt occlusion. The long-term outcomes were monitored, and vital prognoses were analyzed.

RESULTS

The model for end-stage liver disease sodium score did not change significantly 1 month post-balloon-occluded retrograde transvenous obliteration, and the score decreased postoperatively in 31 (44.3%) patients. Univariate analyses showed that decline in the score after portosystemic shunt occlusion was strongly associated with hepatic encephalopathy as a procedural indication, lower liver volumes, and lower liver stiffness levels measured by transient elastography before treatment (P < 0.05). Multivariate logistic regression analysis identified preoperative liver stiffness level as an independent predictor of model for end-stage liver disease sodium score amelioration following balloon-occluded retrograde transvenous obliteration (P < 0.05), and receiver operating characteristic curve analysis determined a liver stiffness cutoff value of 21.6 kPa, with a sensitivity of 76.0% and specificity of 69.6%. The Kaplan-Meier method determined that overall survival rates after treatment in patients with liver stiffness < 21.6 kPa were significantly higher than in patients with liver stiffness ≥ 21.6 kPa (P < 0.05).

CONCLUSIONS

Liver stiffness measured by transient elastography may predict improvements in model for end-stage liver disease sodium scores and in survival rates after portosystemic shunt occlusion in portal hypertension patients.

Plasma Glucose Level Is Predictive of Serum Ammonia Level After Retrograde Occlusion of Portosystemic Shunts

OBJECTIVE

The purpose of this study was to evaluate predictors of reduction in ammonia levels by occlusion of portosystemic shunts (PSS) in patients with cirrhosis.

MATERIALS AND METHODS

Forty-eight patients with cirrhosis (21 women, 27 men; mean age, 67.8 years) with PSS underwent balloon-occluded retrograde transvenous obliteration (BRTO) at one institution between February 2008 and June 2014. The causes of cirrhosis were hepatitis B in one case, hepatitis C in 20 cases, alcohol in 15 cases, nonalcoholic steatohepatitis in eight cases, and other conditions in four cases. The Child-Pugh classes were A in 24 cases, B in 23 cases, and C in one case. The indication for BRTO was gastric varices in 40 cases and hepatic encephalopathy in eight cases. Testing was conducted before and 1 month after the procedure. Statistical analyses were performed to identify predictors of a clinically significant decline in ammonia levels after BRTO.

RESULTS

Occlusion of PSS resulted in a clinically significant decrease in ammonia levels accompanied by increased portal venous flow and improved Child-Pugh score. Univariate analyses showed that a reduction in ammonia levels due to BRTO was significantly related to lower plasma glucose levels, higher RBC counts, and higher hemoglobin concentration before the treatment. Furthermore, multivariate logistic regression identified preoperative plasma glucose level as the strongest independent predictor of a significant ammonia reduction in response to BRTO. In addition, although BRTO resulted in significantly declined ammonia levels in patients with normal glucose tolerance before the procedure, ammonia levels were not significantly decreased after shunt occlusion in patients with diabetes mellitus or impaired glucose tolerance before BRTO, according to 75-g oral glucose tolerance test results.

CONCLUSION

Preoperative plasma glucose level is a useful predictor of clinically significant ammonia reduction resulting from occlusion of PSS in patients with cirrhosis. Even if PSS are present, control of blood ammonia levels by BRTO alone may be difficult in patients with glucose intolerance.

Customization of laparoscopic gastric devascularization and splenectomy for gastric varices based on CT vascular anatomy

BACKGROUND

Laparoscopic gastric devascularization(Lap GDS) and splenectomy (SPL) for gastric varices is technically challenging because of highly developed collateral vessels and bleeding tendency. We investigated the feasibility of customization of Lap GDS and SPL based on CT vascular anatomy.

METHODS

We analyzed 61 cirrhotic patients with gastric varices who underwent Lap GDS and SPL between 2006 and 2014. Lap GDS was customized according to the afferent feeding veins (left gastric vein (LGV) and/or posterior gastric vein (PGV)/short gastric vein (SGV)) and efferent drainage veins (gastrorenal shunt and/or gastrophrenic shunt, or numerous retroperitoneal veins) based on CT imaging.

RESULTS

Thirty-four patients with efferent drainage veins suitable for balloon-occluded retrograde transvenous obliteration (B-RTO) underwent B-RTO instead of surgical GDS, with subsequent Lap SPL. Among 27 patients with gastric varices unsuitable for B-RTO, 15 patients with PGV/SGV underwent Lap GDS of the greater curvature and SPL, and 12 patients with LGV or LGV/PGV/SGV underwent Lap GDS of the greater and lesser curvature and SPL. The mean operation time was 294 min and mean blood loss was 198 g. There was no mortality or severe morbidity. Gastric varices were eradicated in all 61 patients, with no bleeding or recurrence during a mean follow-up of 55.9 months. The cumulative 3-, 5-, and 7-year survival rates were 92, 82, and 64%, respectively.

CONCLUSIONS

Lap GDS and SPL customized based on CT vascular anatomy is a safe and effective procedure for treating gastric varices.

An Algorithm for Management After Transjugular Intrahepatic Portosystemic Shunt Placement According to Clinical Manifestations

We propose an algorithm for management after transjugular intrahepatic portosystemic shunt (TIPS) placement according to clinical manifestations. For patients with an initial good clinical response, surveillance Doppler ultrasound is recommended to detect stenosis or occlusion. A TIPS revision can be performed using basic or advanced techniques to treat stenosis or occlusion. In patients with an initial poor clinical response, a TIPS venogram with pressure measurements should be performed to assess shunt patency. The creation of a parallel TIPS may also be required if the patient is symptomatic and the portal pressure remains high after TIPS revision. Additional procedures may also be necessary, such as peritoneovenous shunt (Denver shunt) placement for refractory ascites, tunneled pleural catheter for hepatic hydrothorax, and balloon-occluded retrograde transvenous obliteration procedure for gastric variceal bleeding. A TIPS reduction procedure can also be performed in patients with uncontrolled hepatic encephalopathy or hepatic failure.

Portal response related to shunt occlusion by balloon-occluded retrograde transvenous obliteration may determine the prognosis of cirrhosis

AIM

To determine the prognostic effect of portal hemodynamic responses after balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices (GV) in cirrhosis patients.

METHODS

This retrospective study consisted of 37 cirrhosis patients (aged 62.5 ± 9.7 years) with medium- or large-grade GV treated with B-RTO. Portal hemodynamic response was assessed by the changes in flow volume in the portal trunk (PFV, mL/min) before and after the treatment. Group I showed increased PFV and group II showed no increase in PFV. The median observation period was 49.8 months (range, 4.7-150.3 months).

RESULTS

All patients showed complete embolization of GV without any recurrence. There were 30 patients in group I and 7 patients in group II (decreased PFV in 6 and unchanged PFV in 1). The PFV at baseline was significantly lower in the former (583.5 ± 232.0 mL/min) than in the latter (880.7 ± 345.9 mL/min; P = 0.009). The survival rate was significantly lower in group II (83.3% at 1 year and 66.7% at 3 years) than in group I (96.7% at 1 year, 81.5% at 3 years, and 61.8% at 5 years; P = 0.012). The incidence of deterioration of the esophageal varices was 18/30 (60%) in group I and 5/7 (71.4%; P = 0.687) in group II. Multivariate analysis identified only no increase in portal response (hazard ratio, 8.086; P = 0.005) as an independent factor for poor prognosis.

CONCLUSION

Balloon-occluded retrograde transvenous obliteration for GV may result in a poor prognosis when portal hemodynamics shows no increase in portal response.

Balloon-occluded retrograde transvenous obliteration for treatment of bleeding gastric varices: case report and review of literature

Gastric variceal bleeding is a major complication of portal hypertension and is associated with high morbidity and mortality. While esophageal varices are more common, gastric varices are often more challenging to treat. Balloon-Occluded Retrograde Transvenous Obliteration is an interventional procedure whereby the portosystemic gastrorenal shunt is accessed via the left renal vein and the gastric varix outflow tract obliterated using direct sclerotherapy. Herein, we present a case of a 68-year-old female patient with cirrhosis who presented with bleeding gastric varices and successfully treated. This case highlights the procedural steps and the importance of detailed knowledge of the patient's portosystemic anatomy for determining suitability for balloon-occluded retrograde transvenous obliteration of gastric varices.

Balloon-Occluded Retrograde Transvenous Obliteration for the Treatment of Gastric Varices: Polidocanol Foam Versus Liquid Ethanolamine Oleate

OBJECTIVE

The purpose of this study was to evaluate the clinical results of the management of gastric varices by balloon-occluded retrograde transvenous obliteration with polidocanol foam versus ethanolamine oleate.

MATERIALS AND METHODS

Twenty patients treated with ethanolamine oleate and 21 patients treated with polidocanol foam were enrolled in this study. Early therapeutic effects were assessed mainly by dynamic contrast-enhanced CT. Subjective symptoms, objective findings associated with the procedures, and changes in laboratory data during the obliteration process were evaluated. Rebleeding from gastric varices was assessed after the procedures.

RESULTS

Complete obliteration was confirmed in all but one case of early recanalization after treatment with polidocanol foam. One patient died of acute respiratory distress syndrome after treatment with ethanolamine oleate. The total sclerosant volume was significantly lower for 3% polidocanol foam (13.5 ± 6.8 mL) than for 5% ethanolamine oleate (30.6 ± 15.6 mL) (p < 0.01). Polidocanol foam caused fewer severe reactions, including pain, during and after injection. High body temperature, hemoglobinuria, and reactive pleural effusion were not observed with polidocanol foam. The variance in laboratory data values associated with hemolysis was significantly greater with ethanolamine oleate. No postprocedural rebleeding from the gastric varices was observed during a median follow-up time of 39.5 months after procedures with ethanolamine oleate and 34 months after procedures with polidocanol foam.

CONCLUSION

Polidocanol foam can achieve obliteration of gastric varices comparable to that of ethanolamine oleate but with a significantly lower sclerosant dose and reduced risk of hemolysis-induced complications and harmful reactions, including pain and fever.

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.

Intraperitoneal bleeding after balloon-occluded retrograde transvenous obliteration: a case report

INTRODUCTION

Hepatic encephalopathy is an important underlying cause of consciousness disorders. Possible causes of hepatic encephalopathy include hepatic failure and shunt encephalopathy resulting from a portosystemic venous shunt. Balloon-occluded retrograde transvenous obliteration is generally an effective treatment for hepatic encephalopathy.

CASE PRESENTATION

A 73-year-old Japanese woman was referred to our department because of disturbance of consciousness. Hepatic venous angiography disclosed a shunt between her left hepatic vein and her portal vein. The shunt was closed with the use of coils and N-butyl 2-cyanoacrylate. One hour after the procedure, she lost consciousness. The bleeding was ascribed to catheter-induced vascular injury. Emergency angiography was performed, and hemostasis was achieved with coils.

CONCLUSION

Although bleeding is relatively rare after balloon-occluded retrograde transvenous obliteration, postoperative intraperitoneal bleeding is a serious complication.

Nonendoscopic management strategies for acute esophagogastric variceal bleeding

Acute variceal bleeding is a potentially life-threatening complication of portal hypertension. Management consists of emergent hemostasis, therapy directed at hemodynamic resuscitation, protection of the airway, and prevention and treatment of complications including prophylactic use of antibiotics. Endoscopic treatment remains the mainstay in the management of acute variceal bleeding in combination with pharmacotherapy aimed at reducing portal pressure. This article intends to highlight only the current nonendoscopic treatment approaches for control of acute variceal bleeding.

Long term results of balloon-occluded retrograde transvenous obliteration for portosystemic shunt encephalopathy in patients with liver cirrhosis and portal hypertension

This study examined 19 patients with portosystemic shunt encephalopathy caused by a splenorenal shunt (SRS), which was treated with balloon-occluded retrograde transvenous obliteration (B-RTO). Long-term treatment outcomes were evaluated based on hepatic functional reserve and vital prognosis. Encephalopathy improved in all patients after shunt embolization and closure. Albumin, serum ammonia, and the Child-Pugh score, a measure of liver function, were significantly improved 3 years after B-RTO, and exacerbation of damage to liver function was avoided (p<0.01). During the follow-up period, three patients died from liver failure and two patients from hepatocellular carcinoma. Patients had a poor prognosis if their albumin levels were less than 2.8 mg / dL before B-RTO (p<0.05). Encephalopathy patients had complete response to B-RTO, but long-term prognosis was affected by hepatic functional reserve before B-RTO and by concurrent hepatocellular carcinoma. The results of this study suggest that in patients with SRS, it is important to perform B-RTO at an early stage when the hepatic functional reserve is still satisfactory.

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.

Percutaneous transvenous embolization for portosystemic shunts associated with encephalopathy: Long-term outcomes in 14 patients

AIM

To evaluate the clinical outcomes of percutaneous transvenous embolization (PTE) for portosystemic shunt (PSS) associated with encephalopathy

METHODS

Fourteen patients with portosystemic encephalopathy (PSE) were enrolled in this retrospective cohort study. We evaluated technical success, clinical success, complication and outcomes.

RESULTS

In cases in which PSS was one of main causes of PSE, three also had splenorenal shunts, four gastrorenal shunts, four superior mesenteric vein systemic shunts, one inferior mesenteric vein systemic shunt and two main trunk of portal vein inferior vena cava shunts. We used only ethanolamine oleate (EO) in five; EO and coils in five; EO, coils and n-butyl 2-cyanoacrylate (NBCA) in two; and coils and NBCA in two patients as embolic materials. The rate of primary and secondary technical success was 93% (13/14 patients) and 100%, respectively. No major complications were encountered related to PTE. Follow-up period was a median of 27 months (range, 12-79). All patients had sustained disappearance of PSE. PSE recurred in one patient because of another PSS development. Thus, clinical success was achieved in 93% (13/14 patients). The ammonia levels 1 year after PTE were significantly improved compared with pre-PTE (median, 102 vs 41 μmol/L) and maintained lower levels 2 and 3 years later. Child-Pugh scores did not change significantly. Esophageal varices were aggravated in 29% (4/14 patients). Five patients died, but no death of hepatic failure related to PTE was encountered.

CONCLUSION

PTE could be one of the useful treatment options for PSE.

Management of gastric varices

According to their location, gastric varices (GV) are classified as gastroesophageal varices and isolated gastric varices. This review will mainly focus on those GV located in the fundus of the stomach (isolated gastric varices 1 and gastroesophageal varices 2). The 1-year risk of GV bleeding has been reported to be around 10%-16%. Size of GV, presence of red signs, and the degree of liver dysfunction are independent predictors of bleeding. Limited data suggest that tissue adhesives, mainly cyanoacrylate (CA), may be effective and better than propranolol in preventing bleeding from GV. General management of acute GV bleeding must be similar to that of esophageal variceal bleeding, including prophylactic antibiotics, a careful replacement of volemia, and early administration of vasoactive drugs. Small sample-sized randomized controlled trials have shown that tissue adhesives are the therapy of choice for acute GV bleeding. In treatment failures, transjugular intrahepatic portosystemic shunt (TIPS) is considered the treatment of choice. After initial hemostasis, repeated sessions with CA injections along with nonselective beta-blockers are recommended as secondary prophylaxis; whether CA is superior to TIPS in this scenario is not completely clear. Balloon-occluded retrograde transvenous obliteration (BRTO) has been introduced as a new method to treat GV. BRTO is also effective and has the potential benefit of increasing portal hepatic blood flow and therefore may be an alternative for patients who may not tolerate TIPS. However, BRTO obliterates spontaneous portosystemic shunts, potentially aggravating portal hypertension and its related complications. The role of BRTO in the management of acute GV bleeding is promising but merits further evaluation.

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.

Long-term outcome of patients with gastric varices treated by balloon-occluded retrograde transvenous obliteration

BACKGROUND AND AIM

To assess the short- and long-term outcome of patients with gastric varices (GV) after balloon-occluded retrograde transvenous obliteration (B-RTO) by comparing bleeding cases with prophylactic cases.

METHODS

Consecutive 100 patients with GV treated by B-RTO were enrolled in this retrospective cohort study. We compared the technical success, complications, and survival rates between bleeding and prophylactic cases.

RESULTS

Of 100 patients, 61 patients were bleeding cases and 39 patients were prophylactic cases. Technical success was achieved in 95% of bleeding case and in 100% of prophylactic case, with no significant difference between these groups (overall technical success rate, 97%). The survival rates at 5 and 10 years were 50% and 22% in bleeding case, and 49% and 36% in prophylactic case, respectively. There was also no significant difference (P = 0.420). By multivariate analysis, survival rates correlated significantly with liver function (hazard ratio 2.371, 95% CI 1.457-3.860, P = 0.001) and hepatocellular carcinoma development (HR 4.782, 95% CI 2.331-9.810, P < 0.001). The aggravating rates of esophageal varices (EV) were 21%, 50%, and 54% at 12, 60, and 120 months after B-RTO. By multivariate analysis, aggravating rates significantly correlated with EV existing before B-RTO (HR 18.114, 95% CI 2.463-133.219, P = 0.004).

CONCLUSION

B-RTO for GV could provide the high rate of complete obliteration and favorable long-term prognosis even in bleeding cases as well as prophylactic cases. Management of EV after B-RTO, especially in coexisting case of GV and EV, would be warranted.

Short-term rebleeding rates for isolated gastric varices managed by transjugular intrahepatic portosystemic shunt versus balloon-occluded retrograde transvenous obliteration

PURPOSE

To assess the short-term rebleeding rate associated with the use of a transjugular intrahepatic portosystemic shunt (TIPS) compared with balloon-occluded retrograde transvenous obliteration (BRTO) for management of gastric varices (GV).

MATERIALS AND METHODS

A single-center retrospective comparison of 50 patients with bleeding from GV treated with a TIPS or BRTO was performed. Of 50 patients, 27 (17 men and 10 women; median age, 55 y; range, 31-79 y) received a TIPS with covered stents, and 23 (12 men and 11 women; median age, 52 y; range, 23-83 y) underwent a BRTO procedure with a foam sclerosant. All study subjects had clinical and endoscopic evidence of isolated bleeding GV and were hemodynamically stable at the time of the procedure. Clinical and endoscopic follow-up was performed. Kaplan-Meier analysis was used to evaluate rebleeding rates from the GV.

RESULTS

The technical success rate was 100% in the TIPS group and 91% in the BRTO group (P = .21). Major complications occurred in 4% of the patients receiving TIPS and 9% of patients the undergoing BRTO (P = .344). Encephalopathy was reported in 4 of 27 (15%) patients in the TIPS group and in none of the patients in the BRTO group (0%; P = .12). At 12 months, the incidence of rebleeding from a GV source was 11% in the TIPS group and 0% in the BRTO group (P = .25).

CONCLUSIONS

BRTO appears to be equivalent to TIPS in the short-term for management of bleeding GV. Further comparative studies are warranted to determine optimal management strategies in individual patients.

Variceal and other portal hypertension related bleeding

Variceal bleeding is one of the commonest and most severe complications of liver cirrhosis. Even with the current best medical care, mortality from variceal bleeding is still around 20%. When cirrhosis is diagnosed, varices are present in about 30-40% of compensated patients and in 60% of those who present with ascites. Once varices have been diagnosed, the overall incidence of variceal bleeding is in the order of 25% at two years. Variceal size is the most useful predictor for variceal bleeding, other predictors are severity of liver dysfunction (Child-Pugh classification) and the presence of red wale marks on the variceal wall. The current consensus is that every cirrhotic patient should be endoscopically screened for varices at the time of diagnosis to detect those requiring prophylactic treatment. Non-selective beta-adrenergic blockers (NSBB) and endoscopic band ligation (EBL) have been shown effective in the prevention of first variceal bleeding. The current recommendation for treating acute variceal bleeding is to start vasoactive drug therapy early (ideally during the transferral or to arrival to hospital, even if active bleeding is only suspected) and performing EBL. Once bleeding is controlled, combination therapy with NSBB + EBL should be used to prevent rebleeding. In patients at high risk of treatment failure despite of using this approach, an early covered-TIPS within 72 h (ideally 24 h) should be considered. Data on management of gastric variceal bleeding is limited. No clear recommendation for primary prophylaxis can be done. In acute cardiofundal variceal bleeding, vasoactive agents together with cyanoacrylate (CA) injection seem to be the treatment of choice. Further CA injections and/or NSBB may be used to prevent rebleeding. TIPS or Balloon-occluded retrograde transvenous obliteration when TIPS is contraindicated may be used as a rescue therapy.

Austrian consensus on the definition and treatment of portal hypertension and its complications (Billroth II)

In November 2004, the Austrian Society of Gastroenterology and Hepatology (ÖGGH) held for the first time a consensus meeting on the definitions and treatment of portal hypertension and its complications in the Billroth-Haus in Vienna, Austria (Billroth I-Meeting). This meeting was preceded by a meeting of international experts on portal hypertension with some of the proponents of the Baveno consensus conferences (http://www.oeggh.at/videos.asp). The consensus itself is based on the Baveno III consensus with regard to portal hypertensive bleeding and the suggestions of the International Ascites Club regarding the treatment of ascites. Those statements were modified by new knowledge derived from the recent literature and also by the current practice of medicine as agreed upon by the participants of the consensus meeting. In October 2011, the ÖGGH organized the second consensus meeting on portal hypertension and its complications in Vienna (Billroth II-Meeting). The Billroth II-Guidelines on the definitions and treatment of portal hypertension and its complications take into account the developments of the last 7 years, including the Baveno-V update and several key publications.

Clinical outcomes of balloon-occluded retrograde transvenous obliteration for the treatment of gastric variceal hemorrhage in Korean patients with liver cirrhosis: a retrospective multicenter study

Background/Aims

This study evaluated the clinical outcomes of balloon-occluded retrograde transvenous obliteration (BRTO) for the treatment of hemorrhage from gastric varices (GV) in Korean patients with liver cirrhosis (LC).

Methods

We retrospectively analyzed data from 183 LC patients who underwent BRTO for GV bleeding in 6 university-based hospitals between January 2001 and December 2010.

Results

Of the 183 enrolled patients, 49 patients had Child-Pugh (CP) class A LC, 105 had CP class B, and 30 had CP class C at the time of BRTO. BRTO was successfully performed in 177 patients (96.7%). Procedure-related complications (e.g., pulmonary thromboembolism and renal infarction) occurred in eight patients (4.4%). Among 151 patients who underwent follow-up examinations of GV, 79 patients (52.3%) achieved eradication of GV, and 110 patients (72.8%) exhibited marked shrinkage of the treated GV to grade 0 or I. Meanwhile, new-appearance or aggravation of esophageal varices (EV) occurred in 54 out of 136 patients who underwent follow-up endoscopy (41.2%). During the 36.0±29.2 months (mean±SD) of follow-up, 39 patients rebled (hemorrhage from GV in 7, EV in 18, nonvariceal origin in 4, and unknown in 10 patients). The estimated 3-year rebleeding-free rate was 74.8%, and multivariate analysis showed that CP class C was associated with rebleeding (odds ratio, 2.404; 95% confidence-interval, 1.013-5.704; P=0.047).

Conclusions

BRTO can be performed safely and effectively for the treatment of GV bleeding. However, aggravation of EV or bleeding from EV is not uncommon after BRTO; thus, periodic endoscopy to follow-up of EV with or without prophylactic treatment might be necessary in LC patients undergoing BRTO.

Balloon-occluded retrograde transvenous obliteration of gastric varices

OBJECTIVE

The purpose of this review is to describe the clinical factors related to balloon-occluded retrograde transvenous obliteration, including the preparation needed, the technique and challenges, and the outcomes.

CONCLUSION

Although the procedure can be performed when transjugular intrahepatic portosystemic shunt is contraindicated or when endoscopic management fails, balloon-occluded retrograde transvenous obliteration is successful as a first-line or second-line therapy. Gastric variceal rebleeding rates are low and serious complications are rare. Randomized controlled trials are required to evaluate the superiority of this procedure over other methods of treating gastric varices and to determine which sclerosant should be used. In the near future, this procedure may play a larger role in emergency care and in the management of nongastric varices.

Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Technique and Intraprocedural Imaging

Balloon-occluded retrograde transvenous obliteration (BRTO) is an endovascular technique used as a therapeutic adjunct or alternative to transjugular intrahepatic shunts (TIPS) in the management of gastric varices. Occlusion balloons are strategically placed to modulate flow within the gastrorenal or gastrocaval shunt to allow stagnation of the sclerosant material within the gastric varix. The approach and complexity of the procedure depends on the anatomic classification of inflow and outflow veins of the varix. Ethanolamine oleate has been described as the main sclerosant used in this procedure. Recently, foam sclerosants have gained popularity as alternative embolization agents, which provide the advantage of better variceal wall contact and potentially less dose of sclerosant.

Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Preprocedural Evaluation and Imaging

Patients undergoing balloon retrograde transvenous obliteration (BRTO) are mostly decompensated cirrhotic with either bleeding gastric varices (GV) or hepatic encephalopathy. It is crucial that clinicians are up-to-date with the assessments needed prior to BRTO to anticipate and prevent complications, and to deliver critical quality care. These patients will require preprocedural assessments and management, including endoscopic, clinical, laboratory, and imaging evaluation. Endoscopic evaluation is mandatory prior to BRTO, and it is highly recommended that it be performed at the same institution where BRTO will be performed. It is essential that clinicians are aware of the potential benefits and complications that may result from BRTO. These complications should be anticipated and prevented when possible. For GV bleeders, there should be consideration of a transvenous intrahepatic portosystemic shunt (TIPS) during or before BRTO in patients with refractory ascites or pleural effusion, as well as endoscopic banding or a TIPS in patients with high-risk esophageal varices. Patients undergoing BRTO are usually complicated and require a team approach. In this article, the authors address these assessment and preparatory management and planning procedures prior to the BRTO procedure as well as expected outcomes and potential complications.

Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Follow-Up and Postprocedural Imaging

The majority of patients undergoing balloon retrograde transvenous obliteration (BRTO) are decompensated cirrhotic for either bleeding gastric varices (GV) or hepatic encephalopathy. These patients will require close follow-up and assessments pre- and post-BRTO including clinical, laboratory, endoscopic, and imaging evaluations. It is essential that clinicians are aware of the potential benefits and complications that may result from BRTO. These complications may include fever, chest or epigastric pain, hemoglobinuria, transient hypertension, nausea or vomiting, and many more. These complications usually resolve within the first 10 days. Laboratory abnormalities are transient and uncommon. Radiologic and endoscopic follow-up are required including computed tomography (CT), magnetic resonance imaging (MRI), routine upper endoscopy and endoscopic ultrasound (EUS), which are detailed in this review. Patients undergoing BRTO are usually complicated and will require a team approach. This team should include the hepatologist, endoscopist, and interventional radiologist. Understanding and open dialogue are essential in the management of post-BRTO patients. The authors review the possible benefits, potential complications, and the evaluation tools needed to improve outcomes.

Anatomy and classification of gastrorenal and gastrocaval shunts

The gastric varices communicate with gastrorenal and gastrocaval shunts and are classified according to the pattern of venous inflow into three types, which differ in the number and location of the inflow veins. The gastric varices are also classified according to their venous drainage into four different types, reflecting the size and number of collateral veins communicating with the gastric varices and the gastrorenal/gastrocaval shunt. Lastly, the gastric varices are classified according to their appearance on balloon-occluded retrograde venography into five grades representing the degree of opacification of the gastric varices and the collateral veins. Understanding these anatomic classifications is crucial in planning endovascular obliteration of gastric varices.