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Pas M, Jogo A, Yamamoto A, Kageyama K, Sohgawa E, Oura T, Terayama E, Asano K, Matsushita K, Sakai Y, Ozaki M, Yonezawa H, Okazaki M, Nota T, Murai K, Kita R, Kaminou T, Miki Y. Transparaumbilical Intravariceal Sclerotherapy for Duodenal Varices Using Outflow Embolization. Intern Med 2024; 63:803-807. [PMID: 37495529 PMCID: PMC11008987 DOI: 10.2169/internalmedicine.2274-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/12/2023] [Indexed: 07/28/2023] Open
Abstract
A 55-year-old patient was admitted for variceal treatment, a complication of chronic portal hypertension and liver cirrhosis. Imaging studies revealed prominent duodenal varices, the pancreaticoduodenal vein as its afferent pathway, a drainer vessel into the inferior vena cava, and a paraumbilical vein. We successfully performed complete obliteration of the varix, including its afferent and efferent vessels, via the paraumbilical vein approach.
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Affiliation(s)
- Maciej Pas
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Tatsushi Oura
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Eisaku Terayama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Kazuo Asano
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Kazuki Matsushita
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Yuki Sakai
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Masanori Ozaki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Hiroki Yonezawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Masahiro Okazaki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Takehito Nota
- Advanced Imaging and Minimally Invasive Therapy Center, Tsukazaki Hospital, Japan
| | - Kazuki Murai
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
| | - Ryuichi Kita
- Department of Gastroenterology, Osaka Red Cross Hospital, Japan
| | - Toshio Kaminou
- Advanced Imaging and Minimally Invasive Therapy Center, Tsukazaki Hospital, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Japan
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Hori A, Watanabe Y, Takahashi K, Tonouchi T, Kimura N, Setsu T, Ikarashi S, Kamimura H, Yokoyama J, Terai S. A rare case of duodenal variceal bleeding due to extrahepatic portal vein obstruction successfully treated with endoscopic injection sclerotherapy. Clin J Gastroenterol 2022; 15:617-622. [PMID: 35378714 DOI: 10.1007/s12328-022-01627-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
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Small Intestine Varices in Cirrhosis at a High-Volume Liver Transplant Center: A Retrospective Database Study and Literature Review. Am J Gastroenterol 2021; 116:1426-1436. [PMID: 33734116 DOI: 10.14309/ajg.0000000000001204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/22/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Esophageal varices are a well-characterized sequela of portal hypertension; however, less is known about varices arising in ectopic locations. We aimed to describe bleeding small intestine varices (SIV) in patients with cirrhosis and compare characteristics and outcomes to published case reports. METHODS We performed an institutional chart review using billing codes and natural language processing between 2008 and 2019. Inclusion criteria were adult patients with cirrhosis and SIV verified by endoscopy, video capsule, or imaging. Patients with noncirrhotic portal hypertension and stomal varices were excluded. We examined demographic and clinical factors, characteristics of SIV, bleeding, intervention, and outcomes in our series and collated data from published cases identified during a literature review. RESULTS We identified 71 patients with cirrhosis and SIV (18 bled). The literature search yielded 76 cases with bleeding SIV. Our series and published cases were matched for age, sex, liver disease etiology, and SIV location. Length of stay and transfusion requirements were similar. Aggregate initial treatments (number, hemostasis rate) included medical (n = 7, 57%), endoscopic (n = 48, 56%), interventional radiology (n = 31, 77%), and surgery (n = 8, 87%). Hospital and overall mortality rates were higher in our series (22% and 38%) compared with the published cases (5.3% and 18.4%), respectively (P = 0.02 and P = 0.07). DISCUSSION A quarter of patients with cirrhosis and SIV experience bleeding, with high transfusion requirements, frequent need for secondary interventions, and high mortality. These findings highlight the need for a multidisciplinary approach and second-line therapeutic modalities in the timely management of bleeding SIV in cirrhosis.
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Howe JH, Jr PRB, Commander CW, Kim KR. Transjugular intrahepatic portosystemic shunt and transcatheter embolization treatment of duodenal variceal bleeding. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jeffrey H. Howe
- Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Peter R. Bream Jr
- Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Clayton W. Commander
- Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kyung Rae Kim
- Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Lee JH, Kim TH, Choi JW, Kim SY, Choi JY, Lee CK, Park BK, Chung JB. A case report of bleeding from duodenal varices treated with percutaneous transhepatic obliteration. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii190002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Ji Hyun Lee
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Hwan Kim
- Department of Vascular and Interventional Radiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jong Won Choi
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sun Young Kim
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jin Young Choi
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Chun Kyon Lee
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Byung Kyu Park
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jae Bok Chung
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
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Jejunal Varices Bleeding in a Patient with Extensive Portomesenteric Thrombosis Secondary to Factor V Leiden Mutation: A Management Dilemma. Case Rep Gastrointest Med 2019; 2019:4526472. [PMID: 30881706 PMCID: PMC6381577 DOI: 10.1155/2019/4526472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 12/06/2018] [Accepted: 01/22/2019] [Indexed: 02/05/2023] Open
Abstract
Ectopic varices are portosystemic collaterals that occur away from the gastroesophageal junction and account for 1-5% of all variceal bleeding. Its occurrence in the jejunum is rare. Most common cause of ectopic jejunal varices is portal hypertension especially in those patients who have undergone prior abdominal surgery. Portomesenteric thrombosis is a rare cause of ectopic jejunal varices. Ectopic varices are rare cause of obscure GI bleeding and hence should be always suspected in patients with history of portal hypertension who present with GI bleeding and have negative upper and lower GI endoscopies. Management of patients with ectopic varices is often very challenging and requires multidisciplinary approach. Therapeutic options include endoscopic therapy, interventional radiologic procedures, surgically creating shunting, or surgical resection. We present the case of a 52-year-old patient who was on anticoagulation for extensive portomesenteric thrombosis secondary to factor V Leiden heterozygous mutation and presented with melena and symptomatic anemia. Investigations showed bleeding jejunal varices as the cause of anemia. We discuss the therapeutic options and dilemma in the management of such cases.
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Lee SJ, Jeon GS. Coil-assisted retrograde transvenous obliteration for the treatment of duodenal varix. ACTA ACUST UNITED AC 2019; 24:292-294. [PMID: 30179159 DOI: 10.5152/dir.2018.18031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Duodenal variceal bleeding is a rare but potentially life-threatening complication of portal hypertension. Endoscopic therapy is usually the initial treatment option for bleeding duodenal varices, but it is not always feasible or successful. We present a technique of coil-assisted retrograde transvenous obliteration in a patient with duodenal varices originating from the inferior pancreaticoduodenal vein and draining into the right ovarian vein.
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Affiliation(s)
- Shin Jae Lee
- Department of Radiology, CHA Bundang Medical Center, CHA University, Gyeonggi-do, Korea
| | - Gyeong Sik Jeon
- Department of Radiology, CHA Bundang Medical Center, CHA University, Gyeonggi-do, Korea
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Garcia MC, Ahlenstiel G, Mahajan H, van der Poorten D. Small bowel varices secondary to chronic superior mesenteric vein thrombosis in a patient with heterozygous Factor V Leiden mutation: a case report. J Med Case Rep 2015; 9:210. [PMID: 26423996 PMCID: PMC4589920 DOI: 10.1186/s13256-015-0705-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 09/02/2015] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Bleeding ectopic small bowel varices pose a clinical dilemma for the physician, given their diagnostic obscurity and the lack of evidence-based medicine to guide therapy. They often occur in the context of portal hypertension, secondary to either liver disease or extrahepatic causes. Rarely is their presence associated with chronic superior mesenteric vein thrombosis and hereditary coagulopathies. CASE PRESENTATION A 74-year-old white woman, with a heterozygous Factor V Leiden mutation and no underlying liver disease or portal hypertension, presented over the course of 13 months for recurrent episodes of melena and per rectal bleeding. An initial endoscopy showed a clean-based chronic gastric ulcer, while colonoscopies showed multiple, non-bleeding angioectasias which were treated with argon plasma coagulation. Subsequent video capsule endoscopy and double balloon enteroscopy revealed red wale marks overlying engorged submucosal veins in her distal ileum, consistent with ectopic varices. A chronic superior mesenteric vein thrombus, found via computed tomography venogram, was the cause of the ileal varices. She underwent curative surgical resection of the affected bowel, with no re-bleeding episodes 17 months post-surgery, despite needing lifelong anticoagulation for recurrent venous thromboembolisms. CONCLUSIONS Clinicians should consider ectopic varices in patients who present with obscure gastrointestinal bleeding, even in the absence of portal hypertension or liver disease. In those with a known thrombophilia, patients should be screened for splanchnic thrombosis, which may precipitate ectopic varices.
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Affiliation(s)
- Maria C Garcia
- Sydney Medical School, Westmead Clinical School, University of Sydney, Sydney, NSW, Australia.
| | - Golo Ahlenstiel
- Department of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Westmead, NSW, Australia.
| | - Hema Mahajan
- Department of Anatomical Pathology, Westmead Hospital, Westmead, NSW, Australia.
| | - David van der Poorten
- Department of Gastroenterology and Hepatology, University of Sydney at Westmead Hospital, Westmead, NSW, Australia.
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Copelan A, Chehab M, Dixit P, Cappell MS. Safety and efficacy of angiographic occlusion of duodenal varices as an alternative to TIPS: review of 32 cases. Ann Hepatol 2015. [PMID: 25864218 DOI: 10.1016/s1665-2681(19)31277-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED BACKGROUND/RATIONALE OF STUDY: Analyze safety and efficacy of angiographic-occlusion-with-sclerotherapy/embolotherapy-without-transjugular-intrahepatic-portosystemic-shunt (TIPS) for duodenal varices. Although TIPS is considered the best intermediate-to-long term therapy after failed endoscopic therapy for bleeding varices, the options are not well-defined when TIPS is relatively contraindicated, with scant data on alternative therapies due to relative rarity of duodenal varices. Prior cases were identified by computerized literature search, supplemented by one illustrative case. Favorable clinical outcome after angiography defined as no rebleeding during follow-up, without major procedural complications. RESULTS Thirty-two cases of duodenal varices treated by angiographic-occlusion-with-sclerotherapy/embolotherapy- without-TIPS were analyzed. Patients averaged 59.5 ± 12.2 years old (female = 59%). Patients presented with melena-16, hematemesis & melena-5, large varices-5, growing varices-2, ruptured varices-1, and other- 3. Twenty-nine patients had cirrhosis; etiologies included: alcoholism-11, hepatitis C-11, primary biliary cirrhosis- 3, hepatitis B-2, Budd-Chiari-1, and idiopathic-1. Three patients did not have cirrhosis, including hepatic metastases from rectal cancer-1, Wilson's disease-1, and chronic liver dysfunction-1. Thirty-one patients underwent esophagogastroduodenoscopy before therapeutic angiography, including fifteen undergoing endoscopic variceal therapy. Therapeutic angiographic techniques included balloon-occluded retrograde-transvenous-obliteration (BRTO) with sclerotherapy and/or embolization-21, DBOE (double-balloon-occluded-embolotherapy)-5, and other-6. Twenty-eight patients (87.5%; 95%-confidence interval: 69-100%) had favorable clinical outcomes after therapeutic angiography. Three patients were therapeutic failures: rebleeding at 0, 5, or 10 days after therapy. One major complication (Enterobacter sepsis) and one minor complication occurred. CONCLUSIONS This work suggests that angiographic-occlusion-with sclerotherapy/ embolotherapy-without-TIPS is relatively effective (~90% hemostasis-rate), and relatively safe (3% major-complication-rate). This therapy may be a useful treatment option for duodenal varices when endoscopic therapy fails and TIPS is relatively contraindicated.
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Affiliation(s)
- Alexander Copelan
- Department of Radiology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Monzer Chehab
- Department of Radiology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Purushottam Dixit
- Department of Radiology, William Beaumont Hospital, Royal Oak, MI, USA; Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Mitchell S Cappell
- Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA; Division of Gastroenterology & Hepatology, William Beaumont Hospital, Royal Oak, MI, USA
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10
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Hwang SW, Sohn JH, Kim TY, Kim JY, Yhi J, Kwak DS, Kim HS, Song SY. Long-term successful treatment of massive distal duodenal variceal bleeding with balloon-occluded retrograde transvenous obliteration. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2015; 63:248-52. [PMID: 24755751 DOI: 10.4166/kjg.2014.63.4.248] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Duodenal variceal bleeding in patients with portal hypertension due to cirrhosis or other causes is uncommon. We report on a case of a 55-year-old male with an ectopic variceal rupture at the distal fourth part of the duodenum who presented with massive hematochezia and shock. Shortly after achievement of hemodynamic stability, due to the limitation of an endoscopic procedure, we initially attempted to find the bleeding focus by abdominal computed tomography, which showed tortuous duodenal varices that drained into the left gonadal vein. He was treated with first-line balloon-occluded retrograde transvenous obliteration (BRTO), resulting in a favorable long-term outcome without rebleeding three years later. This case suggests that BRTO may be a first-line therapeutic option for control of ruptured duodenal varices, especially at a distal location.
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Affiliation(s)
- Soon Woo Hwang
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Joo Hyun Sohn
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Tae Yeob Kim
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Ji Yeoun Kim
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Jiyoung Yhi
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Dong Shin Kwak
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Hae Su Kim
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Soon-Young Song
- Department of Radiology, Hanyang University Seoul Hospital, Seoul, Korea
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Saad WE, Lippert A, Schwaner S, Al-Osaimi A, Sabri S, Saad N. Management of Bleeding Duodenal Varices with Combined TIPS Decompression and Trans-TIPS Transvenous Obliteration Utilizing 3% Sodium Tetradecyl Sulfate Foam Sclerosis. J Clin Imaging Sci 2014; 4:67. [PMID: 25558434 PMCID: PMC4278090 DOI: 10.4103/2156-7514.145903] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 10/07/2014] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Endoscopic experience in the management of duodenal varices (DVs) is limited and challenging given the anatomic constraints and limited experience. The endovascular management of DVs is not yet established and the controversy of whether to manage them by decompression with a transjugular intrahepatic portosystemic shunt (TIPS) or by transvenous obliteration is unresolved. In the literature, the 6-12 month rebleeding rate of DVs after TIPS is 21-37% and after transvenous obliteration is 13%. The purpose of the study is to evaluate the clinical outcome of combined TIPS decompression and transvenous obliteration/sclerosis. MATERIALS AND METHODS This is a retrospective study (case series) of two institutions, evaluating patients who underwent TIPS and/or transvenous obliteration/sclerosis for bleeding DVs (from January 2009 to June 2013). TIPS was performed according to a standard procedure using covered stents. Transvenous obliteration (variceal sclerosis) from the systemic and/or portal venous circulation was performed utilizing 3% sodium tetradecyl sulfate foam. Transvenous obliteration was commonly augmented with coils and/or vascular plugs. Technical (technical success of establishing TIPS and completely obliterating the DVs) and clinical outcomes (rebleeding rate and survival) were evaluated. RESULTS Five patients with liver cirrhosis presenting with bleeding DVs were included in the study with all eventually (and coincidentally) receiving TIPS and transvenous obliteration. Two of the five patients underwent concomitant TIPS and transvenous obliteration in the same procedural setting. However, three patients underwent transvenous obliteration due to bleeding despite a patent TIPS that had been previously placed. The average time from TIPS placement to transvenous obliteration was 125 days (range: 3-324 days). After having both procedures, there was no rebleeding in the patients during a mean follow-up period of 22 months (6-50 months). Coils and/or metallic vascular plugs were used to augment the sclerosant obliteration in four of five patients. CONCLUSION The combination of TIPS decompression and foam sclerosant transvenous obliteration appears to be effective in preventing rebleeding in this limited case series and compares favorably with the existing evidence for either approach [TIPS or balloon-occluded retrograde transvenous obliteration (BRTO)] alone.
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Affiliation(s)
- Wael E Saad
- Department of Radiology, Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, United States
| | - Allison Lippert
- Department of Radiology, University of Virginia, Charlottesville, Virginia, United States
| | - Sandra Schwaner
- Department of Radiology, University of Virginia, Charlottesville, Virginia, United States
| | - Abdullah Al-Osaimi
- Department of Medicine, Temple University Health System, Philadelphia, Pennsylvania, United States
| | - Saher Sabri
- Department of Radiology, University of Virginia, Charlottesville, Virginia, United States
| | - Nael Saad
- Department of Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri, United States
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Saad WEA, Lippert A, Saad NE, Caldwell S. Ectopic varices: anatomical classification, hemodynamic classification, and hemodynamic-based management. Tech Vasc Interv Radiol 2014; 16:158-75. [PMID: 23830673 DOI: 10.1053/j.tvir.2013.02.004] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Ectopic varices are dilated splanchnic (mesoportal) veins/varicosities and/or are dilated portosystemic collaterals that can occur along the entire gastrointestinal tract outside the common pathologic variceal sites. Ectopic varices are complex and highly variable entities that are not fully understood. Ectopic varices represent 2%-5% of a gastrointestinal tract variceal bleeding. However, ectopic varices have a 4-fold increased risk of bleeding when compared with esophageal varices and can have a mortality rate as high as 40%. All treatment strategies and techniques have been utilized in managing these potentially mortal varices and have shown poor outcomes. The debate of whether to manage these varices by decompression with a transjugular portosystemic shunt, or other portosystemic shunts, vs transvenous obliteration is unresolved. The rebleed rates after transjugular portosystemic shunt decompression are 20%-40%. The rebleed rates after transvenous obliteration and the mortality rate at 3-6 months are 30%-40% and 50%-60%, respectively. Hemodynamically from an etiology standpoint, there are 2 types: occlusive (type-b) and nonocclusive (oncotic or type-a). Hemodynamically from a vascular-shunting standpoint, there could be a component of portoportal or portosystemic shunting or both with varying dominance. This is the basis of the new classification system described herein. Management strategies (decompression vs sclerosis) are discussed. The ideal management strategy is a treatment that leads to prompt hemostasis but also addresses the etiology or hemodynamics of the ectopic varices. It is the hope that with better understanding, description, and categorization of ectopic varices comes a more systematic approach to this rare but menacing problem.
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Affiliation(s)
- Wael E A Saad
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA.
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Hashimoto R, Sofue K, Takeuchi Y, Shibamoto K, Arai Y. Successful balloon-occluded retrograde transvenous obliteration for bleeding duodenal varices using cyanoacrylate. World J Gastroenterol 2013; 19:951-954. [PMID: 23429766 PMCID: PMC3574895 DOI: 10.3748/wjg.v19.i6.951] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Accepted: 10/30/2012] [Indexed: 02/06/2023] Open
Abstract
A 76-year-old woman with hepatitis C cirrhosis presented with tarry stools and hematemesis. An endoscopy demonstrated bleeding duodenal varices in the second portion of the duodenum. Contrast-enhanced computed tomography revealed markedly tortuous varices around the wall in the duodenum. Several afferent veins appeared to have developed, and the right ovarian vein draining into the inferior vena cava was detected as an efferent vein. Balloon-occluded retrograde transvenous obliteration (BRTO) of the varices using cyanoacrylate was successfully performed in combination with the temporary occlusion of the portal vein. Although no previous publications have used cyanoacrylate as an embolic agent for BRTO to control bleeding duodenal varices, this strategy can be considered as an alternative procedure to conventional BRTO using ethanolamine oleate when numerous afferent vessels that cannot be embolized are present.
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Anatomic Features and Retrograde Transvenous Obliteration of Duodenal Varices Associated with Mesocaval Collateral Pathway. J Vasc Interv Radiol 2012; 23:1339-46. [DOI: 10.1016/j.jvir.2012.06.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2012] [Revised: 06/25/2012] [Accepted: 06/29/2012] [Indexed: 01/25/2023] Open
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Kakutani H, Sasaki S, Ueda K, Takakura K, Sumiyama K, Imazu H, Hino S, Kawamura M, Tajiri H. Is it safe to perform endoscopic band ligation for the duodenum? A pilot study in ex vivo porcine models. MINIM INVASIV THER 2012; 22:80-3. [PMID: 22793777 DOI: 10.3109/13645706.2012.703955] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM In the digestive tract, endoscopic band ligation (EBL) has been routinely used for the treatment of variceal bleeding and superficial malignancies. In recent years, endoscopic treatments for duodenal varices, adenoma, and cancer have also actively incorporated EBL. Although there have been a number of reports on the risks associated with the use of EBL in the esophagus, stomach, and colon, few studies have focused on EBL in the duodenum. We performed EBL procedures to evaluate the risks associated with the use of EBL in the duodenum. MATERIAL AND METHODS Overall, EBLs were performed at nine sites in duodenum sampled from a pig immediately after sacrifice. Submucosal saline injections were placed in three of the nine studied sites. RESULTS Regardless of saline injection, the full thickness of the duodenal wall was ligated in all attempts. CONCLUSIONS Routine EBL is not recommended in the duodenum because the risk of perforation is unacceptably high.
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Affiliation(s)
- Hiroshi Kakutani
- Department of Endoscopy, The JikeiUniversity School of Medicine, Tokyo, Japan.
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Akasaka T, Shibata T, Isoda H, Taura K, Arizono S, Shimada K, Togashi K. Septic complication after balloon-occluded retrograde transvenous obliteration of duodenal variceal bleeding. Cardiovasc Intervent Radiol 2009; 33:1257-61. [PMID: 19902296 DOI: 10.1007/s00270-009-9740-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Accepted: 10/12/2009] [Indexed: 11/28/2022]
Abstract
We report a 64-year-old woman with duodenal varices who underwent balloon-occluded retrograde transvenous obliteration (B-RTO) complicated by intraprocedural variceal rupture. The patient developed shivering and a fever higher than 40°C 3 days after the B-RTO procedure. A blood culture grew Entereobacter cloacoe. This case represents a rare septic complication of B-RTO for duodenal varices.
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Affiliation(s)
- Thai Akasaka
- Department of Radiology, Kyoto University Graduate School of Medicine, 54-Kawaharacho, Shogoin, Sakyoku, Kyoto 606-8507, Japan
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