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Lee EW, Eghtesad B, Garcia-Tsao G, Haskal ZJ, Hernandez-Gea V, Jalaeian H, Kalva SP, Mohanty A, Thabut D, Abraldes JG. AASLD Practice Guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage. Hepatology 2024; 79:224-250. [PMID: 37390489 DOI: 10.1097/hep.0000000000000530] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023]
Affiliation(s)
- Edward Wolfgang Lee
- Department of Radiology and Surgery, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Bijan Eghtesad
- Department of General Surgery, Digestive Disease and Surgery Institute Cleveland Clinic, Cleveland, Ohio, USA
| | - Guadalupe Garcia-Tsao
- Yale University School of Medicine, Department of Internal Medicine, Section of Digestive Diseases, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging/Interventional Radiology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Universitat de Barcelona (UB). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Hamed Jalaeian
- Department of Interventional Radiology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | | | - Arpan Mohanty
- Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Dominique Thabut
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'Hépato-gastroentérologie, Paris, France
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
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Shim J, Lee JM, Cho Y, Kim YS, Kim SG, Yoo JJ. Efficacy and Technical Feasibility of Plug-Assisted Retrograde Transvenous Obliteration of Gastric Varices via Pathways Other than the Gastrorenal Shunt. Cardiovasc Intervent Radiol 2023; 46:664-669. [PMID: 36997696 DOI: 10.1007/s00270-023-03416-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 03/06/2023] [Indexed: 05/04/2023]
Abstract
PURPOSE To evaluate the efficacy and technical feasibility of plug-assisted retrograde transvenous obliteration of gastric varices via pathways different from the typical gastrorenal shunt. MATERIALS AND METHODS We retrospectively reviewed the medical records of 130 patients who underwent plug-assisted retrograde transvenous obliteration for gastric varices between 2013 and 2022. Eight patients underwent plug-assisted retrograde transvenous obliteration via different pathways. We evaluated the types of portosystemic shunts in these patients, the procedure technical and clinical success rates, and clinical outcomes. RESULTS In these eight patients (6 males, 2 females; mean age = 60 ± 6 years), the most common type of portosystemic shunt was a gastrocaval shunt (n = 7). Five patients had a gastrocaval shunt only; two had coexisting gastrocaval and gastrorenal shunts. One patient had a pericardiacophrenic shunt without a gastrorenal or gastrocaval shunt. The mean procedure time was 55 min. For patients with a gastrocaval shunt alone (n = 5), the mean procedure time was 40.8 min. The technical and clinical success rates were 100%. No major complication related to the procedure occurred. An initial follow-up computed tomography was performed within 2-3 weeks in all patients and revealed complete thrombosis of the gastric varices. Subsequent follow-up computed tomography (interval: 2-6 months) was performed in seven patients and showed complete disappearance of the gastric varices in all patients. During the follow-up period (range: 42 days-6.25 years), no patients experienced rebleeding or recurrence of gastric varices. CONCLUSION Plug-assisted retrograde transvenous obliteration via alternative portosystemic shunts is effective and technically feasible in the treatment of gastric varices.
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Affiliation(s)
- Jongjoon Shim
- Department of Radiology, Soonchunhyang University College of Medicine, Soonchunhyang University Bucheon Hospital, 170, Jomaru-Ro, Bucheon-Si, Gyeonggi-do, 14584, Republic of Korea
| | - Jae Myeong Lee
- Department of Radiology, Soonchunhyang University College of Medicine, Soonchunhyang University Bucheon Hospital, 170, Jomaru-Ro, Bucheon-Si, Gyeonggi-do, 14584, Republic of Korea.
| | - Youngjong Cho
- Department of Radiology, Ulsan University College of Medicine, Gangneung Asan Hospital, Gangneung, Gangwon-do, Republic of Korea
| | - Young Seok Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Gyeonggi-do, Republic of Korea
| | - Sang Gyune Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Gyeonggi-do, Republic of Korea
| | - Jeong-Ju Yoo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Gyeonggi-do, Republic of Korea
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Mukund A, Choudhury SP, Tripathy TP, Ananthashayana VH, Jagdish RK, Arora V, Singh SP, Mishra AK, Sarin SK. Influence of shunt occlusion on liver volume and functions in hyperammonemic cirrhosis patients having large porto-systemic shunts: a randomized control trial. Hepatol Int 2023; 17:150-158. [PMID: 36094625 DOI: 10.1007/s12072-022-10418-4] [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: 06/18/2022] [Accepted: 08/24/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Spontaneous-portosystemic-shunts (SPSS) in cirrhosis deprive the liver of nutrient-rich portal blood and contribute to recurrent hepatic encephalopathy (HE). We evaluated the effects of shunt occlusion and redirecting portal blood to liver on its volume and functions. METHODS Cirrhosis patients presenting with recurrent HE and having SPSS were randomized to receive standard medical treatment (SMT) or shunt occlusion (SO). The later was performed by plug-assisted or balloon-occluded retrograde transvenous obliteration. The primary endpoint was change in liver volume after a minimum follow-up of 3 months. Secondary objectives included clinical course, liver disease severity indices, arterial ammonia levels and bone density. RESULTS Of 40 enrolled patients, 4 in SMT and 2 in SO group were lost to follow-up. The SO was complete in 17 and partial in one, achieving non-recurrence of HE in 17 (94.4%). In these patients, the mean liver volume increased (baseline 1040 ± 335 ml to 1132 ± 322 ml, 8.8% increase, p < 0.001) and was observed in 16/18 (88.89%) patients. In the SMT group, the liver volume decreased (baseline 988 ± 270 ml to 904 ± 226 ml, 8.6% reduction, p = 0.009) during the same period. Serum albumin increased in SO group (2.92 ± 0.40 g/dl to 3.30 ± 0.49 g/dl, p = 0.006) but reduced in SMT group (2.89 ± 0.43 g/dl to 2.59 ± 0.65 g/dl, p = 0.047). After SO, the patients showed a reduction in serum-ammonia levels (181.06 ± 86.21 to 107.28 ± 44.53 μ/dl, p = 0.001) and an improvement in MELD-Na and bone density compared to SMT group. There were no major adverse events following shunt occlusion. CONCLUSION Occlusion of large SPSS results in improving the volume and synthetic functions of the liver by restoring hepato-petal portal flow besides reducing serum-ammonia level and recurrence of HE. CLINICALTRIALS gov number, NCT03293459.
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Affiliation(s)
- Amar Mukund
- Department of Intervention Radiology, ILBS, New Delhi, India
| | - Shakti Prasad Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, ILBS, New Delhi, 110070, India
| | | | | | - Rakesh Kumar Jagdish
- Department of Hepatology, Institute of Liver and Biliary Sciences, ILBS, New Delhi, 110070, India
| | - Vinod Arora
- Department of Hepatology, Institute of Liver and Biliary Sciences, ILBS, New Delhi, 110070, India
| | - Satender Pal Singh
- Department of Hepatology, Institute of Liver and Biliary Sciences, ILBS, New Delhi, 110070, India
| | - Ajay Kumar Mishra
- Department of Hepatology, Institute of Liver and Biliary Sciences, ILBS, New Delhi, 110070, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, ILBS, New Delhi, 110070, India.
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Masood I, Moshksar A, Wong B, Khan H, Saleem A. A comprehensive review of transvenous obliteration techniques in the management of gastric varices. Diagn Interv Radiol 2023; 29:146-154. [PMID: 36960571 PMCID: PMC10679599 DOI: 10.5152/dir.2022.21193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 10/13/2021] [Indexed: 01/13/2023]
Abstract
Bleeding gastric varices (GVs) is a life-threatening complication of portal hypertension, with higher morbidity and mortality rates compared with bleeding esophageal varices (EVs). The endovascular techniques for the management of GVs are mainly transjugular intrahepatic portosystemic shunt (TIPS) and transvenous obliteration of the GVs. Transvenous obliteration techniques can be an alternative or an adjunct to TIPS for treatment of GVs, depending on the clinical scenario, and are less invasive than TIPS. However, these procedures are associated with increased portal pressure and related complications, mainly worsening of the EVs. In this article, the different techniques of transvenous obliteration of GVs, their indications, contraindications, and outcomes are discussed.
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Affiliation(s)
- Irfan Masood
- Department of Interventional Radiology, University of Texas Medical Branch, Texas, USA
| | - Amin Moshksar
- Department of Interventional Radiology, University of Texas Medical Branch, Texas, USA
| | - Brian Wong
- Department of Interventional Radiology, University of Texas Medical Branch, Texas, USA
| | - Hasan Khan
- Department of Interventional Radiology, University of Texas Medical Branch, Texas, USA
| | - Arsalan Saleem
- Department of Interventional Radiology, University of Texas Medical Branch, Texas, USA
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Lee HA, Kwak J, Cho SB, Lee YS, Jung YK, Kim JH, Kim SU, An H, Yim HJ, Yeon JE, Seo YS. Endoscopic variceal obturation and retrograde transvenous obliteration for acute gastric cardiofundal variceal bleeding in liver cirrhosis. BMC Gastroenterol 2022; 22:355. [PMID: 35883035 PMCID: PMC9317208 DOI: 10.1186/s12876-022-02428-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND/AIMS We retrospectively compared the effect of endoscopic variceal obturation (EVO) and retrograde transvenous obliteration (RTO) in acute cardiofundal variceal bleeding. METHODS Patients with acute cardiofundal variceal bleeding treated with EVO or RTO at two hospitals were included. RESULTS Ninety patients treated with EVO and 86 treated with RTO were analyzed. The mean model for end-stage liver disease score was significantly higher in EVO group than in RTO group (13.5 vs. 11.7, P = 0.016). The bleeding control rates were high (97.8% vs. 96.5%), and the treatment-related complication rates were low in both EVO and RTO groups (2.2% vs. 3.5%). During the median follow-up of 18.0 months, gastric variceal (GV) and esophageal variceal rebleeding occurred in 34 (19.3%) and 7 (4.0%) patients, respectively. The all-variceal rebleeding rates were comparable between EVO and RTO groups (32.4% vs. 20.8% at 2-year, P = 0.150), while the GV rebleeding rate was significantly higher in EVO group than in RTO group (32.4% vs. 12.8% at 2-year, P = 0.003). On propensity score-matched analysis (71 patients in EVO vs. 71 patients in RTO group), both all-variceal and GV rebleeding rates were significantly higher in EVO group than in RTO group (all P < 0.05). In Cox regression analysis, EVO (vs. RTO) was the only significant predictor of higher GV rebleeding risk (hazard ratio 3.132, P = 0.005). The mortality rates were similar between two groups (P = 0.597). CONCLUSIONS Both EVO and RTO effectively controlled acute cardiofundal variceal bleeding. RTO was superior to EVO in preventing all-variceal and GV rebleeding after treatment, with similar survival outcomes.
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Affiliation(s)
- Han Ah Lee
- Departments of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jungwon Kwak
- Department of Radiology, Korea University College of Medicine, Seoul, Korea
| | - Sung Bum Cho
- Department of Radiology, Korea University College of Medicine, Seoul, Korea
| | - Young-Sun Lee
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Young Kul Jung
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Ji Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea. .,Yonsei Liver Center, Severance Hospital, Seoul, Korea.
| | - Hyonggin An
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Hyung Joon Yim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jong Eun Yeon
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Yeon Seok Seo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.
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Le H, Thukral S, Devane AM, Saddekni S, Varma RK. Endovascular Management of Hepatic Encephalopathy. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2021. [DOI: 10.1055/s-0041-1730869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
AbstractTransjugular intrahepatic portosystemic shunt (TIPS) and spontaneous portosystemic shunts (SPSS) may lead to new or worsening hepatic encephalopathy (HE), especially in patients with chronic liver disease. Patients with medically refractory HE (rHE) may benefit from endovascular interventions. In this review, we briefly describe the post-TIPS and SPSS vascular anatomy, pathophysiology, classification, factors associated with HE, and the medical management of HE. In addition, we will discuss current endovascular techniques for HE management, their advantages, disadvantages, and review of the current literature.
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Affiliation(s)
- Hieu Le
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, United States
| | - Siddhant Thukral
- Department – School of Medicine, University of Missouri – Kansas City School of Medicine, Kansas City, Missouri, United States
| | - A. Michael Devane
- University of South Carolina School of Medicine Greenville, Prisma Health, Greenville, South Carolina, United States
| | - Souheil Saddekni
- Department of Radiology, Division of Interventional Radiology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, United States
| | - Rakesh K. Varma
- Department of Radiology, Division of Interventional Radiology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, United States
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Matsuo K, Lee SW, Tanaka R, Imai Y, Honda K, Yamamoto K, Uchiyama K. A successful case of varix of the left gastroepiploic vein preoperatively diagnosed by 3D-CT angiography and resected by laparoscopy: A case report. Medicine (Baltimore) 2021; 100:e25347. [PMID: 33879664 PMCID: PMC8078386 DOI: 10.1097/md.0000000000025347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/11/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Gastric varices can be present in up to 20% of patients with portal hypertension. However, a varix of the left gastroepiploic vein (LGV) is extremely rare. Surgery is required if bleeding occurs; thus, precise diagnosis is crucial. We present a successful case of preoperative diagnosis intraabdominal varix of the LGV using three-dimensional-computed tomography angiography (3D-CTA) followed by laparoscopic resection. This is the first report of a case with variant LGV. Our study demonstrates the efficacies of 3D-CTA and laparoscopic surgery for the diagnosis and safe resection of the intraabdominal varix, respectively. PATIENT CONCERNS A 74-year-old woman was referred to our department with a tumor in the abdominal cavity. On physical examination, no lumps were palpable in the upper abdomen. DIAGNOSIS The enhanced CT was revealed that the tumor was not enhanced in the early phase, but in the equilibrium phase. Moreover, 3D-CTA clearly revealed that the tumor was being supplied by the LGV. Thus, it was diagnosed as a variant of the LGV. INTERVENTIONS Surgical resection was performed laparoscopically as per the guidance of preoperative 3D-CTA findings. During surgery, a dark tumor was found along the gastroepiploic vessels, supplied by the LGV. The tumor was resected safely based on the preoperative information. OUTCOMES Histopathological examination of the tumor showed accumulation of various vessels, but no malignant cells. Therefore, we made a final diagnosis of the tumor as an LGV varix. For follow-up, an annual CT examination was performed and after 3 years postoperation, no recurrence was observed. CONCLUSIONS In the present case, we have achieved a successful preoperative diagnosis using 3D-CTA, and resection was safely accomplished using laparoscopy guided by preoperative anatomical information. This is the first report of an LGV variant. Appropriate management is crucial because bleeding is a catastrophic event. Therefore, imaging procedures such as 3D-CTA for diagnosis, followed by safe resection by laparoscopic surgery, are effective tools for the treatment of epiploic vein varices.
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Affiliation(s)
| | | | - Ryo Tanaka
- Department of General and Gastroenterological Surgery
| | - Yoshiro Imai
- Department of General and Gastroenterological Surgery
| | - Kotaro Honda
- Department of General and Gastroenterological Surgery
| | - Kazuhiro Yamamoto
- Department of Diagnostic Radiology, Osaka Medical College, 2-7, Daigaku-machi, Takatsuki, Osaka, Japan
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Ierardi AM, Carnevale A, Tosetti G, D'Amico M, Giganti M, Mura VL, Bonelli C, Renzulli M, Lampertico P, Primignani M, Carrafiello G. Combined approach for embolization of otherwise unmanageable gastric varices. Ann Gastroenterol 2021; 34:510-515. [PMID: 34276189 PMCID: PMC8276367 DOI: 10.20524/aog.2021.0616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/28/2021] [Indexed: 11/24/2022] Open
Abstract
Background This study aimed to determine the feasibility, safety and effectiveness of
combined percutaneous transhepatic obliteration (PTO) and balloon-occluded
retrograde transvenous obliteration (BRTO) therapy for the treatment of
patients with high-risk bleeding gastric varices. Methods Ten patients were retrospectively reviewed. All the patients presented
gastric varices, according to the Sarin classification, at high risk of
bleeding, and not otherwise manageable. Patients with portal vein thrombosis
were excluded. All patients were treated with a combination of PTO and BRTO.
In all cases the gastric varices were embolized with glue, combined with
coils or not, with an occlusion balloon inflated into the shunt. In 7 cases,
embolization was immediate; in the remaining 3 the balloon remained inflated
for 4 h and in 2 of them embolization of the shunt was required. Technical
success was defined as complete obliteration of the gastric varices observed
during a contrast-enhanced computed tomography study and endoscopy within 1
month following treatment. Clinical success was defined as absence of
bleeding of gastric varices during the follow-up period. Major and minor
complications during the follow up were recorded. Results Twelve sessions of combined PTO and BRTO procedures were performed in 10
patients; in 2 patients a new combined treatment was required during the
follow up. Technical and clinical success was 100%. Neither major nor
minor procedure-related complications were observed. Conclusion Combined PTO and BRTO therapy is safe and effective for the treatment of
gastric varices that cannot be managed otherwise.
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Affiliation(s)
- Anna Maria Ierardi
- Radiology Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan (Anna Maria Ierardi, Gianpaolo Carrafiello)
| | - Aldo Carnevale
- Radiology Department, University Radiology Unit, Sant'Anna University Hospital, Ferrara (Aldo Carnevale)
| | - Giulia Tosetti
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan (Giulia Tosetti, Massimo Primignani)
| | - Mario D'Amico
- UOC Radiodiagnostica; Ospedali Riuniti Villa Sofia-Cervello, Palermo (Mario D'Amico)
| | - Melchiore Giganti
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara (Melchiore Giganti)
| | - Vincenzo La Mura
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, U.O.C. Medicina Generale Emostasi e Trombosi, University of Milan (Vincenzo La Mura)
| | - Cristian Bonelli
- Healthcare Professionals Department, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan (Cristian Bonelli)
| | - Matteo Renzulli
- Radiology Unit, Department of Experimental, Diagnostic and Speciality Medicine, Sant'Orsola Hospital, University of Bologna (Matteo Renzulli)
| | - Pietro Lampertico
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan (Giulia Tosetti, Massimo Primignani).,Department of Pathophysiology and Transplantation, University of Milan, Milano, Lombardia (Pietro Lampertico)
| | - Massimo Primignani
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan (Giulia Tosetti, Massimo Primignani)
| | - Gianpaolo Carrafiello
- Radiology Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan (Anna Maria Ierardi, Gianpaolo Carrafiello).,Department of Health Sciences, Università degli Studi di Milano, Milan (Gianpaolo Carrafiello), Italy
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Mukund A, Anandpara KM, Ramalingam R, Choudhury A, Sarin SK. Plug-Assisted Retrograde Transvenous Obliteration (PARTO): Anatomical Factors Determining Procedure Outcome. Cardiovasc Intervent Radiol 2020; 43:1548-1556. [PMID: 32676958 DOI: 10.1007/s00270-020-02580-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/26/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE To study various anatomical factors determining procedure success versus failure for plug-assisted retrograde transvenous obliteration (PARTO) of gastro-lieno-renal shunt. MATERIALS AND METHODS A retrospective review of 50 patients (M:F-37:13; mean age 58.4yrs) who were planned for PARTO of gastro-lieno-renal shunt from July 2017 to July 2019 was done. Anatomical factors [shunt diameter, shunt angle, shunt orientation, left renal vein (LRV) size/calibre and distance of shunt from renal vein-IVC confluence] were analysed on a pre-procedure CT. Statistical analysis of the data was done to assess the relationship between these factors and technical success/failure. RESULTS PARTO was successfully performed in 82% (n = 41). Analysis of anatomical factors showed that aneurysmal dilatation of the LRV, extreme acute/obtuse angulation and extreme antero-posterior orientation of the shunt in relation to the LRV was associated with higher probability of technical failure of PARTO. Minimum/maximum and entry point shunt diameter was not associated with procedure outcome. It was also noted that an increased distance of the shunt from the renal vein-IVC confluence favoured trans-jugular over trans-femoral venous access for PARTO. CONCLUSION Knowledge of various anatomical factors of gastro-lieno-renal shunt may help in deciding the access route for PARTO and may determine technical success/failure. Alternate methods like BRTO or coil-assisted obliteration (CARTO) or anterograde obliteration of the shunt via trans-hepatic/splenic route might be needed in such circumstances.
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Affiliation(s)
- Amar Mukund
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India.
| | - Karan Manoj Anandpara
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India
| | - Ravindran Ramalingam
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, , New Delhi, 110070, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, , New Delhi, 110070, India
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10
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Lee EW, Shahrouki P, Alanis L, Ding P, Kee ST. Management Options for Gastric Variceal Hemorrhage. JAMA Surg 2020; 154:540-548. [PMID: 30942880 DOI: 10.1001/jamasurg.2019.0407] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Edward Wolfgang Lee
- Division of Interventional Radiology, Department of Radiology, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles.,Division of Liver and Pancreas Transplantation, Department of Surgery, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles
| | - Puja Shahrouki
- Division of Interventional Radiology, Department of Radiology, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles
| | - Lourdes Alanis
- Division of Interventional Radiology, Department of Radiology, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles
| | - Pengxu Ding
- Division of Interventional Radiology, Department of Radiology, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles
| | - Stephen T Kee
- Division of Interventional Radiology, Department of Radiology, University of California at Los Angeles Medical Center, David Geffen School of Medicine at University of California, Los Angeles
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11
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Combined Balloon-, Plug- and Coil-assisted Retrograde Transvenous Obliteration of Multiple Portosystemic Shunts to Treat Recurrent Hepatic Encephalopathy: A Case Report. J Clin Exp Hepatol 2020; 10:402-406. [PMID: 32655241 PMCID: PMC7335714 DOI: 10.1016/j.jceh.2019.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/16/2019] [Indexed: 12/12/2022] Open
Abstract
Balloon- or plug-assisted retrograde transvenous obliteration of portosystemic shunts is an effective endovascular technique for the treatment of type B bypass hepatic encephalopathy. We describe a patient who underwent balloon- and plug-assisted obliteration for a lienorenal and lienogonadal shunt, respectively. He returned with symptoms of recurrent hepatic encephalopathy two years later due to reformation of new lienorenal and lienogonadal shunts. Repeat obliteration of these new shunts was now performed using balloon and coil assistance. We describe the treatment for multiple portosystemic shunts with combined usage of vascular plug, balloon and coils depending on anatomical and technically factors. Our case also highlights that after shunt obliteration increased portal pressure may form new portosystemic collateral pathways which leads to clinical failure and may require repeat treatment.
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12
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Abstract
Portal hypertension, a consequence of end-stage liver disease and liver cirrhosis can lead to significant morbidity and mortality for patients through abnormal fluid accumulation as well as the formation of portosystemic shunts and varices. Treatment of the sequelae of portal hypertension can be achieved through endovascular management by referral to an interventional radiologist on an outpatient or emergent basis as required. Current techniques include the placement of peritoneovenous shunts and tunneled peritoneal drains, the creation of transjugular intrahepatic portosystemic shunts, or the obliteration of shunts via balloon-occluded retrograde transvenous obliteration (BRTO). In addition, newer procedural techniques utilizing vascular plugs and coils have reduced risks of the traditional BRTO procedure. Modified-BRTO procedures, known as plug-assisted and coil-assisted retrograde transvenous obliteration (PARTO and CARTO, respectively) have become the standard of care at many institutions for the treatment of gastric varices and portosystemic shunt-induced hepatic encephalopathy. This review examines the most recent literature of the management of portal hypertension by interventional radiologists, evaluating treatment options as well as the clinical and technical outcomes of TIPS, peritoneovenous shunts, tunneled peritoneal drains, BRTOs, and modified-BRTOs as well as future directions in the development of procedural techniques.
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13
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Philips CA, Rajesh S, Augustine P, Padsalgi G, Ahamed R. Portosystemic shunts and refractory hepatic encephalopathy: patient selection and current options. Hepat Med 2019; 11:23-34. [PMID: 30774483 PMCID: PMC6355170 DOI: 10.2147/hmer.s169024] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Portosystemic shunt (PS) syndrome encompasses a spectrum of disease manifestations ranging from asymptomatic portal hypertension to recurrent and refractory hepatic encephalopathy, ultimately culminating in progressive hepatic failure in patients of cirrhosis and associated large PSs. PSs commonly seen in cirrhosis include splenorenal, gastrorenal, and dilated paraumbilical veins, all of which can present with recurrent or refractory hepatic encephalopathy. In this exhaustive review, we describe the anatomy of PSs, elucidate new theories on their pathophysiology, discuss the clinical implications of PSs in cirrhosis, provide details on different techniques (classical and novel) of shunt embolization, and explore all the pertinent current literature on shunt embolization for refractory and recurrent hepatic encephalopathy, all of which are enumerated with extensive images and illustrations.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Cochin, Kerala, India,
| | - Sasidharan Rajesh
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Cochin, Kerala, India,
| | - Philip Augustine
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Cochin, Kerala, India,
| | - Guruprasad Padsalgi
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Cochin, Kerala, India,
| | - Rizwan Ahamed
- The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Cochin, Kerala, India,
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14
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Response to Yang et al. Am J Gastroenterol 2018; 113:1902-1903. [PMID: 30361624 PMCID: PMC6768581 DOI: 10.1038/s41395-018-0385-0] [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: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 12/11/2022]
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15
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Patel M, Molvar C. Evolution of Retrograde Transvenous Obliteration Techniques. Semin Intervent Radiol 2018; 35:185-193. [PMID: 30087521 DOI: 10.1055/s-0038-1660796] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Gastric variceal hemorrhage is a life-threatening complication of portal hypertension with a poorer prognosis compared with esophageal variceal hemorrhage. The presence of an infradiaphragmatic portosystemic shunt, often a gastrorenal shunt, allows for treatment with retrograde transvenous obliteration (RTO). RTO is an evolving treatment strategy, which includes balloon-assisted RTO, plug-assisted RTO, and coil-assisted RTO, for both gastric variceal hemorrhage and hepatic encephalopathy. RTO techniques are less invasive than transjugular intrahepatic portosystemic shunt creation, with the benefit of improved hepatic function, but at the expense of increased portal pressure. This article discusses the techniques of RTO, including patient eligibility, as well as technical and clinical outcomes, including adverse events.
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Affiliation(s)
- Mihir Patel
- Department of Interventional Radiology, Loyola University Medical Center, Maywood, Illinois
| | - Christopher Molvar
- Department of Interventional Radiology, Loyola University Medical Center, Maywood, Illinois
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16
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Gwon DI, Ko GY, Kwon YB, Yoon HK, Sung KB. Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Varices: The Role of Intra-Procedural Cone-Beam Computed Tomography. Korean J Radiol 2018. [PMID: 29520179 PMCID: PMC5840050 DOI: 10.3348/kjr.2018.19.2.223] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Objective To investigate the technical and clinical outcomes of plug-assisted retrograde transvenous obliteration (PARTO) for the treatment of gastric varices (GV) and to evaluate the role of intra-procedural cone-beam computed tomography (CBCT) performed during PARTO to confirm its technical success. Materials and Methods From January 2016 to December 2016, 17 patients with GV who had undergone PARTO were retrospectively evaluated. When the proximal part of the afferent vein was identified on a fluoroscopy, non-contrast CBCT images were obtained. In patients with incomplete embolization of GV, an additional injection of gelatin sponges was performed. Follow-up data from contrast-enhanced CT and upper intestinal endoscopy, as well as clinical and laboratory data were collected. Results Plug-assisted retrograde transvenous obliteration procedures were technically successful in all 17 patients. Complete embolization of GV was detected on CBCT images in 15 patients; whereas, incomplete embolization was detected in two. Complete embolization of GV was then achieved after an additional injection of gelatin sponges in these two patients as demonstrated on the 2nd CBCT image. The mean follow-up period after PARTO was 193 days (range, 73–383 days). A follow-up CT obtained 2–4 months after PARTO demonstrated marked shrinkage or complete obliteration of GV and portosystemic shunts in all 17 patients. There were no cases of variceal bleeding during the follow-up. Conclusion Plug-assisted retrograde transvenous obliteration is technically and clinically effective for the treatment of GV. In addition, intra-procedural CBCT can be an adjunct tool to fluoroscopy, because it can provide an immediate and accurate evaluation of the technical success of PARTO.
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Affiliation(s)
- Dong Il Gwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Gi-Young Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Young Baek Kwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Hyun-Ki Yoon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Kyu-Bo Sung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
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17
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Kim DJ, Darcy MD, Mani NB, Park AW, Akinwande O, Ramaswamy RS, Kim SK. Modified Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) Techniques for the Treatment of Gastric Varices: Vascular Plug-Assisted Retrograde Transvenous Obliteration (PARTO)/Coil-Assisted Retrograde Transvenous Obliteration (CARTO)/Balloon-Occluded Antegrade Transvenous Obliteration (BATO). Cardiovasc Intervent Radiol 2018; 41:835-847. [PMID: 29417267 DOI: 10.1007/s00270-018-1896-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 01/31/2018] [Indexed: 01/25/2023]
Abstract
Gastric varices in the setting of portal hypertension occur less frequently than esophageal varices but occur at lower portal pressures and are associated with more massive bleeding events and higher mortality rate. Balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices has been well documented as an effective therapy for portal hypertensive gastric varices. However, BRTO requires lengthy, higher-level post-procedural monitoring and can have complications related to balloon rupture and adverse effects of sclerosing agents. Several modified BRTO techniques have been developed including vascular plug-assisted retrograde transvenous obliteration, coil-assisted retrograde transvenous obliteration, and balloon-occluded antegrade transvenous obliteration. This article provides an overview of various modified BRTO techniques.
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Affiliation(s)
- David J Kim
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, 510 S Kingshighway Boulevard, Campus Box 8131, St. Louis, MO, 63110, USA
| | - Michael D Darcy
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, 510 S Kingshighway Boulevard, Campus Box 8131, St. Louis, MO, 63110, USA
| | - Naganathan B Mani
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, 510 S Kingshighway Boulevard, Campus Box 8131, St. Louis, MO, 63110, USA
| | - Auh Whan Park
- Interventional Radiology, University of Virginia Hospital, Charlottesville, VA, USA
| | - Olaguoke Akinwande
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, 510 S Kingshighway Boulevard, Campus Box 8131, St. Louis, MO, 63110, USA
| | - Raja S Ramaswamy
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, 510 S Kingshighway Boulevard, Campus Box 8131, St. Louis, MO, 63110, USA
| | - Seung Kwon Kim
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, 510 S Kingshighway Boulevard, Campus Box 8131, St. Louis, MO, 63110, USA.
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