Disseminated intravascular coagulation (DIC) after endoscopic injection sclerotherapy with ethanolamine oleate

Utility of low-dose gelatin sponge particles and 5% ethanolamine oleate iopamidol mixture in retrograde transvenous obliteration (GERTO) for gastric varices

OBJECTIVE

To determine the utility of low-dose gelatin sponge particles and 5% ethanolamine oleate iopamidol (EOI) mixture in retrograde transvenous obliteration (GERTO) for gastric varices (GV).

METHODS

57 consecutive patients who underwent balloon-occluded retrograde transvenous obliteration (B-RTO) for GV were divided into three groups with Hirota's grade by balloon-occluded retrograde transvenous venography. Hirota's Grade 1 patients were assigned to G1 group and underwent treatment with 5% EOI. Grade ≥ 2 patients prior to August 2015 were G ≥ 2 group treated with 5% EOI, and those treated thereafter were GERTO group. The amount of EOI used per unit GV volume (EOI/GV ratio), the times to embolization and recurrence rate of GV were evaluated.

RESULTS

The EOI/GV ratio was 0.66 ± 0.19 in G1, 1.5 ± 0.8 in G ≥ 2, and 0.58 ± 0.23 in GERTO (G ≥ 2 vs GERTO, p < 0.0001). The times to embolization were 26.5 ± 10.5 min for G1, 39.2 ± 26.8 for G ≥ 2, and 21.4 ± 9.4 for GERTO (G ≥ 2 vs GERTO, p = 0.005). The recurrence rate was not significantly different in any of the groups.

CONCLUSION

GERTO was performed in lower amount of sclerosants and in less time compared to conventional B-RTO in Hirota's grade ≥2.

ADVANCES IN KNOWLEDGE

Feasibility of low-dose gelatin sponge particles and 5% EOI mixture as sclerosants for GV.

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.

Prevention and management of gastroesophageal varices

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

Balloon-occluded retrograde transvenous obliteration of varices: focusing on the portal hemodynamics and the recent techniques

PURPOSE

To evaluate the recent topics of Ballloon-occluded retrograde trasnvenous obliteration(B-RTO).

METHOD

We overviewed the recent scientific papers regarding B-RTO.

RESULT

B-RTO is a treatment method for occluding varices retrogradely using a sclerosing agent under balloon occlusion of a major draining vein. It has been recognized as an effective treatment method for gastric varices. Hepatic function reserve is improved and liver volume is increased after B-RTO. In recent years, various technical options, such as plug-assisted retrograde transvenous obliteration, coil-assisted retrograde transvenous obliteration, or foam B-RTO, have also been reported. In performing B-RTO, portal hemodynamics must be thoroughly examined radiologically. Judging the classification of the grade of collateral venous hemodynamics is important to select the appropriate embolization technique of B-RTO and to successfully occlude varices. Finally, the word "portosystemic shunt syndrome" has been proposed and the condition should be considered while selecting a treatment for gastric varices.

CONCLUSION

B-RTO is effective for gastrointestinal varices and portosystemic shunts.

Vascular Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Varices and Hepatic Encephalopathy: A Prospective Multicenter Study

PURPOSE

To evaluate technical and clinical outcomes of vascular plug-assisted retrograde transvenous obliteration (PARTO) for the treatment of gastric varices (GVs) and hepatic encephalopathy (HE).

MATERIALS AND METHODS

From March 2012 to June 2014, 73 consecutive patients (47 men, 26 women; mean age, 59 y; range, 28-79 y) who had undergone PARTO were evaluated in a prospective multicenter study. Among 57 patients with GVs, 28 had GVs in danger of rupture, 23 had experienced recent bleeding, and 6 had active variceal bleeding. The 16 patients with HE had been treated unsuccessfully with medical therapies.

RESULTS

Placement of the vascular plug and subsequent gelatin sponge embolization were technically successful in all 73 patients. There were no procedure-related complications. Follow-up CT obtained within 1 wk after PARTO showed complete thrombosis of GVs and portosystemic shunts in 72 of 73 patients (98.6%). Sixty patients who underwent follow-up longer than 3 mo showed complete obliteration of GVs and portosystemic shunts. There were no cases of variceal bleeding or HE at the end of follow-up (mean, 544 d). Improvement in Child-Pugh score was observed in 24 patients (40%) at 1-mo follow-up. Worsening of ascites and esophageal varices was observed in 14 (23.3%) and 16 (26.7%) patients at 3-mo follow-up.

CONCLUSIONS

The present results of PARTO indicate that it can be rapidly performed with high technical success and durable clinical efficacy for the treatment of GVs and HE in the presence of a portosystemic shunt. Therefore, PARTO might be considered a first-line treatment in appropriate patients.

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.

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.

Ethanolamine oleate sclerotherapy combined with transarterial embolization using n-butyl cyanoacrylate for extracranial arteriovenous malformations

PURPOSE

This study was designed to assess the safety and effectiveness of ethanolamine oleate (EO) sclerotherapy combined with transarterial embolization using a liquid adhesive agent (n-butyl cyanoacrylate, NBCA) for treatment of extracranial arteriovenous malformations (AVMs).

METHODS

Twenty-four patients with symptomatic AVMs in the head and neck (n = 15), extremity (n = 5), and trunk (n = 4) with a mean age of 44 years (range, 18-78) treated with EO sclerotherapy were retrospectively assessed. AVMs were classified according to the angiographic morphology of the nidus. There were 7 type II (arteriolovenous fistulae), 6 type IIIa (arteriolovenulous fistulae with nondilated fistula), and 11 type IIIb (arteriolovenulous fistulae with dilated fistula). Transarterial embolization using NBCA was performed to reduce arterial flow before sclerotherapy. EO mixed with contrast material was delivered by percutaneous direct puncture or by catheterization into the draining vein under balloon occlusion.

RESULTS

Three (13%) of 24 patients were cured, 17 (71%) had partial remission, and 4 (16%) no remission. Treatment was considered effective (cure and partial remission) in 20 patients (83%). Four patients (16%) experienced transient minor complications, including self-healing skin ulcer (n = 3) and localized deep venous thrombosis (n = 1). There were no major complications.

CONCLUSIONS

EO sclerotherapy combined with transarterial embolization using NBCA is safe and effective for treating extracranial AVMs with an acceptable risk of minor complications.

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

Objective

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

Materials and Methods

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

Results

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

Conclusion

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

Balloon-occluded retrograde transvenous obliteration of gastric varices: outcomes and complications in 49 patients. AJR Am J Roentgenol. 2007;189:W365-W372. [PMID: 18029851 DOI: 10.2214/ajr.07.2266]

OBJECTIVE

Our aim was to evaluate the clinical outcomes, techniques, and complications of balloon-occluded retrograde transvenous obliteration for treating gastric varices with spontaneous gastrosystemic shunts.

MATERIALS AND METHODS

From November 2002 through October 2005, 49 consecutive patients with gastric varices were treated by balloon-occluded retrograde transvenous obliteration. The sclerosant was injected through the outflow veins during balloon occlusion. Immediate postprocedural CT scans were obtained to evaluate the procedural details. Recurrence and rebleeding of gastric varices and worsening of esophageal varices were evaluated by endoscopic examination and CT. The survival rates and prognostic factors after the procedure were also assessed.

RESULTS

There were six procedural failures and two procedure-related deaths. Disappearance or marked shrinkage of the treated gastric varices with no recurrent gastric variceal bleeding was noted in 39 patients (79.6% clinical success rate). Approximately two thirds of our patients experienced worsening of esophageal varices during the median follow-up period of 457 days. The cumulative survival rates at 1 year and 3 years after balloon-occluded retrograde transvenous obliteration were 83.1% and 65.7%, respectively. The prognostic factors associated with survival were the preprocedural Child-Pugh classification and the total bilirubin level. The survival rates and procedural outcomes for the patients with severely compromised liver function were poor.

CONCLUSION

Balloon-occluded retrograde transvenous obliteration is an effective treatment for the obliteration of gastric varices. However, application of this procedure to severely compromised patients should be considered carefully.

Ruptured high flow gastric varices with an intratumoral arterioportal shunt treated with balloon-occluded retrograde transvenous obliteration during temporary balloon occlusion of a hepatic artery

A patient presented with hematemesis due to gastric variceal bleeding with an intratumoral arterioportal shunt. Contrast-enhanced CT revealed gastric varices and hepatocellular carcinoma with tumor thrombi in the right portal vein. Angiography and angio-CT revealed a marked intratumoral arterioportal shunt accompanied with reflux into the main portal vein and gastric varices. Balloon-occluded retrograde venography from the gastro-renal shunt showed no visualization of gastric varices due to rapid blood flow through the intratumoral arterioportal shunt. The hepatic artery was temporarily occluded with a balloon catheter to reduce the blood flow through the arterioportal shunt, and then concurrent balloon-occluded retrograde transvenous obliteration (BRTO) was achieved. Vital signs stabilized immediately thereafter, and contrast-enhanced CT revealed thrombosed gastric varices. Worsening of hepatic function was not recognized. BRTO combined with temporary occlusion of the hepatic artery is a feasible interventional procedure for ruptured high flow gastric varices with an intratumoral arterioportal shunt.

Spontaneous regression of gastric varices after iatrogenic injury to a gastrorenal shunt

We present a patient with gastric varices complicating portal hypertension caused by liver cirrhosis related to hepatitis C virus. The patient underwent balloon-occluded retrograde transvenous obliteration. The gastric varices almost completely disappeared, without any sclerotic agent being used, after iatrogenic injury of the gastrorenal shunt at the time of the interventional procedure.

TIPS-related hepatic encephalopathy: management options with novel endovascular techniques

Hepatic encephalopathy is a common complication that develops after creation of a transjugular intrahepatic portosystemic shunt (TIPS). Although most patients respond well to conservative medical therapy (ie, protein-restricted diet, nonabsorbable disaccharides, nonabsorbable antibiotics), a small percentage of patients (3%-7%) do not benefit from these methods and require more invasive therapeutic approaches. One option is emergent liver transplantation, but the majority of patients are not suitable candidates. Recently, various percutaneous techniques have been described that alter the hemodynamics through the shunt by occluding it with coils or balloons or by reducing its diameter by inserting constrained stents or stent-grafts. Other techniques have been used for patients with TIPS-related hepatic encephalopathy in whom spontaneous splenorenal shunts are present. In many patients with refractory hepatic encephalopathy, these percutaneous techniques have produced symptomatic improvement, with either a complete resolution or a substantial reduction in hepatic encephalopathy symptoms that can be controlled with medical therapy. Unfortunately, despite all attempts, some patients remain incapacitated and ultimately die. Further research is necessary to improve our understanding of TIPS-related hepatic encephalopathy so that newer, less invasive and safer procedures can be developed to treat this difficult clinical problem.

Transcatheter obliteration of gastric varices. Part 1. Anatomic classification

Since its introduction in the mid-1990s, balloon-occluded retrograde transvenous obliteration (BRTO) has become widely accepted in Japan as a minimally invasive, highly effective treatment for gastric varices. Sufficient filling and stagnation of the sclerosing agent in the entire variceal complex is essential for successful BRTO of gastric varices. However, the success of BRTO in this context also requires familiarity with the hemodynamic features of the varices, including the patterns of their afferent and draining veins, which affect the degree of difficulty in performing BRTO. Thus, accurate assessment of the hemodynamic pattern before and during each procedure is essential for successful treatment. Sixty cases of gastric varices that were successfully treated with transcatheter techniques over the past 5 years were reviewed and analyzed. From this study, a classification system for gastric varices was developed that is based on the hemodynamic pattern of the varices.

Balloon-occluded retrograde transvenous obliteration of gastric fundal varices with hemorrhage

OBJECTIVE

This study was performed to evaluate the clinical efficacy, feasibility, and complications of balloon-occluded retrograde transvenous obliteration for patients with hemorrhage from gastric fundal varices.

SUBJECTS AND METHODS

Between December 1994 and February 2001, 24 consecutive patients with hemorrhage from gastric fundal varices were enrolled in this study. Balloon-occluded retrograde transvenous obliteration consisted of injecting 5% ethanolamine oleate iopamidol through the outflow vessels during balloon occlusion. The treatment was performed during acute bleeding in 11 patients and electively in 13 patients. Among those patients with acute bleeding, six were treated for temporary hemostasis with balloon tamponade, and five were treated endoscopically.

RESULTS

Cannulation into the outflow vessels was performed in 23 patients, but the balloon catheter could not be inserted in one patient who had inferior phrenic vein outflow. Complete success was obtained in 88% (21/24) of patients, and partial success was obtained in two patients. In nine of 11 patients with acute bleeding, complete success was achieved. Rebleeding from gastric varices was not observed in patients treated with complete success, whereas two patients treated partially rebled within 1 week of the treatment (rate of rebleeding, 9%). Eradication of gastric varices was obtained in all patients (n = 19) who were examined by endoscopy 3 months after the treatment. Eight patients experienced worsening of esophageal varices. These patients were treated endoscopically because of findings that suggested a risk of hemorrhage. The overall mortality rate was 4% (1/24). No damage to the kidney was observed, although 11 patients had macrohematuria.

CONCLUSION

Balloon-occluded retrograde transvenous obliteration followed by any hemostatic procedure might be effective for both prophylaxis of rebleeding and eradication of gastric fundal varices, even in urgent cases.

Management of gastrointestinal bleeding induced by gastrointestinal endoscopy

Therapeutic gastrointestinal endoscopy has a much greater risk of inducing gastrointestinal hemorrhage than diagnostic endoscopy. For example, colonoscopic polypectomy has a risk of approximately 1.6% of inducing bleeding, compared with a risk of approximately 0.02% for diagnostic colonoscopy. Higher-risk procedures include colonoscopic polypectomy, endoscopic biliary sphincterotomy, endoscopic dilatation, endoscopic variceal therapy, percutaneous endoscopic gastrostomy, and endoscopic sharp foreign body retrieval. The risk of inducing hemorrhage is decreased by meticulous endoscopic technique. Hemorrhage from endoscopy may be immediate or delayed. Immediate hemorrhage should be immediately treated by endoscopic hemostatic therapy, including injection therapy, thermocoagulation, or electrocoagulation. Delayed hemorrhage generally requires repeat endoscopy for diagnosis and for therapy, using the same hemostatic techniques.

Retrograde transvenous obliteration of gastric varices

PURPOSE

To evaluate the clinical efficacy, techniques, and complications associated with balloon-occluded retrograde transvenous obliteration of gastric varices.

MATERIALS AND METHODS

Between December 1994 and November 1997, balloon-occluded retrograde transvenous obliteration was performed on 20 patients with gastric varices in danger of rupture and with gastrorenal shunts; three patients also had hepatic encephalopathy. The sclerosant was injected into the gastric varices during balloon occlusion. The degree of progression of the gastric varices and of collateral veins was classified into five grades, with grade 1 being least progression and grade 5 most progression; collateral veins that had developed were treated with embolization. Follow-up consisted of fiberoptic endoscopy and computed tomography.

RESULTS

Technical success was achieved in all patients. Occlusion of collateral veins was essential for the occlusion of gastric varices with a grade greater than grade 2. The clinical symptoms of hepatic encephalopathy in the three patients improved remarkably. Follow-up endoscopy 3 months after the procedure revealed the disappearance of gastric varices in 15 patients and reduced variceal size in five. During the follow-up period, 19 patients had no recurrence of gastric varices; three patients had aggravation of the esophageal varices.

CONCLUSION

Balloon-occluded retrograde transvenous obliteration is a feasible alternative to a transjugular intrahepatic portosystemic shunt for patients with large gastrorenal shunts or hepatic encephalopathy (or both).