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[Gvataken]

balloon retrograde transcatheter venous occlusion:

http://radiology.casereports.net/index.php/rcr/article/viewArticle/290/607

This is an innovative way to take care of isolated gastric varices, especially in patients who are not candidates for TIPS.

It scleroses the gastric varices without side effects of hepatic encephalopathy

There has been a growing utliization of this novel technique.

Go in from the femoral vein into the left renal vein and then through the portosystemic shunts into the gastric varices. You inflate an occlusion balloon and then administer a mixture of air, sclerosant, and ethiodol . Let the balloon sit for 4 hours and then deflate it and these patients have their gastric varices blocked and reduce their risk of bleeding from their variceal bleed.

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[Lacuna]

Dr. Vataken,

Is this being used for acute variceal bleed? Doesn't the sclerosant enter the systemic circulation after deflating the balloon?

 

[Gvataken]

Great question. You leave it occluded for 4 hours. The sclerosant tends to damage the endothelium and then you check under fluoroscopy and see if the contrast impregnated sclerosant is sitting or moving as you deflate the balloon under real time imaging.

 

[IRGuru]

balloon retrograde transcatheter venous occlusion:

http://radiology.casereports.net/index.php/rcr/article/viewArticle/290/607

This is an innovative way to take care of isolated gastric varices, especially in patients who are not candidates for TIPS.

It scleroses the gastric varices without side effects of hepatic encephalopathy

There has been a growing utliization of this novel technique.

Go in from the femoral vein into the left renal vein and then through the portosystemic shunts into the gastric varices. You inflate an occlusion balloon and then administer a mixture of air, sclerosant, and ethiodol . Let the balloon sit for 4 hours and then deflate it and these patients have their gastric varices blocked and reduce their risk of bleeding from their variceal bleed.

That's a pretty interesting article. A few questions...I'm assuming when they say it's for pts for whom TIPS is prohibitive, this primarily means a MELD > 18? Any other patients?

Has this technique been used to treat esophageal varices electively or in case of an acute bleed?

Additionally, since you're essentially closing off collaterals, you'd be increasing portal pressure thus potentially creating new porto-systemic shunts which they alluded to by addressing the complication of new esophageal varices. Would you follow these patients in clinic for ex. to look for these complications or evaluate a return to refractory status as new collaterals open up and then consider closing those etc.

Finally, I wonder if the algorithm for this treatment will eventually change with respect to its relationship with a TIPS procedure. I mean, could this potentially be first choice prior to doing a TIPS since with the latter, you're essentially creating a new porto-systemic shunt. Another potential scenario being doing this procedure to improve a pt's MELD score to make them eligible for a TIPS (closing porto-systemic shunts elsewhere would allow the patient to tolerate a porto-systemic shunt in the liver without developing encephalopathy)

 

[Gvataken]

All great questions.

So, this is often done in patients who are not ideal TIPS candidates. Sky high bilirubins, refractory encephalopathy, tons of liver tumor or cysts etc.

These patients should get EGD follow up to look for new esophageal varices.

Not usually done for esophageal varices. Endoscopists are really good with sclerosant and banding . They are not as aggressive about banding, sclerosing gastric varices. Some endoscopists will inject glue into the gastric varices.

There is some controversy if a patient is a TIPS candidate whether BRTO should be offered initially.

 

[Gvataken]

So, I assisted on my first BRTO for the treatment of isolated gastric varices this past week. Performed with local anesthesia and mild sedation. Elderly lady with a history of cirrhosis and some component of encephalopathy (so not a good TIPS candidate). Has had a couple of bout of gastric variceal bleed (seen on endoscopy). My colleague and I got a guiding sheath into the left renal vein and then put an occlusion balloon into the outflow vein (inferior phrenic vein) and then did a venogram of the gastric varix. Then we noted that the inflow vein was likely the posterior gastric vein. We subsequently injected a mixture of 3 % sotradecol, air, and ethiodol. We left the balloon up and kept her in the angiosuites to make sure the sclerosant persisted and then we secured the catheters and balloons and sent her to the floor. We then brought her back the next day and deflated the balloon and the gastric varix appeared to be obliterated. Can't wait to get a follow up CT to see the effects. But, certainly was an interesting technique and very interesting anatomy.

Another tool to aid us in the treatment of this very complex patient population. We should at least consider it in patients with gastric variceal bleed as an adjunct or in patients who are not candidate for TIPS due to encephalopathy or elevated MELD scores etc.

On a side note, Dr. Kee and his IR group at UCLA performed a percutaneous mesocaval shunt using CT and fluoroscopic guidance. It was published recently in JVIR.

 

[Dotterer]

Gastric varices are notoriously difficult to treat endoscopically and isolated gastric varices tend to form at much lower portal pressure gradients than other types of portosystemic shunts (esophageal varices, etc). In the setting of a normal or near normal gradient, a TIPS is of limited utility and BRTO can be very a very effective first line therapy.