Vascular and Interventional Radiology
Retrograde Transvenous Obliteration of Gastric Varices
Published Online:May 1 1999https://doi.org/10.1148/radiology.211.2.r99ma25349
Abstract
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).
References
- 1 Rosch J, Hanafee WN, Snow H. Transjugular portal venography and radiologic portocaval shunt: an experimental study. Radiology 1969; 92: 1112-1114. Link, Google Scholar
- 2 Idezuki Y, Japanese Research Society for Portal Hypertension. Japanese Research Society for Sclerotherapy of Esophageal Varices. Present status of sclerotherapy and surgical treatment for esophageal varices in Japan. World J Surg 1992; 16: 1193-1201. Crossref, Medline, Google Scholar
- 3 Sarin SK, Sachdev G, Nanda R, Misra SP, Broor SL. Endoscopic sclerotherapy in the treatment of gastric varices. Br J Surg 1988; 75: 747-750. Crossref, Medline, Google Scholar
- 4 Sandy H. The role of sclerotherapy in the treatment of esophageal varices: personal experience and a review of randomized trials. Am J Gastroenterol 1987; 82: 813-822. Medline, Google Scholar
- 5 Korula J, Chin K, Ko Y, Yamada S. Demonstration of two distinct subsets of gastric varices: observations during a seven-year study of endoscopic sclerotherapy. Dig Dis Sci 1991; 36: 303-309. Crossref, Medline, Google Scholar
- 6 Paquet KJ, Oberhammer E. Sclerotherapy of bleeding oesophageal varices by means of endoscopy. Endoscopy 1978; 10: 7-12. Crossref, Medline, Google Scholar
- 7 Freig WE, Strange EF, Ruettenauer K, Ditschuneit H. Emergency endoscopic sclerotherapy for bleeding esophageal varices: a prospective study in patients not responding to balloon tamponade. Gastrointest Endosc 1983; 2: 8-14. Google Scholar
- 8 Sanyal AJ. The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts. Gastroenterology 1997; 112: 889-898. Crossref, Medline, Google Scholar
- 9 Kerlan RK, Jr, LaBerge JM, Baker EL, et al. Successful reversal of hepatic encephalopathy with intentional occlusion of transjugular intrahepatic portosystemic shunts. JVIR 1995; 6: 917-921. Crossref, Google Scholar
- 10 Brown RS, Jr, Lake JR. Transjugular intrahepatic portosystemic shunt as a form of treatment for portal hypertension: indication and contraindications. Adv Intern Med 1997; 42: 485-504. Medline, Google Scholar
- 11 Somberg KA. TIPS: safe, effective, better? (editorial). Am J Gastroenterol 1997; 92: 1412-1416. Medline, Google Scholar
- 12 Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol 1996; 11: 51-58. Crossref, Medline, Google Scholar
- 13 Kawanaka H, Ohta M, Hashizume M, et al. Portosystemic encephalopathy treated with balloon-occluded retrograde transvenous obliteration. Am J Gastroenterol 1995; 90: 508-510. Medline, Google Scholar
- 14 Idezuki Y, The Japanese Research Society for Portal Hypertension. The general rules for recording endoscopic findings on esophageal and gastric varices. Liver 1992; 3: 277-281. Google Scholar
- 15 Hashizume M, Kitano S, Yamaga H, Koyanagi N, Sugimachi K. Endoscopic classification of gastric varices. Gastrointest Endosc 1990; 36: 276-280. Crossref, Medline, Google Scholar
- 16 Miyoshi H, Oshiba S, Matsumoto A, Takada K, Umegaki E, Hirata I. Haptoglobin prevents renal dysfunction associated with intravariceal infusion of ethanolamine oleate. Am J Gastroenterol 1991; 86: 1638-1641. Medline, Google Scholar
- 17 Watanabe K, Kimura K, Matsutani S, Ohoto M, Okuda K. Portal hemodynamics in patients with gastric varices. Gastroenterology 1988; 95: 434-440. Crossref, Medline, Google Scholar
- 18 Obara K, Kasukawa R. Location and classification of gastric varices, and the mechanism of their development. Shokakinaishikyo 1992; 4: 1005-1012. Google Scholar
- 19 Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992; 16: 1343-1349. Crossref, Medline, Google Scholar
- 20 Masaki M, Obara K, Suzuki S, et al. The destructive effects of sclerosant ethanolamine oleate on mammalian vessel endothelium. Gastroenterol Jpn 1990; 25: 230-235. Crossref, Medline, Google Scholar
- 21 Smith R, Tanford C. The critical micelle concentration of l-α-dipalmitoylphosphatidylcholine in water and water/methanol solutions. J Mol Biol 1972; 67: 75-83. Crossref, Medline, Google Scholar
- 22 Weltzien HU. Cytolytic and membrane-perturbing properties of lysophosphatidylcholine. Biochim Biophys Acta 1979; 559: 259-287. Crossref, Medline, Google Scholar
- 23 Kobayashi T, Takahashi K, Yamada A, Nojima S, Inoue K. Lysis of erythrocytes by phosphatidylcholine containing polyunsaturated fatty acid. J Biochem 1983; 93: 675-680. Crossref, Medline, Google Scholar
- 24 Jensen DM. Sclerosants for injection sclerosis of esophageal varices. Gastrointest Endosc 1983; 29: 315-317. Crossref, Medline, Google Scholar
- 25 Iwasaki T, Akahane T, Takahashi N, et al. A case of gastric varices successfully treated by arranged balloon-occluded retrograde transvenous obliteration. Nippon Shokakibyo Gakkai Zasshi 1995; 92: 1178-1182[Japanese]. Medline, Google Scholar
- 26 Stamatoyannopoulos G, Chen SH, Fukui M. Liver alcohol dehydrogenase in Japanese: high population frequency of atypical form and its possible role in alcohol sensitivity. Am J Hum Genet 1975; 27: 789-796. Medline, Google Scholar
- 27 Hassab MA. Gastro-esophageal decongestion and splenectomy in the treatment of esophageal varices in bilharzial cirrhosis: further studies with a report on 355 operations. Surgery 1967; 61: 169-176. Medline, Google Scholar
- 28 Haskal ZJ, Ring EJ. Role of parallel transjugular intrahepatic portosystemic shunts in patients with persistent portal hypertension. Radiology 1992; 185: 813-817. Link, Google Scholar
- 29 Lee JY, Moon SH, Lee SM, et al. A case of noncardiogenic pulmonary edema by ethanolamine oleate. Korean J Intern Med 1994; 9: 125-127. Crossref, Medline, Google Scholar
- 30 Uchibori S. Pulmonary circulatory disturbance following endoscopic injection sclerotherapy. Nippon Kyobu Shikkan Gakkai Zasshi 1993; 31: 833-839. Google Scholar
- 31 Rajagopalan N, Hoffstein V. Hemothorax following uncomplicated sclerotherapy for esophageal varices. Chest 1994; 106: 314-315. Crossref, Medline, Google Scholar
- 32 Bellary SV, Isaacs P. Disseminated intravascular coagulation (DIC) after endoscopic injection sclerotherapy with ethanolamine oleate (letter). Endoscopy 1990; 22: 151. Crossref, Medline, Google Scholar
