Korean J Radiol.  2003 Jun;4(2):109-116. 10.3348/kjr.2003.4.2.109.

Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Variceal Bleeding: Its Feasibility Compared with Transjugular Intrahepatic Portosystemic Shunt

• Choi YH
• Yoon CJ
• Park JH
• Chung JW
• Kwon JW
• Choi GM

• KMID: 1118813
• DOI: http://doi.org/10.3348/kjr.2003.4.2.109

Abstract

OBJECTIVE
To assess the feasibility of balloon-occluded retrograde transvenous obliteration (BRTO) in active gastric variceal bleeding, and to compare the findings with those of transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS: Twenty-one patients with active gastric variceal bleeding due to liver cirrhosis were referred for radiological intervention. In 15 patients, contrast-enhanced CT scans demonstrated gastrorenal shunt, and the remaining six (Group 1) underwent TIPS. Seven of the 15 with gastrorenal shunt (Group 2) were also treated with TIPS, and the other eight (Group 3) underwent BRTO. All patients were followed up for 6 to 21 (mean, 14.4) months. For statistical inter-group comparison of immediate hemostasis, rebleeding and encephalopathy, Fisher's exact test was used. Changes in the Child-Pugh score before and after each procedure in each group were statistically analyzed by means of Wilcoxon's signed rank test. RESULTS: One patient in Group 1 died of sepsis, acute respiratory distress syndrome, and persistent bleeding three days after TIPS, while the remaining 20 survived the procedure with immediate hemostasis. Hepatic encephalopathy developed in four patients (one in Group 1, three in Group 2, and none in Group 3) ; one, in Group 2, died while in an hepatic coma 19 months after TIPS. Rebleeding occurred in one patient, also in Group 2. Except for transient fever in two Group-3 patients, no procedure-related complication occurred. In terms of immediate hemostasis, rebleeding and encephalopathy, there were no statistically significant differences between the groups (p > 0.05). In Group 3, the Child-Pugh score showed a significant decrease after the procedure (p = 0.02). CONCLUSION: BRTO can effectively control active gastric variceal bleeding, and because of immediate hemostasis, the absence of rebleeding, and improved liver function, is a good alternative to TIPS in patients in whom such bleeding, accompanied by gastrorenal shunt, occurs.

Keyword

Hypertension, portal; Interventional procedures, technology; Stomach, varices; Stomach, bleeding; Veins, therapeutic blockade

Figure

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  Fig. 1 Balloon-occluded retrograde transvenous obliteration of gastric varix. A. CT scan obtained before balloon-occluded retrograde transvenous obliteration shows dilated gastric varix (arrowheads) and gastrorenal shunt (arrow). B. Narrow segment of the shunt tract (arrow) is demonstrated at angiography. C. Gastric varix (small arrows), gastrorenal shunt (large arrow), and its multiple fine collaterals (arrowheads) are seen at angiography. In the narrow segment, an inflated balloon catheter (long arrow) is visible. D. With the balloon inflated (arrow), 2×2×2-mm gelatin sponge particles were injected into the gastrorenal shunt, from where they flowed into collateral veins. Subsequent angiography shows that the fine collaterals have disappeared. E. Three hours after the injection of ethanolamine oleate into the varix, as much as possible of the remaining sclerosing agent was aspirated. Fluoroscopy shows that some, however, was retained. F. Immediate follow-up angiography demonstrates obliteration of both the varix and gastrorenal shunt. G. Follow-up CT scan obtained three months after balloon-occluded retrograde transvenous obliteration depicts contraction of the varix (arrowheads) and gastrorenal shunt (arrow), with deposition of sclerosing agent. H. One year later, there is no trace of either the varix or shunt.

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