J Korean Soc Radiol.  2016 Aug;75(2):92-103. 10.3348/jksr.2016.75.2.92.

Vascular Plug-Assisted Retrograde Transvenous Obliteration for the Management of Gastric Varices: Comparative Effectiveness between Gelatin Sponge Embolization and Permanent Sclerosant

• Lee J
• Jo J
• Park JH
• Jung GS
• Park BH

• KMID: 2344798
• DOI: http://doi.org/10.3348/jksr.2016.75.2.92

Abstract

PURPOSE
To evaluate the short-term outcome of plug-assisted retrograde transvenous obliteration (PARTO) using vascular plugs and gelatin sponges in comparison with balloon-occluded retrograde transvenous obliteration (BRTO) for the management of gastric varices.
MATERIALS AND METHODS
From January 2005 to October 2014, 171 patients were referred for management of gastric varices, of which, 52 patients with hemodynamically stable gastric varices (48 recent bleeding; 4 primary prophylaxes) were evaluated. Of these, 38 received BRTO (men/women 23/15; mean age 61.3; Child-Pugh classes A/B/C = 11/25/2) and 14 underwent PARTO (men/women 11/3; mean age 63.4; Child-Pugh classes A/B/C = 9/4/1). The technical success rate, complications, variceal changes, liver function, and exacerbation of ascites/pleural effusion were compared between the 2 groups within 3 months after the procedure.
RESULTS
The technical success rates were 92.1% in the BRTO and 100% in the PARTO group. Procedure-related early complications occurred in the BRTO group alone (8%, n = 3). Among patients with technical success, follow-up CT at 1 month was available for 98% (n = 48/49). Complete thrombosis of gastric varices was achieved in 97.1% in the BRTO and 100% in the PARTO group. Worsening of esophageal varices was observed in 24% of the BRTO group alone (n = 8). The albumin level increased significantly in both groups and aspartate aminotransferase/alanine aminotransferase level improved significantly in the PARTO group (p < 0.05). Exacerbation of ascites/pleural effusion was observed in both groups (35.2% vs. 21.4%, both p > 0.05).
CONCLUSION
PARTO appears to be equivalent to BRTO for short-term management of gastric varices.

MeSH Terms

Aspartic Acid
Balloon Occlusion
Esophageal and Gastric Varices*
Follow-Up Studies
Gastrointestinal Hemorrhage
Gelatin Sponge, Absorbable
Gelatin*
Hemorrhage
Humans
Liver
Porifera*
Thrombosis
Aspartic Acid
Gelatin

Figure

• 

  Fig. 1 Schematic diagram for BRTO/PARTO management. Solid arrows: from 2005 to 2011. Dashed arrows: from 2012 to 2014. The types of gastric varices were classified using 3D volume rendering images based on the criteria of Sabri and Saad (16). *Gastric variceal bleeding within 2 weeks, †GR shunt: gastrorenal shunt. BRTO = balloon-occluded retrograde transvenous obliteration, PARTO = plug-assisted retrograde transvenous obliteration, TIPS = transjugular intrahepatic portosystemic shunt, ø = largest diameter of gastrorenal shunt

• 

  Fig. 2 Preprocedural evaluation of PARTO in a 49-year-old man. The 3D volume rendering image provides clear visualization of the gastrorenal shunt (white arrows) and collateral vessels, as well as the presence and size of the gastrorenal shunt and venous drainage pattern. PARTO = plug-assisted retrograde transvenous obliteration

• 

  Fig. 3 PARTO procedure (the same patient as in Fig. 2). A. After a 9 Fr vascular sheath was placed in the gastrorenal shunt and the efferent shunt was accessed coaxially using a 4 Fr Cobra catheter, the vascular plug was deployed halfway at the narrowest region of the gastrorenal shunt through the vascular sheath (white arrow). B. The efferent shunt was evaluated by advancing the catheter proximally into or close to the gastric varices using a coaxial catheter technique. C. After embolization of the gastrorenal shunt using gelfoam particle, a static fluoroscopic view showed stasis of the contrast material and gelfoam within the varices and gastrorenal shunt. Then, the vascular plug was deployed completely and detached. D. Final venography through the vascular sheath showed complete occlusion of the gastrorenal shunt without backflow from the gastric varices. PARTO = plug-assisted retrograde transvenous obliteration

• 

  Fig. 4 Pre- and postprocedural CT images of PARTO (the same patient as in Figs. 2 and 3). A, B. Preprocedural axial (A) and coronal (B) CT scan images show prominent fundal gastric varices and a gastrorenal shunt. C, D. Axial (C) and coronal (D) CT images 1 month after PARTO show complete obliteration of the targeted varices. PARTO = plug-assisted retrograde transvenous obliteration

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