Abstract
To evaluate the incidence and significance of intraprocedural shunt rupture in patients undergoing retrograde transvenous obliteration procedures (RTO) for symptomatic gastric varices. Retrospective review over a 13-year period (August 1, 2007 – August 1, 2019) was performed of all patients undergoing a RTO procedure for symptomatic gastric varices at a single academic institution. Over the study period, three techniques were utilized at the discretion of the treating physician: balloon-assisted retrograde transvenous obliteration (BRTO), plug-assisted retrograde transvenous obliteration (PARTO), or coil-assisted retrograde transvenous obliteration (CARTO). All patients underwent follow-up evaluation of their gastric varices with endoscopic US and/or CT/MRI at the discretion of the treatment team. Technical success was defined as satisfactory delivery of embolic/sclerosant material into the shunt with angiographic evidence of shunt occlusion. Clinical success was defined as resolution of gastric variceal bleeding. Intraprocedural shunt rupture occurred in 18 of 149 (12%) RTO procedures performed during the study period. Rupture occurred in the retroperitoneal segment in 16 patients (11%), intraperitoneal segment in 1 patient (<1%), and left renal vein in 1 patient (<1%). Thirteen of 18 (72%) ruptures occurred during shunt/side branch selection while 4/18 (22%) occurred during sclerosant/embolic administration. Technical success was 89%, with 2 cases requiring conversion to an antegrade approach following rupture. Overall clinical success was 94%. Patients who had residual flow within the shunt on follow-up imaging were subsequently treated successfully with endoscopic glue injection and did not require a repeat RTO procedure. Additional periprocedural complications included non-target embolization in 1 patient and postprocedural bleeding requiring transfusion in 2 patients. Shunt rupture during RTO for symptomatic gastric varices is an infrequent but observed intraprocedural complication. Even in the setting of this complication, high technical and clinical success rates can still be achieved comparable to reported rates in RTO patients without shunt rupture.
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