Antegrade Gastric Variceal Embolization Simultaneously With Tips in Treatment of Patients with Acute Gastric Variceal Bleeding Having Unfavorable Gastric Variceal Anatomy

Abstract

Gastric varices bleed at a lower Porto systemic pressure, have more catastrophic consequences and associated with large Porto systemic shunts. Occluded retrograde Trans-venous obliteration (RTO) is the mainstay of therapy for gastric variceal bleeding refractory to endoscopic therapy. A favorable afferent (Kiyosue type 1) and efferent (Kiyosue type A) anatomy of gastric varices is required for successful and safe RTO. Complex modifications in the RTO procedure are required for unfavorable afferent and efferent anatomies with high failure rates. RTO is not feasible in a type D efferent anatomy. RTO may aggravate potential complications associated with portal hypertension (ascites, catastrophic esophageal variceal bleeding). Antegrade gastric variceal embolization in adjunct to TIPS placement offers a safe, easier and effective alternative to modified RTO for gastric varices with unfavorable afferent and efferent anatomy. Concomitant placement of a TIPS stent leads to portal decompression and diminishes the risks associated with aggravation of portal hypertension. In this review, we discuss the anatomic and hemodynamic classification of gastric varices and describe the advantages of antegrade embolization (+TIPS) over RTO for management of gastric variceal bleeding in patients with complex variceal anatomies.