Abstract
Aims To evaluate the safety and effectiveness of percutaneous transhepatic antegrade embolization (PTAE) with 2-octyl cyanoacrylate assisted with balloon occlusion of the left renal vein or gastrorenal shunts (GRSs) for the treatment of isolated gastric varices (IGVs) with large GRSs. Methods Thirty patients with IGVs associated with large GRSs who had underwent PTAE assisted with a balloon to block the opening of the GRS in the left renal vein were retrospectively evaluated and followed up. Clinical and laboratory data were collected to evaluate the technical success of the procedure, complications, changes in the liver function using Child-Pugh scores, worsening of the esophageal varices, the rebleeding rate, and survival. Laboratory data obtained before and after PTAE were compared (paired-sample t-test). Results PTAE was technically successful in all 30 patients. No serious complications were observed except for one nonsymptomatic pulmonary embolism. During a mean follow-up of 30 months, rebleeding was observed in 4/30 (13.3%) patients, worsening of esophageal varices was observed in 4/30 (13.3%) patients, and newly developed or aggravated ascites were observed on CT in 3/30 (10%) patients. Significant improvement was observed in Child-Pugh scores (p=0.009) and the international normalized ratio (INR) (p=0.004) at 3 months after PTAE. The cumulative survival rates at 1, 2, 3, and 5 years were 96.3%, 96.3%, 79.9%, and 79.9%, respectively. Conclusion Balloon-assisted PTAE with 2-octyl cyanoacrylate is technically feasible, safe, and effective for the treatment of IGV associated with a large GRS.
Highlights
Variceal bleeding from gastric varices is a serious complication of portal hypertension, which is associated with high mortality [1, 2]
Treatment of Isolated gastric varices (IGVs) associated with large gastrorenal shunts (GRSs) is challenging
The inclusion criteria were as follows: (1) diagnosis of liver cirrhosis by biopsy or clinical examination and imaging, including ultrasound, computed tomography (CT), or magnetic resonance imaging; (2) patients suffered from bleeding within 3 months before being admitted or acute bleeding that achieved hemostasis by pharmacological treatment; (3) IGVs diagnosed by endoscopy with no other potential source of bleeding; (4) a large GRS >5 mm associated with IGVs observed by preoperative imaging, and (5) patients aged between 20 and 75 years old
Summary
Variceal bleeding from gastric varices is a serious complication of portal hypertension, which is associated with high mortality [1, 2]. A large GRS may lead to a potential risk of cyanoacrylate migration and pulmonary embolism when endoscopic embolization therapy is performed [4, 5]. Balloon-occluded retrograde transvenous obliteration (BRTO) has been shown in a number of studies to have reliable clinical results in IGV treatment, it has a relatively long procedure time (a few hours to overnight) and is inherently limited by its association with sclerosantrelated complications [6,7,8,9,10]. The efferent vessels rather than the afferent vessels are obliterated during the BRTO procedure, and this may potentially results in the development of esophageal varices and an increased risk of esophageal variceal bleeding [7, 11,12,13]. The traditional BRTO technique is usually used in Asia (predominantly Japan), it is not selected as the first-choice therapy in the West (United States and Europe) [14]
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