Balloon-occluded Transvenous Obliteration Research Articles

FRI493 - Transjugular intrahepatic portosystemic shunt versus balloon-occluded transvenous obliteration for the management of ectopic varices

FRI493 - Transjugular intrahepatic portosystemic shunt versus balloon-occluded transvenous obliteration for the management of ectopic varices

S1139 Transjugular Intrahepatic Portosystemic Shunt vs Balloon-Occluded Transvenous Obliteration for the Management of Non-Esophagogastric Varices

INTRODUCTION: There are few options for bleeding rectal or peristomal varices in patients unable to undergo transjugular intrahepatic portosystemic shunt (TIPS). There is extensive experience with balloon-occluded antegrade or retrograde transvenous obliteration (BA-RTO) of gastric and esophageal (GE) varices. However, there is a paucity of data regarding the use of BA-RTO for the management of non-esophagogastric (Non-GE) varices. In this study, we assess the outcomes of patients with bleeding Non-GE varices managed by BA-RTO vs. TIPS. METHODS: Patients undergoing TIPS vs. BA-RTO procedures for Non-GE varices at our liver center were compared for demographics, MELD-Na labs prior to and following procedure, rebleeding, frequency of paracentesis and hepatic encephalopathy and mortality. RESULTS: 14 patients underwent procedures for bleeding Non-EV varices. Nine patients had rectal varices, four peristomal and one duodenal. Six patients undergoing BA-RTO were compared to eight patients undergoing TIPS. Of the BA-RTO patients, 5 had BATO and 1 BRTO. There were no differences in age, gender, race or cause of liver disease. In the BA-RTO groups, mean MELD-Na prior to procedures was 23.3 ± 9.4 declining to 20.0 ± 10.4 and 18.0 ± 4.2 at 30 and 90 days after procedure. TIPS patients had a MELD-Na prior to procedure of 18.5 ± 6.1 increasing to 21.7 ± 5.5 and 24.0 ± 7.5.4. Of the BA-RTO patients, 4 were felt to be too ill for TIPS and, of these, 2 died within 90 days: 1 from uncontrolled bleeding and 1 from sepsis. 2 of 8 TIPs patients died within 90 days with 1 from uncontrolled bleeding. Rebleeding rates were 16.7 for BA-RTO vs. 12.5% for TIPS (P = 1.00) and no procedures were repeated. Comparing BA-RTO to TIPS, median length of stay was 14.5 ± 9.8 vs. 7.8 ± 7.5 (P = 0.14), paras 90 days prior and after procedure were 3.5 ± 4.5 vs. 0.0 ± 0.0 (P = 0.018) and 3.0 ± 4.6 vs. 0.0 ± 0.0 (P = 0.028). There were no differences in hepatic encephalopathy in the 90 days before and after the procedure (66.7 vs. 50% and 33.3 vs. 25.0%). CONCLUSION: TIPS remains an excellent option for bleeding Non-EV varices. Despite the fact that BA-RTO patients were more ill and typically not candidates for TIPS, BA-RTO was an excellent alternative with non-inferiority in terms of rebleeding and mortality. Patients undergoing BA-RTO had a decline in MELD score whereas TIPS patients had an increase. Either modality should be considered early before patients are increasingly ill.Figure 1.: Overall survival between groups with three patients removed Note: Patient which had the event of interest at 3000 days was censored at 2000 days.

Balloon occluded retrograde transvenous obliteration for bleeding gastric varices: Eyes see what the mind knows.

Approximately one in six patients with portal hypertension who develop varices at sites of portosystemic venous collaterals has gastric varices due to hepatofugal flow into the gastric veins. Bleeding from gastric varices, though less common, has a higher mortality and morbidity compared to bleeding esophageal varices, which are easier to manage endoscopically. The efferent channel for gastric varices is mostly the gastrorenal shunt (GRS) which opens into the left renal vein. Balloon-occluded transvenous obliteration (BRTO) involves accessing the GRS with an aim to temporarily occlude its outflow using a balloon catheter and at the same time injecting sclerosant mixture within the varix so as to cause its thrombosis and thereby obliteration. BRTO is one of the mainstays of minimally invasive treatment for bleeding gastric varices. In the minority of cases where the GRS is absent, conventional BRTO is technically not possible. However, accessing the small alternate shunt from the inferior phrenic vein may be possible if one is aware of its existence.

B-RTOにおけるportopulmonary venous anastomosisについて

B-RTOにおけるportopulmonary venous anastomosisについて

The Conventional Balloon-Occluded Retrograde Transvenous Obliteration Procedure: Indications, Contraindications, and Technical Applications

Transvenous obliteration of gastric varices can be performed from the systemic venous side (draining veins or shunts) or from the portal venous side (portal afferent feeders). Balloon-occluded transvenous obliteration from the systemic veins is referred to as balloon-occluded retrograde transvenous obliteration (BRTO) and balloon-occluded transvenous obliteration from the portal veins is referred to as balloon-occluded antegrade (anterograde) transvenous obliteration (BATO). BRTO is the conventional balloon-occluded transvenous obliteration procedure and BATO is considered an alternative or adjunctive approach. This is because, from a technical standpoint, the least invasive choice of access or approach for balloon-occluded transvenous obliteration of gastric varices is the traditional or conventional transrenal route. The objective of BRTO or BATO or both is complete obliteration of the gastric varices with preservation of the anatomical hepatopetal flow of the splenoportal circulation. This article reviews the indications, contraindications, and technical considerations of the conventional BRTO procedure. The indications of concomitant portal venous modulators such as splenic embolization or the creation of a transjugular intrahepatic portosystemic shunt or both are also discussed.

The Effect of Balloon-Occluded Transvenous Obliteration of Gastric Varices and Gastrorenal Shunts on the Hepatic Synthetic Function

To evaluate the effect of balloon-occluded transvenous obliteration (BRTO) on the model for end-stage liver disease (MELD) and the Child-Pugh (C-P) score and their individual components. A retrospective review of patients undergoing only BRTO without transjugular intrahepatic portosystemic shunt was performed (08, 2007 to 06, 2010). Pre- and post-BRTO MELD and C-P scores were calculated. The post-BRTO MELD and C-P score samplings were categorized as (1) immediate (within 14 days), (2) early (14-90 days), and (3) delayed (90-180 days) post-BRTO. The C-P and MELD scores and their individual components before and after (various sample intervals) were compared. A total of 29 consecutive successful BRTO procedures were found and assessed. In all, 26 had immediate post-BRTO sampling (average 1.8 days after BRTO), 13 (57%) had an early post-BRTO sampling (average 47 days from BRTO), and 10 (38%) had a delayed post-BRTO sampling (average 121 days from BRTO). The bilirubin rises significantly (P = .007) within days after BRTO, but synthetic function improves significantly between 1.5 and 4.0 months post-BRTO (international normalized ration: P = .02, bilirubin: P = .027, and albumin: P = .012). However, 31% (N = 8/ 26) of the patients had worsening ascites with or without hydrothorax. The MELD score significantly improved circa 4 months post-BRTO (from 14.1 to 10.7, P = .0008). However, the C-P score did not change significantly (from 7.6 to 6.7, P = .063). The BRTO has a positive effect on the hepatic synthetic function. However, there is a high incidence of post-BRTO ascites (31% of the patients). As a result, the MELD score appears to be a more sensitive gauge for hepatic synthetic function compared to the C-P score for patients undergoing BRTO.