Ethanolamine Oleate Iopamidol Research Articles

Conventional versus selective balloon-occluded retrograde transvenous obliteration of gastric varices

BackgroundBalloon-occluded retrograde transvenous obliteration (BRTO) is a well-established interventional radiological technique for treatment of isolated gastric varices (GV). The aim of this study is to compare outcome after different BRTO techniques, i.e., conventional, selective and superselective techniques.Fifty-nine consecutive patients underwent BRTO as a primary prophylactic treatment for GV were retrospectively categorized into group A (38 patients underwent conventional BRTO) and group B (21 patients underwent selective or superselective BRTO). Group B was sub-grouped into group B1 (11 patients underwent selective BRTO) and group B2 (10 patients underwent superselective BRTO).ResultsMedian volume of ethanol amine oleate iopamidol (EOI) was significantly higher in group A than in group B2 (14.8 Vs 7.4 ml, p = 0.03). Complete GV thrombosis was significantly lower in group B2 (50%) than in A (89.5%, p = 0.01) and B1 (100%, p = 0.01). GV bleeding rate after BRTO was significantly higher in group B2 than in group A (20% vs 0%, p = 0.04). GV recurrence rate was not significantly different between group A and B (p = 0.5) or between group A, B1 and B2 (p = 0.1). Cumulative ascites exacerbation rate was significantly higher in group A than B (p = 0.005), B1 (p = 0.03), and B2 (p = 0.03). Cumulative esophageal varices (Es.V) aggravation rate was significantly higher in group A than B (p = 0.001), B1 (p = 0.01), and B2 (p = 0.03). Volume of EOI was a significant risk factor for ascites exacerbation (p = 0.008) while shunt occlusion and pre-existing partial portal vein thrombosis were significant risk factors for Es.V aggravation (p = 0.01 and 0.03, respectively).ConclusionSelective and super-selective techniques had a lower ascites exacerbation, and Es.V aggravation rates than conventional technique. However, superselective BRTO had a lower GV complete thrombosis and higher GV bleeding rates after BRTO than other techniques.

Utility of low-dose gelatin sponge particles and 5% ethanolamine oleate iopamidol mixture in retrograde transvenous obliteration (GERTO) for gastric varices.

To determine the utility of low-dose gelatin sponge particles and 5% ethanolamine oleate iopamidol (EOI) mixture in retrograde transvenous obliteration (GERTO) for gastric varices (GV). 57 consecutive patients who underwent balloon-occluded retrograde transvenous obliteration (B-RTO) for GV were divided into three groups with Hirota's grade by balloon-occluded retrograde transvenous venography. Hirota's Grade 1 patients were assigned to G1 group and underwent treatment with 5% EOI. Grade ≥ 2 patients prior to August 2015 were G ≥ 2 group treated with 5% EOI, and those treated thereafter were GERTO group. The amount of EOI used per unit GV volume (EOI/GV ratio), the times to embolization and recurrence rate of GV were evaluated. The EOI/GV ratio was 0.66 ± 0.19 in G1, 1.5 ± 0.8 in G ≥ 2, and 0.58 ± 0.23 in GERTO (G ≥ 2 vs GERTO, p < 0.0001). The times to embolization were 26.5 ± 10.5 min for G1, 39.2 ± 26.8 for G ≥ 2, and 21.4 ± 9.4 for GERTO (G ≥ 2 vs GERTO, p = 0.005). The recurrence rate was not significantly different in any of the groups. GERTO was performed in lower amount of sclerosants and in less time compared to conventional B-RTO in Hirota's grade ≥2. Feasibility of low-dose gelatin sponge particles and 5% EOI mixture as sclerosants for GV.

Utility of Coil-Assisted Retrograde Transvenous Obliteration II (CARTO-II) for the Treatment of Gastric Varices.

PurposeTo investigate the technical feasibility, safety and clinical outcomes of coil-assisted retrograde transvenous obliteration II (CARTO-II) for gastric varices (GV).Materials and MethodsThirty-six consecutive patients who had undergone CARTO-II between June 2016 and April 2018 were included in the study. In the CARTO procedure, coil embolization of the drainage vein is performed “before” injection of the sclerosant to replace the use of balloon catheter. In the CARTO-II procedure, coil embolization of the drainage vein was performed “after” injection of the sclerosant to prevent migration of the sclerosant. CARTO-II was performed with ethanolamine oleate iopamidol, and the balloon catheter was immediately removed after coil placement. Technical and clinical success rates, number of coils used, presence or absence of severe complications, timing of the procedure, and rate of GV recurrence after the procedure were analyzed retrospectively.ResultsIn all patients, GV sclerosis, coil placement and removal of the balloon catheter were successfully completed. The technical success rate was 100%. No patients experienced severe complications such as coil migration or pulmonary embolization. The mean number of metallic coils used per procedure was 3.36. Mean length of the procedure was 132.8 min. Contrast-enhanced computed tomography after CARTO-II confirmed complete variceal thrombosis in all cases. The recurrence rate of GV during follow-up was 2.8% (mean follow-up, 207 days).ConclusionCARTO-II was feasible and safe and could be performed relatively quickly. The number of coils used and the rate of GV recurrence were both low. CARTO-II may have an important role to play in the management of GV.

PS01.080: A CASE REPORT OF JEJUNAL VARICEAL BLEEDING SUCCESSFULLY TREATED WITH PERCUTANEOUS TRANSHEPATIC OBLITERATION AFTER SURGERY OF ESOPHAGOGASTRIC JUNCTIONAL CARCINOMA

Abstract Background Varicose veins in the esophagogastric junction rarely occur after surgery of esophagogastric junctional carcinoma, because the collateral pathway of the left gastric vein and short gastric vein was sacrificed. We presented a case of jejunal variceal bleeding successfully treated with percutaneous transhepatic obliteration after surgery of esophagogastric junctional carcinoma. Methods Case report. Results A 50-year-old man with alcoholic liver cirrhosis (Child-B) was admitted for abdominal pain, three months after proximal gastrectomy for esophagogastric junctional carcinoma. After diagnosed with peritonitis due to jejunal perforation, emergency surgery was performed. The next day after surgery, he had developed a lot of black stool. Gastroduodenoscopy revealed the variceal bleeding at the anal side of the esophagojejunal anastomois. Although endoscopic clipping was performed, intermittent bleeding was observed for several days. Since the contrast-enhanced computed tomography scanning revealed jejunal vein dilation at the anal side of the esophagojejunal anastomois, we planned to perform percutaneous transhepatic obliteration. Percutaneous transhepatic portography revealed jejunal varices and drained to the inferior vena cava, and continuously obliterated by 5% EOI (Ethanolamine oleate iopamidol). He was discharged without re-bleeding on the 14th day after the obliteration. Conclusion Percutaneous transhepatic obliteration might be a useful treatment option for jejunal variceal bleeding after surgery of esophagogastric junctional carcinoma. Disclosure All authors have declared no conflicts of interest.

Percutaneous transhepatic obliteration and percutaneous transhepatic sclerotherapy for intractable hepatic encephalopathy and gastric varices improves the hepatic function reserve.

Percutaneous transhepatic obliteration (PTO) and percutaneous transhepatic sclerotherapy (PTS) are widely performed as an emergency measure in cases of variceal hemorrhage and intractable hepatic encephalopathy. The PTO/PTS technique is capable of directly blocking the blood supply in cases in which balloon-occluded retrograde transvenous obliteration (B-RTO) is not effective, or in cases with complicated collateral flow. Although PTO/PTS is not currently the first choice due to the invasiveness of transhepatic puncture, this procedure can modify the blood flow in an antegrade manner. The present study examined the changes in hepatic function reserve following PTO/PTS for intractable hepatic encephalopathy and/or gastric varices. In total, the study included 37 patients (mean age, 61.75±12.77 years; age range, 32-88 years; male to female ratio, 23:14) with a variety of gastrorenal shunts, or B-RTO-intractable hepatic encephalopathy and gastric varices without gastrorenal shunts. The patients underwent PTO/PTS by embolizing a microcoil or injection of a sclerosing agent (5% ethanolamine oleate iopamidol). Alterations in hepatic function reserve prior to and following the procedure were compared. The patients were treated for hepatic encephalopathy in 11 patients, gastric varices in 19 patients, and both conditions in 7 patients. The results indicated that the blood ammonia level improved from 135.76±75.23 mg/dl to 88.00±42.16 and 61.81±33.75 mg/dl at 3 and 6 months after therapy, respectively. In addition, the Child-Pugh score improved from 8.48±2.01 prior to therapy to 7.70±1.84 and 7.22±2.01 at 3 and 6 months after the procedure, respectively. Although there was a concern that PTO/PTS may cause complications due to an increase in portal venous pressure (PVP) arising from shunt occlusion, no severe complications were observed. In conclusion, for patients with various gastrorenal shunts or those with B-RTO-intractable hepatic encephalopathy and gastric varices without gastrorenal shunts, PTO/PTS can improve the antegrade blood flow to the liver, as demonstrated by improvement in the hepatic function reserve.

Percutaneous transhepatic portal embolization using foam ethanolamine oleate and carbon dioxide (CO₂): a pilot study.

Percutaneous transhepatic portal embolization (PTPE) can induce atrophy of the embolized- and hypertrophy of the residual area. These effects are advantageous in patients scheduled for extended hepatectomy. To evaluate the clinical safety and effectiveness of foam sclerotherapy with foam ethanolamine oleate (EO) and carbon dioxide (CO2) for PTPE before hepatectomy. We performed sclerotherapy for PTPE in 15 patients with: hepatocellular carcinoma (HHC; n = 9), bile duct carcinoma (n = 5), or metastatic liver tumor from colon cancer (n = 1). The foam contained 5% EO iopamidol (EOI) and CO2 at a 1:2 ratio. We compared the percentage of the pre- and post-PTPE future liver remnant (FLR) volumes and calculated the percent FLR volume (%FLR) increase after PTPE. The amount of EOI used (range, 14-20 mL; median, 16.8 mL) was based on the volume of the target portal vein. Technical success was achieved in 14 of 15 patients (93%); the other patient presented with computed tomography evidence of recanalization 1 week after PTPE. The FLR volume before and after portal vein embolization was 599 ± 342 and 691 ± 318 cm(3), respectively (P < 0.01); the mean %FLR volume increase was 29.5%. There was no significant difference in the mean platelet count, total bilirubin, total aspartate aminotransferase, and total creatinine before and after PTPE. One patient suffered intra-abdominal bleeding that required transcatheter arterial embolization. No other patients developed major complications higher than grade 3. Sclerotherapy using foam EOI and CO2 is clinically safe and effective for PTPE before hepatectomy.

Balloon‐occluded retrograde transvenous obliteration using a microballoon catheter for intractable gastric fundal varices

Balloon-occluded retrograde transvenous obliteration (B-RTO) is recognized as the standard therapy for patients with gastric fundal varices in Japan; however, the procedure is difficult when drainage veins other than the gastrorenal shunt developed. The efficacy and safety of B-RTO using a microballoon catheter for such patients were evaluated. The subjects were 99 patients with gastric fundal varices who fulfilled the criteria for receiving endoscopic and/or interventional therapies. Among these, 95 patients underwent B-RTO. Of the 95 patients, 14 were treated with the use of microballoon catheters, including nine in whom the left inferior phrenic vein was found as a secondary drainage vein in addition to the gastrorenal shunt, and five in whom a gastrorenal shunt was absent. The B-RTO procedure performed using a microballoon catheter inserted through the left inferior phrenic vein in 13 patients, and through the pericardiophrenic vein in one patient. The B-RTO procedure using microballoon catheters was successful in 13 of the 14 patients (93%), while in the remaining one patient, multiple drainage veins were visualized on venography. Complete obliteration of the varices was achieved in all the 13 patients by injection of 5% ethanolamine oleate iopamidol at a median volume of 25 mL (range, 11 to 40 mL) through the catheters. None of the patients showed injuries of the drainage veins or any systemic complications. B-RTO using a microballoon catheter is useful for the treatment of gastric fundal varices in which drainage veins other than the gastrorenal shunt developed.

Emergency balloon-occluded retrograde transvenous obliteration of ruptured gastric varices

To evaluate the effectiveness and safety of emergency balloon-occluded retrograde transvenous obliteration (BRTO) for ruptured gastric varices. Emergency BRTO was performed in 17 patients with gastric varices and gastrorenal or gastrocaval shunts within 24 h of hematemesis and/or tarry stool. The gastric varices were confirmed by endoscopy, and the gastrorenal or gastrocaval shunts were identified by contrast-enhanced computed tomography (CE-CT). A 6-Fr balloon catheter (Cobra type) was inserted into the gastrorenal shunt via the right internal jugular vein, or into the gastrocaval shunt via the right femoral vein, depending on the varices drainage route. The sclerosant, 5% ethanolamine oleate iopamidol, was injected into the gastric varices through the catheter during balloon occlusion. In patients with incomplete thrombosis of the varices after the first BRTO, a second BRTO was performed the following day. Patients were followed up by endoscopy and CE-CT at 1 d, 1 wk, and 1, 3 and 6 mo after the procedure, and every 6 mo thereafter. Complete thrombosis of the gastric varices was not achieved with the first BRTO in 7/17 patients because of large gastric varices. These patients underwent a second BRTO on the next day, and additional sclerosant was injected through the catheter. Complete thrombosis which led to disappearance of the varices was achieved in 16/17 patients, while the remaining patient had incomplete thrombosis of the varices. None of the patients experienced rebleeding or recurrence of the gastric varices after a median follow-up of 1130 d (range 8-2739 d). No major complications occurred after the procedure. However, esophageal varices worsened in 5/17 patients after a mean follow-up of 8.6 mo. Emergency BRTO is an effective and safe treatment for ruptured gastric varices.

Multiple utilities of portal vein embolization for patients with hepatocellular carcinoma.

319 Background: Portal vein embolization (PVE) is a multi-potential treatment for hepatocellular carcinoma (HCC). The aim of this study is to identify the efficacies of PVE for resectable and unresectable HCC patients. Methods: Until 2011, 668 HCC patients underwent hepatic resection and 102 HCC patients treated with PVE. PVE was performed with percutaneous and ipsilateral approach using ethanolamine oleate iopamidol. Preoperative future remnant liver volume (%LV) and functional liver volume (%FLV ) were assessed with our developed combined 99mTc- galactosyl human serum albumin (GSA) scintigraphy (SPECT)/CT system. In unresectable cases chemoembolization (TACE) was repeated after PVE. Results: 1. Comparison of %LV and %FLV after right-PVE (n=40). %FLV before PVE was significantly lower in PVE group (38%) compared to non-PVE group (58%), but increased remarkably after PVE (from 38% to 55%, P &lt; 0.0001). Right hepatectomy was successfully completed in 10 patients based on %FLV, instead of conventional %LV. 2. Long-term prognosis after right-hepatectomy with /without PVE (n=60). The 3- and 5-year disease-free survival (DFS) rates in the PVE group were significantly greater than those in the non-PVE group (78% and 78% versus 20% and 0%, P = 0.01). The 3- and 5-year overall survival (OS) rates in the PVE group were also higher than those in the non-PVE group (72% and 72% versus 57% and 12%, P &lt;0.05). By multivariate analysis, independent prognostic factors for DFS were application of PVE (HR3.59), Multiple tumor (HR3.57), Fibrosis stage F3–4 (HR2.81), and protein induced by vitamin K absence or antagonists-II (PIVKA-II) ≥678AU/ml (HR2.69). 3. Prevention of intrahepatic metastases in unresectable HCCs in hemi-liver (n=40). The 3-year intrahepatic recurrence rates in the non-portal-embolized area was 58.8% and 81.8%, and the 5-year OS was 38.2% and 8.5%, in the PVE/TACE group and TACE group, respectively. The former rates were sinificantly higher (P&lt;0.05). Conclusions: PVE can improve resectability, and might improve disease-free and overall survival for patients with both resectable and unresectable HCC.

Development of Thrombus in a Systemic Vein after Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices

ObjectiveTo retrospectively evaluate the frequency and risk factors for developing thrombus in a systemic vein such as the infrarenal inferior vena cava or the iliac vein, in which a balloon-occluded retrograde transvenous obliteration (B-RTO) catheter was indwelled.Materials and MethodsForty-nine patients who underwent B-RTO for gastric varices were included in this study. The B-RTO procedure was performed from the right femoral vein, and the B-RTO catheter was retained overnight in all patients. Pre- and post-procedural CT scans were retrospectively compared in order to evaluate the development of thrombus in the systemic vein in which the catheter was indwelled. Additionally, several variables were analyzed to assess risk factors for thrombus in a systemic vein.ResultsIn all 49 patients (100%), B-RTO was technically successful, and in 46 patients (94%), complete thrombosis of the gastric varices was achieved. In 6 patients (12%), thrombus developed in the infrarenal inferior vena cava or the right common-external iliac vein. All thrombi lay longitudinally on the right side of the inferior vena cava or the right iliac vein. One of the aforementioned 6 patients required anticoagulation therapy. No symptoms suggestive of pulmonary embolism were observed. Prothrombin time-international normalized ratio and the addition of 5% ethanolamine oleate iopamidol, on the second day, were related to the development of thrombus.ConclusionDevelopment of a thrombus in a systemic vein such as the inferior vena cava or iliac vein, caused by indwelling of the B-RTO catheter, is relatively frequent. Physicians should be aware of the possibility of pulmonary embolism due to iliocaval thrombosis.

A new approach to percutaneous transhepatic portal embolization using ethanolamine oleate iopamidol

We aimed to examine the therapeutic efficacy of ethanolamine oleate iopamidol (EOI) as an embolic material for percutaneous transhepatic portal embolization (PTPE). Eighty-two patients with liver tumors were treated with PTPE. Fifty-eight patients had hepatocellular carcinomas, 11 had liver metastases, and 13 had other liver tumors. A total of 55 patients (group E) were treated with 5% ethanolamine oleate after gelatin sponge administration. As a control, we evaluated 27 patients (group F) who were treated with fibrin glue and iodized oil. PTPE was mainly indicated before hepatic resection, for patients with high nontumorous volumetric resection ratios (the nontumorous volumetric resection ratio was estimated to be greater than 65% in patients with an indocyanine green retention ratio of 15 min (ICG R15) of 10% or less, and the nontumorous volumetric resection ratio was estimated to be greater than 40% in the patients with an ICG R15 of 10-20%). All patients were successfully treated percutaneously under local anesthesia. Balloon-occluded and ipsilateral approaches were used in 81 patients (99%) and 62 (75%) patients, respectively. The rate of insufficient embolization or recanalization was significantly lower in group E (7.3%) in comparison to group F (25.9%; p < 0.05). The volumetric resection ratios, before and after PTPE, decreased from 60 to 45% in group E and from 63 to 55% in group F. The post-PTPE resection ratio was significantly decreased in group E. Before and after PTPE, average ICG R15 values changed from 17 to 27% in group E and from 18 to 26% in group F. The complication rates in groups E and F were similar (7.3 vs. 7.4%). EOI is a safe embolic material that can be used to induce greater liver hypertrophy, in comparison to fibrin glue, in PTPE for liver tumors.

Balloon-occluded retrograde transvenous obliteration of a gastric varix via the left inferior phrenic vein

We encountered a patient with a gastric varix that drained through the left inferior phrenic vein, which directly entered the inferior vena cava at the point just inferior to the diaphragm. In this patient, gastrorenal shunt was not seen. Balloon-occluded retrograde transvenous obliteration of the gastric varix was performed, in which 50% glucose and 5% ethanolamine oleate-iopamidol were injected as sclerosing agents while the balloon was inflated in the left inferior phrenic vein. 1 week after the procedure, the disappearance of enhancement in the gastric varix was confirmed on contrast-enhanced multidetector row CT. Furthermore, a significant reduction in the size of the varix was confirmed on endoscopic examination 4 months later.

Development of a New Coaxial Balloon Catheter System for Balloon-Occluded Retrograde Transvenous Obliteration (B-RTO)

To develop a new coaxial balloon catheter system and evaluate its clinical feasibility for balloon-occluded retrograde transvenous obliteration (B-RTO). A coaxial balloon catheter system was constructed with 9 Fr guiding balloon catheter and 5 Fr balloon catheter. A 5 Fr catheter has a high flexibility and can be coaxially inserted into the guiding catheter in advance. The catheter balloons are made of natural rubber and can be inflated to 2 cm (guiding) and 1 cm (5 Fr) maximum diameter. Between July 2003 and April 2005, 8 consecutive patients (6 men, 2 women; age range 33-72 years, mean age 55.5 years) underwent B-RTO using the balloon catheter system. Five percent ethanolamine oleate iopamidol (EOI) was used as sclerosing agent. The procedures, including maneuverability of the catheter, amount of injected sclerosing agent, necessity for coil embolization of collateral draining veins, and initial clinical results, were evaluated retrospectively. The occlusion rate was assessed by postcontrast CT within 2 weeks after B-RTO. The balloon catheter could be advanced into the proximal potion of the gastrorenal shunt beyond the collateral draining vein in all cases. The amount of injected EOI ranged from 3 to 34 ml. Coil embolization of the collateral draining vein was required in 2 cases. Complete obliteration of gastric varices on initial follow-up CT was obtained in 7 cases. The remaining case required re-treatment that resulted in complete obstruction of the varices after the second B-RTO. No procedure-related complications were observed. B-RTO using the new coaxial balloon catheter is feasible. Gastric varices can be treated more simply by using this catheter system.

Balloon-occluded retrograde transvenous obliteration for gastric varices: a feasibility study.

To evaluate the clinical feasibility of balloon-occluded retrograde transvenous obliteration (BORTO) for gastric varices. BORTO was performed in 14 patients with gastric varices due to liver cirrhosis. The gastric varices were confirmed by endoscopy, and their feeding and draining veins were identified by contrast-enhanced computed tomography (CT) and angiography. A 6 Fr Simmons-shaped balloon catheter was inserted into the gastrorenal shunt. The balloon was inflated, and 5% ethanolamine oleate iopamidol was infused slowly through the catheter. Patients were followed up with endoscopy and enhanced CT at 1 week, 1, 3, and 6 months after the procedure and every 6 months thereafter. The gastric varices completely disappeared in 12 of 14 patients and was partially resolved in the remaining 2 patients. Neither a recurrence nor an aggravation of gastric varices were found. No major complications were experienced. BORTO is a safe and effective treatment for gastric varices.