Gastrorenal Shunt Research Articles

Synchronous hybrid procedure combining interventional radiology and endoscopy for esophagogastric varices with large gastro-renal shunt.

Successful treatment of esophagogastric varices (EGV) with giant portal-systemic shunt is challenging. To explore the feasibility and safety of a novel hybrid procedure involving interventional radiology and endoscopy in the same sitting.Three cases clinically diagnosed to have decompensated cirrhosis and EGV with giant gastrorenal shunt (GRS) on contrast-enhanced computed tomography (CT) were included. The hybrid procedures included: indirect portography, hepatic vein pressure gradient (HVPG) measurement, HVPG-based partial splenic embolization (PSE), retrospective GRS balloon occlusion, endoscopic histoacryl injection (EHI), balloon catheter radiography and withdrawal. All the procedures were done in the same operation room. Main outcomes measurements included operation time, complications, and re-bleeding events.Hybrid interventions were performed successfully in 3 cases with a mean operation time of 63.3 minutes without any major intra- and post-operation complications. No rebleeding occurred at 6-month follow-up.Synchronous hybrid intervention combining radiology and endoscopy is feasible and safe for patients with EGV and giant GRS, preliminary study with limited cases deserves further exploration.

PTFE-covered TIPS is an effective treatment for secondary preventing variceal rebleeding in cirrhotic patients with high risks.

AimTo compare the effectiveness and safety of transjugular intrahepatic portosystemic shunt (TIPS) with endoscopic therapy plus non-selective β-blockers (NSBBs) for secondary prevention of gasroesophageal variceal bleeding (GEVB) in cirrhotic patients with high-risk factors of treatment failure.Methods and material:A total of 122 cirrhotic patients with history of gasroesophageal variceal bleeding and high factors including hepatic vein pressure gradient (HVPG) ≥ 20 mmHg, portal vein thrombosis (PVT), gastrorenal shunt (GRS), or extraluminal para-gastric veins (ep-GVs) detected by endoscopic ultrasound, were analyzed retrospectively. Seventy-seven patients underwent TIPS with PTFE-covered stent (group A) and 102 patients received endoscopic therapy combined with nonselective β-blockers (NSBBs) (group B). According to above high-risk factors, both groups were stratified into four paired subgroups (A1–A4 and B1–B4). Two-year rebleeding rate, overt hepatic encephalopathy, overall survival, and procedure-related adverse events were compared between the two groups and paired subgroups.Results:The 2-year cumulative probability of free of variceal rebleeding was higher in group A than group B (93 vs. 62%, P < 0.001). Similarly, the 2-year cumulative probability of free of variceal rebleeding was also higher in the subgroups A1–A4 than the subgroups B1–B4 (91 vs. 67%, P = 0.022, 90 vs. 67%, P = 0.021, 94 vs. 59%, P = 0.029, and 90 vs. 58%, P = 0.016, respectively). There was no significant difference between the two groups and corresponding subgroups in overt hepatic encephalopathy and survival.Conclusion:Compared to secondary prophylaxis with endoscopic therapy plus NSBBs, polytetrafluoroethylene-covered TIPS could significantly reduce the variceal rebleeding rate in cirrhotic patients with HVPG ≥ 20 mmHg, PVT, GRS, or ep-GVs, without increasing the incidence of hepatic encephalopathy.

Safety and Efficacy of Modified BRTO-Assisted Endoscopic Cyanoacrylate Injection for the Treatment of Isolated Gastric Varices with Gastro-Renal Shunt

Safety and Efficacy of Modified BRTO-Assisted Endoscopic Cyanoacrylate Injection for the Treatment of Isolated Gastric Varices with Gastro-Renal Shunt

Successful Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Varices Using Foam Sclerosant Followed by Glue Embolization of Gastrorenal Shunt via the Brachial Vein Approach in a Severely Obese Patient.

Balloon-occluded retrograde transvenous obliteration is an effective treatment for gastric varices. In this report, we illustrate a consecutive treatment strategy via brachial vein approach and n-butyl cyanoacrylate (NBCA) packing of the gastrorenal shunt (GRS) after injecting sclerosing agent in a severely obese patient. The brachial vein approach reduced the burden on the patient, and the closure of the GRS using NBCA shortened the procedure time. These techniques may improve patient comfort as well as reduce medical costs and the risks of several complications.

Endoscopic clipping prior to GVO vs. GVO in IGV1 bleeding: a multicenter retrospective clinical trial.

Background and study aims Bleeding from isolated gastric varices type I (IGV1) is more dangerous and fatal than other types of esophageal variceal hemorrhages. However, optimum treatment for bleeding from IGV1 remains undefined. This retrospective study compared the efficacy of endoscopic clipping prior to N-butyl-2-cyanoacrylate injection (GVO) and only GVO for treatment of IGV1. Patients and methods Data were collected retrospectively at three medical centers. Ninety-six patients were enrolled between March 2015 and April 2017 and divided into two groups: group I (patients with endoscopic clipping prior to GVO, n = 46) and group II (patients with only GVO, n = 50). Computed tomography angiography (CTA) was performed to evaluate the status of gastrorenal shunts (GRS). Results GRS was found in 59 of 66 patients (59/66). The groups did not differ in baseline characteristics. Initial hemostasis was successfully achieved in all patients. There was a significant difference in volume of N-butyl-2-cyanoacrylate administered (3.39 ± 1.20 mL in group I versus 2.53 ± 1.05 mL in group II ( P = 0.03). Rebleeding occurred in 4.35% of patients in group I and 18.00 % in group II ( P = 0.007). Variceal obliteration was achieved in all patients in group I and 72 % in group II ( P < 0.001) with only one session. Rate of complications was similar in both the groups with the exception of one patient in group II who developed ectopic cerebral embolism. Conclusions Endoscopic clipping prior to GVO may be an appropriate alternative to GVO as a treatment modality for IGV1 bleeding.

First results of distal gastric shunting with one anastomosis in patients, suffering morbid obesity

Objective. To study a metabolic effect of distal gastric shunting with one anastomosis in patients, suffering morbid obesity (MO).&#x0D; Materials and methods. The results of surgical treatment of 53 patients, suffering MO, in whom in the clinic a distal gastric shunting with one anastomosis, were analyzed. The patients age range have varied from 27 to 66 yrs old. A median body mass index have constituted 53 kg/m2 (38 - 80 kg/m2). Metabolic syndrome have had all 53 (100%) patients, hypertensive disease, atherosclerotic cardiosclerosis, dyslipidemia - 30 (56.6%) patients, Pickwick syndrome - 4 (7.5%), diabetes mellitus Type II - 11 (20.8%). There were estimated the excessive body mass, laboratory indices - a НOMA index, the levels of insulin, C-peptide, lipids, general protein.&#x0D; Results. In a one year postoperatively a median index of the excessive body mass loss have constituted 67.1%, in 2 yrs - 76.4%. Preoperatively a НOMA index have constituted 8.02 conventional units, level of insulin - 21 mcU/ml, C-peptide - 4.2 ng/ml. Already in 3 mo after distal gastric shunting a НOMA index, the levels of insulin and C-peptide have normalized.&#x0D; Conclusion. Distal gastric shunting constitutes an effective method of surgical correction of MO, metabolic syndrome and in accordance to results is completely comparable with other bariatric operations, and they are technically easier to perform in patients, suffering morbid superobesity, using surgical access with 3 trocars.

1944 BRTO for Treatment of Persistent Gastric Variceal Bleed in a Patient With HCC

INTRODUCTION: Gastric varices are often associated with formation of spontaneous left-sided porto-systemic shunts, which arise to relieve portal hypertension or bypass obstruction. Gastro-renal shunts are the most common (80%), followed by gastro-caval shunts. Balloon Retrograde Transvenous Obliteration remains one of the primary measures to prevent re-bleeding from gastric varices. This procedure consists of inserting a balloon into the outflow vein of a shunt, allowing injection of a sclerosant for occlusion. It has the advantage of not diverting blood to bypass the liver, but it can worsen portal pressure and increase risk for ascites or esophageal variceal bleeding. CASE DESCRIPTION/METHODS: 67-year-old male with past medical history of untreated Hepatitis C was admitted after syncope. He also had nausea, lightheadedness and hematemesis. In the ED, his blood pressure was stable with an Hb of 9.5 mg/dL. Ceftriaxone, an octreotide drip and PPI were promptly started. 3 units of blood were transfused. Urgent endoscopy did not reveal esophageal varices, but profuse active bleeding in the fundus was seen. Attempts to control the hemorrhage were ineffective due to lack of visibility. CT scan of the abdomen showed a cirrhotic liver with a 6 cm mass in the right lobe and a large gastric varix with a gastrorenal shunt. Importantly, there was no evidence of portal or splenic vein thrombosis. Left-sided TIPS was tried, but attempts to pass from left portal vein to left hepatic vein were futile due to challenging anatomy. After multiple transfusions the patient eventually underwent successful BRTO. He had no further bleeding and was ultimately diagnosed with HCC. DISCUSSION: BRTO is indicated primarily for prevention of recurrent gastric variceal bleeding. It is useful in patients with elevated MELD score, right-sided heart failure or hepatic encephalopathy, who are at high risk for TIPS. Patients with gastric variceal bleeding and concomitant HCC usually have more advanced cirrhosis and lower possibility of HCC treatment. This is due to bleeding-related hepatic decompensation and overall poorer liver functional reserve. Although BRTO has its disadvantages, its ability to divert blood flow towards the liver is thought to possibly preserve hepatic function. This might make patients with HCC and gastric varices good candidates for BRTO, allowing better possibility for treatment and increased survival. Further long-term studies are needed to evaluate prognosis and complications of BRTO in these patients.

2428 Direct Intrahepatic Portocaval Shunt (DIPS) as a Therapeutic Option in Acute Variceal Hemorrhage

INTRODUCTION: Direct Intrahepatic Portocaval Shunt (DIPS) is a modified transjugular intrahepatic portosystemic shunt (TIPS) procedure, in which a stent is placed across the inferior vena cava directly into the portal vein under intravascular ultrasound guidance. DIPS is a recognized salvage therapy for acute variceal hemorrhage, but not commonly utilized. Indications for DIPS include patients with hepatic venous anomalies not amenable to TIPS, distorted post-surgical vascular anatomy of the liver, intrahepatic portal venous thrombus, or a prior failed TIPS. CASE DESCRIPTION/METHODS: A 73-year-old male with a history of cirrhosis from alcohol and hepatitis C virus and right lobe hepatocellular carcinoma status-post laparoscopic microwave ablation presented with hematemesis. An EGD revealed a gastric varix (Figure 1), which was deemed too large for treatment with cyanoacrylate glue deposition. A TIPS was attempted but failed due to hepatic venous anomalies. Subsequently, the varix was treated with a balloon-occluded antegrade transvenous obliteration (BATO) and a balloon occluded retrograde transvenous obliteration (BRTO). Figure 2 demonstrates the BATO, which coiled the afferent vessels to the varix (red arrow), and the BRTO, which coiled the efferent gastro-renal shunt of the varix (blue arrow). Two days after the BATO/BRTO, the patient had recurrent melena and anemia. An EGD doppler-guided glue deposition into the gastric varix was attempted but failed. A TIPS was not a viable option as an ultrasonography revealed a new portal vein thrombus extending into the anterior and posterior branches of the right portal vein. Thus, a DIPS was performed. Under intravascular ultrasound guidance, a catheter (red arrows) was advanced from the IVC directly to the left portal vein creating a shunt with stent placement as seen in Figure 3. The pre-procedure portosystemic gradient was 18 mm Hg, and post-procedure portosystemic gradient was 5 mm Hg with a reduction in the gastric varix. The patient is well three-months post-procedure without recurrent melena or anemia. DISCUSSION: This case demonstrates the successful utilization of DIPS in a patient where TIPS was not feasible due to hepatic venous anomalies and a portal vein thrombus. Furthermore, DIPS was successful in the treatment of a variceal hemorrhage when other therapies such as cyanoacrylate glue deposition, BATO, and BRTO failed. Therefore, DIPS should be utilized in challenging cases of variceal hemorrhage when performed by an experienced interventional radiologist.

Endoscopic Therapy and Radiologic Intervention of Acute Gastroesophageal Variceal Bleeding.

Acute gastroesophageal variceal hemorrhage is a dreaded complication in patients with liver cirrhosis. Endoscopic therapy and radiologic intervention for gastroesophageal bleeding have rapidly developed in the recent decades. Endoscopic treatment is initially performed to stop variceal hemorrhage. For the treatment of esophageal variceal bleeding, endoscopic variceal ligation (EVL) is considered the endoscopic treatment of choice. In cases of gastric variceal hemorrhage, the type of gastric varices (GVs) is important in deciding the strategy of endoscopic treatment. Endoscopic variceal obturation (EVO) is recommended for fundal variceal bleeding. For the management of gastroesophageal varix type 1 bleeding, both EVO and EVL are available treatment options; however, EVO is preferred over EVL. If endoscopic management fails to control variceal hemorrhage, radiologic interventional modalities could be considered. Transjugular intrahepatic portosystemic shunt is a good option for rescue treatment in refractory variceal bleeding. In cases of refractory hemorrhage of GVs in patients with a gastrorenal shunt, balloon-occluded retrograde transvenous obliteration could be considered as a salvage treatment.

Clip-assisted endoscopic cyanoacrylate injection for gastric varices with a gastrorenal shunt: a multicenter study.

The aim of this study was to evaluate the safety and efficacy of clip-assisted endoscopic cyanoacrylate injection for gastric varices with a gastrorenal shunt. Records were reviewed of patients with gastric varices and concomitant gastrorenal shunts who underwent clip-assisted endoscopic cyanoacrylate injection at three tertiary centers between April 2016 and October 2018. The assessed outcomes were technical success rate, eradication of gastric varices, cyanoacrylate embolization, and all-cause rebleeding. A total of 61 patients were analyzed. The procedure was successful in all patients (100 %). Gastric varices were eradicated in 30 of 33 patients (90.9 %) according to contrast-enhanced computed tomography re-examination within 1 month after the procedure. No symptoms or signs of cyanoacrylate embolization related to the procedure were observed. Four patients (6.6 %) were lost to follow-up. All-cause rebleeding occurred in 13/57 patients (22.8 %) during a median follow-up period of 225 days (interquartile range 114 - 507 days). Clip-assisted endoscopic cyanoacrylate injection appeared to be a safe procedure that was convenient and efficacious in the treatment of gastric varices with concomitant gastrorenal shunt.

Acute hyperammonemic encephalopathy due to a portosystemic shunt in a non-cirrhotic adult patient

ObjectiveTo report a successfully treated hyperammonemia due to a portosystemic shunt in adult patient. Data sourceA patient with an altered mental status due to severe elevated ammonia level because of a portosystemic shunt. ConclusionsHyperammonemia is not always related to liver failure in critically ill patients, but should be considered in all unknown origins of an altered mental status. A portosystemic shunt can be the responsible for this phenomenon, and it has a newly treatment technique named plug-assisted retrograde transvenous obliteration (PARTO), which can be quickly performed with high technical success rate and clinical efficacy for the treatment of the splenorenal and/or gastrorenal shunt.

Su1535 – Safety and Efficacy of Combined Endoscopic Cyanoacrylate Injection and Angiographic Balloon Catheter Occlusion of Gastrorenal Shunts in Patients with Bleeding Gastric Varices

Su1535 – Safety and Efficacy of Combined Endoscopic Cyanoacrylate Injection and Angiographic Balloon Catheter Occlusion of Gastrorenal Shunts in Patients with Bleeding Gastric Varices

Balloon-Assisted Percutaneous Transhepatic Antegrade Embolization with 2-Octyl Cyanoacrylate for the Treatment of Isolated Gastric Varices with Large Gastrorenal Shunts

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.

The Frequency and Significance of Portopulmonary Venous Anastomosis (PPVA) and Transvenous Obliteration for Gastric Varices

A Portopulmonary Venous Anastomosis (PPVA) is a direct vascular connection between the portal venous system and the pulmonary veins, close to the left atrium. We describe a patient with advanced cirrhosis and moderately severe Hepatopulmonary Syndrome (HPS) in whom (PPVA) was demonstrated by a high resolution computed tomographic scan. In order to reduce the symptoms of hypoxia in our patient, we sequentially performed Transjugular Intrahepatic Portosystemic Shunt (TIPS) followed by a catheter based obliteration of the PPVA. The case raised three questions which were addressed through an extensive literature review. Among patients with advanced cirrhosis, what is the frequency of PPVA? Our literature review suggests that the frequency of finding a PPVA in patients with portal hypertension depends on the imaging technique used. Transhepatic or transvenous portal venography may demonstrate PPVA in about 20% of patients with cirrhosis and varices. Limited published experience with contrast enhanced (bubble) echocardiography suggests that PPVA may be present in about 30% of such patients. An increasing number of case reports of PPVA have been published in recent years. This observation indicates that routine use of High Resolution Computed Tomography (HRCT) and magnetic resonance imaging is able to identify PPVA in cirrhotic patients. The visualization of PPVA with HRCT depends on the timing of the contrast injection and the expertise of the viewer. The present report describes three patients with portopulmonary venous anastomosis (PPVA) in whom balloon-occluded retrograde transvenous obliteration (B-RTO) of gastric varices was attempted. No patients had a gastrorenal shunt. In one patient, after an approach from the inferior phrenic vein (IPV), the PPVA was embolized with the use of microcoils. Portopulmonary Venous Anastomosis Detected at Balloon-occluded Retrograde Transvenous Obliteration for Gastric Varices among cirrhotic patients with PPVA, what is the clinical significance of the PPVA? There are multiple causes of clinically significant hypoxia in patients with cirrhosis. A PPVA is a right to left shunt that, theoretically, could be associated with clinically significant systemic arterial hypoxemia or emboli. There is not definitive evidence in the published literature that PPVA alone causes clinically significant hypoxia in cirrhotic patients. PPVA is, however, a documented important risk factor for systemic emboli when needle or catheter techniques are used to treat or prevent bleeding from gastroesophageal varices.

Laparoscopic ligation of a congenital extrahepatic portosystemic shunt for children with hyperammonemia: a single-institution experience.

A congenital extrahepatic portosystemic shunt (CEPS) associated with hyperammonemia requires occlusion of the shunt vessels. We evaluated the effectiveness and safety of laparoscopic ligation of a CEPS in children with hyperammonemia. The subjects of this retrospective study were seven children with hyperammonemia who underwent laparoscopic ligation of a CEPS. Their median age was 5.2years (range 1-16years). Before the laparoscopic procedure, a catheter was inserted through the femoral vein and placed in the portal vein via the shunt vessel. The shunt vessel was dissected and taped laparoscopically. After measuring the portal vein pressure under temporal occlusion, the shunt vessels were ligated. The types of shunts according to location were patent ductus venosus (n = 2), splenorenal shunt (n = 2), gastrorenal shunt (n = 2), and superior mesenteric vein-inferior vena cava shunt (n = 1). Laparoscopic ligation of the shunt vessel was completed uneventfully in all patients. The median portal vein pressure was 19mmHg after ligation. The median preoperative blood ammonia level was 94µg/dL (range 71-259µg/dL), which decreased after ligation in all patients. There was no incidence of postoperative liver failure. Laparoscopic ligation of a CEPS is safe and effective for children with hyperammonemia.

Clinical efficacy of pericardial devascularization combined with splenectomy and partial gastric fundus resection in the treatment of portal hypertension-induced severe gastric varices complicated with gastrorenal shunt

Objective To investigate the clinical efficacy of pericardial devascularization (PCDV) combined with splenectomy and partial gastric fundus resection (PGFR) in the treatment of portal hypertension-induced severe gastric varices complicated with gastrorenal shunt (GRS). Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 18 patients with portal hypertension-induced severe gastric varices complicated with GRS who were admitted to the Fujian Provincial Hospital from January 2010 to December 2015 were collected. According to the stage of technical development, open surgery or laparoscopic surgery was selected based on patients′ and their family's wishes. Observation indicators: (1) surgical and postoperative recovery situations; (2) postoperative pathological examination; (3) follow-up and survival. The follow-up using outpatient examination and telephone interview was performed once every 3 months within 1 year postoperatively and once every 6 months after 1 year to detect long-term complications and survival up to June 2017. The reexaminations of gastroscopy, enhanced scan of X-ray computed tomography (CT) on the epigastric region or magnetic resonance imaging (MRI) were done at 1 month postoperatively for detecting resection of fundus ventriculi varicosity. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). The survival rate was calculated by the Kaplan-Meier method. Results (1) Surgical and postoperative recovery situations: 18 patients underwent successful PCDV combined with splenectomy and PGFR, including 12 with open surgery and 6 with laparoscopic surgery (1 with conversion to open surgery due to intraoperatively uncontrollable bleeding). There was no perioperative death. The operation time, volume of intraoperative blood loss, recovery time of gastrointestinal function, time of postoperative drainage-tube removal and duration of hospital stay were (192±20)minutes, (280±30)mL, (33±6)hours, 8 days (range, 5-9 days), 8 days (range, 5-12 days) in 12 patients with open surgery and (208±40)minutes, (210±10)mL, (28±5)hours, 7 days (range, 5-26 days), 7 days (range, 5-10 days) in 6 patients with laparoscopic surgery, respectively. One patient with laparoscopic surgery had intraoperative condensed erythrocyte infusion with 2 U. Seven, 1, 0 patients with open surgery and 4, 1, 1 patients with laparoscopic surgery were respectively complicated with pleural effusion, delayed gastric emptying and pancreatic leakage in level A, and they were cured by conservative treatment. (2) Postoperative pathological examination: results of postoperative pathological examination in 18 patients showed that a large number of varicose veins in the mucous and serosal layers of gastric fundus and moderate or severe hepatic cirrhosis. (3) Follow-up and survival: 18 patients were followed up for 8-78 months with a median time of 39 months. The gastroscopy and enhanced scan of X-ray CT at 1 month postoperatively showed that no varicose veins in the gastric fundus. During the follow-up, there was no recurrence of gastric varices with GRS and esophageal stenosis. Of 4 patients with portal vein thrombosis, 1 died of portal hypertensive gastropathy-induced upper gastrointestinal bleeding due to stop taking warfarin, and other 3 patients had portal vein patency by warfarin therapy. One patient was complicated with liver cancer at 32 months postoperatively and received radiofrequency ablation therapy. Two patients died, including 1 dying of hepatic failure at 35 months postoperatively and 1 dying of advanced liver cancer at 54 months postoperatively. The 1-, 3- and 5-year overall survival rates of 18 patients were respectively 93.8%, 84.4% and 70.3%. Conclusion The PCDV combined with splenectomy and PGFR is safe and effective in the treatment of portal hypertension-induced severe gastric varices with GRS, with a dissemination value for appropriate patients. Key words: Liver cirrhosis; Portal hypertension; Gastric varices; Gastrorenal shunt; Partial gastrectomy; Pericardial devascularization; Splenectomy; Laparoscopy

Measurement of Inferior Vena Cava to Shunt Distance in Deciding Access Route for Balloon-Occluded Retrograde Transvenous Obliteration Procedure: A Pilot Study

Purpose: Why and how to decide whether femoral or jugular approach should be used for shunt catheterization for a successful balloon-occluded retrograde transvenous obliteration (BRTO) procedure. Materials and Methods: Sixteen patients had undergone BRTO for variceal bleeding (11 cases) and encephalopathy (5 cases) with the femoral (13) and jugular approach (5). In two patients, both femoral and jugular approaches were used. There were four failed shunt catheterizations with the femoral or jugular approach two each. In all patients, the inferior vena cava (IVC) to shunt distance (ISD) was measured on the reformatted coronal computed tomography image. Results: The IVC to shunt distance (ISD) was between 2.0 and 3.5 cm in 13 patients and &gt;3.5 cm in five. Two patients were having both proximal gastrorenal and distal splenorenal shunts. The ISD was &gt;3.5 cm in two patients with failed initial femoral approach and &lt; 3.5 cm in two other patients with failed initial jugular approach. In each of the four failures, the alternative approach resulted in obtaining a successful BRTO. Conclusion: The femoral approach is recommended for catheterization of the gastrorenal shunt for BRTO when the shunt joins the renal vein within 3.5 cm from the IVC. However, when the shunt is farther than 3.5 cm from the IVC, the jugular approach is suitable for a BRTO procedure.

Hemodynamically efficient portal decompression: the concept of competing spontaneous and surgical shunts

Introduction: Temporary portocaval shunt (PCS) has a positive impact on short-term outcomes after liver transplantation (LT). An alternative to this proximal shunt is a distal passive decompression through mesenterico-saphenous shunt (MSS). The goal of this study was to compare the efficiency of spontaneous and surgical distal versus proximal shunts and discuss their respective place during the anhepatic phase in regard to the anatomy of preexisting spontaneous shunts. Method: Patients transplanted in a 2-year period who underwent portal decompression during the anhepatic phase were included. Intraoperative and in-hospital course were compared according to 2 types of surgical decompression techniques: PCS (n = 44) and MSS (n = 77). The impact of spontaneous shunt anatomy on the hemodynamic and metabolic efficiency of surgical shunts using portal pressure and capillary lactate measurements as well as on early graft function were evaluated. Results: MSS and PCS showed a comparable hemodynamic and metabolic efficiency with no significant difference in terms of portal pressure variations and gut lactate production. There was no significant difference in terms of reperfusion syndrome, transfusion rate, renal failure nor early allograft dysfunction (p = 0.956, 0.575, 0.239 and 0.976 respectively). In case of competing shunts (example: PCS and splenorenal shunt or MSS and left gastric shunt), there was a significantly higher rate of EAD (67% vs 13%; p = 0.002). Conclusion: Classical portacaval anastomosis and passive mesenterico-saphenous shunt offer similar hemodynamic and metabolic efficiency without impacting on the outcomes after liver transplantation. Their respective place should be discussed in regard to the anatomy of preexisting portosystemic shunts.

Evolution of Retrograde Transvenous Obliteration Techniques.

Gastric variceal hemorrhage is a life-threatening complication of portal hypertension with a poorer prognosis compared with esophageal variceal hemorrhage. The presence of an infradiaphragmatic portosystemic shunt, often a gastrorenal shunt, allows for treatment with retrograde transvenous obliteration (RTO). RTO is an evolving treatment strategy, which includes balloon-assisted RTO, plug-assisted RTO, and coil-assisted RTO, for both gastric variceal hemorrhage and hepatic encephalopathy. RTO techniques are less invasive than transjugular intrahepatic portosystemic shunt creation, with the benefit of improved hepatic function, but at the expense of increased portal pressure. This article discusses the techniques of RTO, including patient eligibility, as well as technical and clinical outcomes, including adverse events.

864 SUCCESSFUL EUS-GUIDED TREATMENT OF GASTRIC VARICES WITH COIL EMBOLIZATION AND INJECTION OF ABSORBABLE GELATIN SPONGE

Gastric varices occur in 15-20% of patients with portal hypertension and are associated with significant gastrointestinal bleeding and high mortality. Endoscopic options are currently limited in patients with bleeding gastric varices. Here, we report our experience with endoscopic ultrasound-guided coil embolization and injection of absorbable gelatin sponge for the treatment of gastric varices. A 51 year old female with alcoholic cirrhosis, complicated by ascites, hepatic encephalopathy, and known type 1 gastric varices, presents to the hospital with hematemesis. She was deemed by interventional radiology to not be a suitable candidate for either transjugular intrahepatic portosystemic shunt (TIPS) or balloon occluded retrograde transvenous obliteration (BRTO). It was therefore decided to offer EUS-guided treatment of her gastric varices. On EUS, four large collections of gastric varices were visualized, each with multiple individual compartments measuring 7-12 mm in short axis. Multiple varices were seen to directly contact the surface of the fundus. Using a 19 gauge EUS needle, a collection of gastric varices was punctured, followed by deployment of multiple 20 mm x 14 cm and 20 mm x 7 cm embolization coils. Following coil embolization, there was immediate obliteration of Doppler flow. After multiple coils were deployed, and contrast injections ruled out the presence of a gastrorenal shunt, additional injection was performed of absorbable gelatin sponge (prepared as a slurry) in order to further enhance variceal eradication. The process was then repeated until all four collections of gastric varices were eradicated. In total, eight vascular coils were deployed. The patient tolerated the procedure well and has not had recurrent bleeding on follow-up. EUS guided coil embolization and injection of absorbable gelatin sponge is a feasible and effective technique for the endoscopic management of symptomatic gastric varices in patients considered to be poor candidates for standard treatments such as TIPS and BRTO. This case highlights the advantages of coil embolization and absorbable gelatin sponge application, as well as the benefit of EUS guidance, over traditional direct cyanoacrylate injection for the endoscopic management of gastric varices.