Percutaneous Transhepatic Obliteration Research Articles

Variations of Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Balloon-occluded Antegrade Transvenous Obliteration (BATO) and Alternative/Adjunctive Routes for BRTO

Alternative routes for transvenous obliteration are often sought in the management of gastric varices, as well as in the management of other nongastric varices (ectopic varices) such as duodenal and mesenteric varices. These alternative routes can be classified into A-portal venous access routes and B-systemic venous access routes. Anecdotally, alternative routes are more commonly required with duodenal and mesenteric varices compared with gastric varices. Twelve percent (2-19%) of patients with gastric varices require alternative/adjunctive variceal access routes. The most common alternative route described for transvenous obliteration of gastric varices is the percutaneous transhepatic route, which is commonly referred to in the Japanese literature as percutaneous transhepatic obliteration (PTO). The percutaneous transhepatic obliteration route can be performed alone or in combination with the more traditional balloon-occluded retrograde transvenous obliteration (BRTO) transrenal route. Percutaneous transhepatic obliteration by itself is successful in 44-100% of cases for obliterating gastric varices and is rarely unsuccessful when it is combined with BRTO. Other alternative routes are less commonly described and as a result, their clinical outcomes are relatively anecdotal. However, they are technically more challenging and are less commonly successful. These routes include, but are not confined to transphrenic, transileocolic, trans-TIPS (transvenous intrahepatic portosystemic shunt), transgonadal, transazygous, and transrenal capsular vein approaches.

Treatments for Rectal Varices with Portal Hypertension

Rectal varices are considered to occur infrequent, however, potentially serious cause of hematochezia. Various treatments have been performed to control bleeding rectal varices. Some investigators have reported that endoscopic treatments such as endoscopic injection sclerotherapy (EIS) and endoscopic band ligation (EBL) were successfully employed for rectal variceal bleeding. EIS may be superior to EBL with regard to long-term effectiveness and complications as endoscopic treatments of rectal varices, and percutaneous transhepatic obliteration may be useful for large rectal varices. Hemorrhage from rectal varices should be kept in mind in patients with portal hypertension presenting with lower gastrointestinal bleeding, however, it is difficult to determine the best medical treatment strategy for rectal varices because of difficulty in diagnosis and subsequent difficulty in treatment.

Gastrointestinal: Successful obliteration of bleeding duodenal varices using band ligation

A 57 year old male with hepatitis C and alcohol induced cirrhosis, presented to the emergency with hemetemesis and hematochezia, followed by lightheadness and diaphoresis. He had no history of gastrointestinal hemorrhage. The patient was on warfarin and naproxen following recent knee surgery. He continued to drink 2-3 beers daily. On admission, his BP was 96/60 and pulse was 90/min. Physical exam was otherwise unremarkable. Investigations included a hemoglobin of 7.5 g/dl, platelet count 123, BUN of 30, creatinine 0.7, INR of 1.4 and normal liver enzymes. He was resuscitated with blood and IV fluids, and was started on IV esomeprazole and octreotide. An emergent upper endoscopy demonstrated an oozing duodenal varix between the first and the second portion of the duodenum with a platelet plug (Figure 1). Two bands were successfully placed upon the variceal column (Figure 2). No esophageal or gastric varices were identified. The patient had no further bleeding and was discharged several days later. Follow up endoscopy at one month revealed scarring and healing ulceration at the band ligation sites (Figure 3 arrows). Duodenal varix with platelet plug. Duodenal varix immediately post banding. Duodenal varix site one month later. Varices outside the gastro esophageal region, are referred to as ectopic varices. Ectopic varices are rare, and constitute 1 to 5% of all variceal hemorrhage. Nearly 17% of ectopic variceal bleeding occurs in the duodenum. Duodenal varices (DV) in the absence of esophageal varices, as seen in this patient, are an even more uncommon manifestation of portal hypertension. They result from retroperitoneal porto-systemic shunts caused by increased hepatofugal blood flow through the cystic branch of the superior mesenteric vein, superior and inferior pancreaticoduodenal veins, and gastroduodenal and pyloric veins. Such varices are less effective in lowering the portal pressure, compared with esophageal and gastric varices. The serosal and submucosal location of DV, limits visualization during endoscopy. Their clinical significance is not apparent until the varix expands into the submucosal space where it can hemorrhage into the gastrointestinal lumen. Because of the infrequency of DV hemorrhage, treatment modalities have not been prospectively validated. These include surgical intervention (variceal ligation, duodenal resection, and extra-hepatic portosystemic shunt creation), interventional radiological procedures (tranjugular intrahepatic portosystemic shunt, percutaneous transhepatic obliteration, trans-ileocolic vein obliteration, balloon occluded retrograde transvenous obliteration), and endoscopic techniques (band ligation, sclerotherapy and clipping). Contributed by

C-arm CT-guided Foam Sclerotherapy for the Treatment of Gastric Varices

The authors describe here the use of foam sclerotherapy under C-arm computed tomography (CT) guidance for the treatment of gastric varices via balloon-occluded retrograde transvenous obliteration in seven patients and percutaneous transhepatic obliteration in one patient. All gastric varices were occluded successfully after replacement of blood by foam, which was trapped in the gastric varices as shown by C-arm CT. It also helped reduce the amount of sclerosant, an issue that is associated with severe complications, such as hemolysis, allergy, acute respiratory distress syndrome, and others. Foam sclerotherapy under C-arm CT guidance is a promising tool in the therapeutic armamentarium against gastric varices.

Transabdominal color Doppler ultrasonography for the diagnosis of small intestinal and vesical varices in a patient successfully treated with percutaneous transhepatic obliteration.

A 52-year-old asymptomatic female was admitted to our hospital in January 2008 with enlarged esophageal varices due to alcoholic liver cirrhosis. Color Doppler ultrasonographic examination showed images of vessels on the small intestinal wall around the umbilical area and the anterior wall of the bladder. Images of the vessels were obtained for the small intestinal wall and the anterior wall of the bladder with computed tomography. Percutaneous transhepatic portography was performed, and hepatofugal blood flow was observed in the inferior epigastric vein connected to the superior mesenteric vein and the contrast medium passed into the small intestinal varices and the vesical varices, which drained into the right ovarian vein. Percutaneous transhepatic obliteration was then successfully performed via the afferent veins of the small intestinal varices and vesical varices. One week after the treatment, color Doppler ultrasonography showed a remarkable decrease in blood flow in the varices.

Role of percutaneous transhepatic obliteration for special types of varices with portal hypertension

Role of percutaneous transhepatic obliteration for special types of varices with portal hypertension

Management of gastric fundal varices without gastro-renal shunt in 15 patients

To examine the portal hemodynamics of gastric fundal varices (GV) without gastro-renal shunt (GRS), and to retrospectively investigate the effects of various kinds of treatment on eradication. Ninety-four liver cirrhosis patients at high-risk of GV were treated in our hospital and enrolled in this study. We retrospectively examined their characteristics, liver function, and portal hemodynamics of GV. We performed balloon-occluded retrograde transvenous obliteration (BRTO) at first. If it was not technically possible to perform BRTO, endoscopic injection sclerotherapy using alpha-cyanoacrylate glue (CA) or percutaneous transhepatic obliteration (PTO) was performed. Among the 94 patients, a GRS was present in 79 (84.0%), and absent in the remaining 15 (16.0%). The subphrenic vein was connected to the inferior vena cava as the drainage vein in 13 (86.7%) out of the 15 cases without GRS. We performed BRTO in 6 patients, CA in 4 patients and PTO in 5 patients. The eradication rate was 100% for each procedure, but the rate of early recurrence within 6 mo was 16.7% for BRTO, 50.0% for CA and 40.0% for PTO, respectively. We should examine the hemodynamics before treatment of GV irrespective of the existence of GRS. If this hemodynamic examination reveals that the drainage vein connects directly to the inferior vena cava in GV without GRS, BRTO may be an effective treatment for GV with GRS.

Hepatic perfusion changes after interventional disconnection evaluated by CT perfusion imaging

To evaluate the changes in hepatic perfusion after interventional obliteration in patients with cirrhosis and portal hypertension by means of spiral CT perfusion imaging. Twenty-three patients who suffered from cirrhosis and portal hypertension were selected to undergo interventional disconnection. Partial spleen embolization (PSE) was performed in 15 patients and PSE combined with percutaneous transhepatic obliteration (PTO) was carried out in 8 patients. Hepatic perfusion was carried out pre- and post-operation. The density-time curve was obtained from the interest region of liver, abdominal artery, portal vein. The parameters of perfusion were calculated by the means of deconvolution simultaneously. The portal vein perfusion (PVP) decreased in patients with PSE, but total hepatic blood perfusion was not statistically different from that of pre-operation. After treatment, the hepatic artery perfusion increased obviously. PVP decreased from 0.862 to 0.722 ml x min(-1) x ml(-1) but was not statistically different from that of pre-operation. Hepatic arterial perfusion and total hepatic blood perfusion increased from 0.128, 0.990 ml x min(-1)x ml(-1) pre-operatively to 0.290, 1.021 ml x min(-1) x ml(-1) postoperatively in patients with PSE combined with PTO. Spiral CT perfusion could objectively reflect the hemodynamic change in hepatic parenchyma after the interventional vascular obliteration.

Efficacy of color Doppler ultrasonography for the diagnosis of duodenal varices successfully treated with percutaneous transhepatic obliteration

We treated a 74-year-old woman who complained of tarry stool. Neither endoscopic examination of the upper gastrointestinal tract nor colonoscopy revealed any finding indicative of bleeding, and (99m)Tc-HSA-D pool scintigraphic imaging showed no accumulation of blood in the digestive tract. Small tortuous collateral veins were observed on computed tomography (CT) in the distal third portion of the duodenum. Color Doppler ultrasonography obtained color flow images of varices in the distal third portion of the duodenum indicating turbulent flow, and color flow imaging showed the outflow vessel from duodenal varices. Duodenoscopy revealed tortuous varices, with erosions and blue in appearance, in the same area. Percutaneous transhepatic portography was carried out 18 days after the treatment of ascites, and hepatofugal blood flow was confirmed in the pancreatic duodenal vein originating near the junction between the splenic and inferior mesenteric veins with the passage of contrast medium into the duodenal varices, which drained into the left ovarian vein. We performed selective catheterization into the afferent vein of the varices, and injected 8 ml of a 5% solution of ethanolamine oleate containing iopamidol. Microcoil embolization using steel coils was added because the therapeutic effect resulting after the relatively rapid washout of sclerosant was insufficient. CT and color Doppler ultrasonography showed absence of blood flow in the varices 1 week after the therapy. This patient has had no episodes of rebleeding in the 24 months after therapy. Color Doppler ultrasonography was useful in diagnosing this case of duodenal varices and in evaluating therapeutic effect.

ＧＡＦ Ｓｙｓｔｅｍを用いた腹部ＩＶＲ時の患者皮膚線量の検討

Radiation-induced skin injury caused by interventional radiology(IVR)is a deterministic effect. If exposure dose exceeds threshold dose, injuries may occur. It therefore is important to understand the maximum exposure dose in skin. The purpose of this study was to determine the maximum exposure dose and its dose distribution. Moreover, to analyze the factors from measuring the absorbed dose in the incoming radiation side, a film-type dosimeter was used. When the measured results were determined in terms of the clinical aspect, fluoroscopic time(total time)in procedure, it ranged from 3.3 to 64.0 minutes, and DSA images obtained ranged from 8 to 280 images. Absorbed dose ranged from 0.3 to 6.0 Gy, with an average dose of 3.2 Gy. It thus exceeded 2 or 3 Gy, which was the threshold dose of temporary erythematic or depilation in 10 of 14 cases. The maximum dose was 6.0 Gy for a procedure of percutaneous transhepatic obliteration. The maximum exposure dose can be determined objectively by using a film-type dosimeter. It was also possible to grasp the overall dose distribution visually.

Management of gastric variceal bleeding

We read with interest the article by Jang et al. [1] about a case of gastric variceal bleeding that was treated by endoscopic band ligation (EBL). Treatment of gastric varices with EBL has been reported to cause massive and fatal bleeding from EBL-related ulceration [2]. We therefore believe that EBL for the treatment of gastric variceal bleeding was an inadequate management. The best preventive approach for gastric variceal bleeding has been believed to be surgery [3]. However, its high invasiveness has limited the wide application of the procedure because these patients usually have poor hepatic functional reserve [3]. Although percutaneous transhepatic obliteration (PTO) is a well-established technique in the management of gastric variceal bleeding, the procedure is associated with a high incidence of rebleeding and recurrence [3]. Transjugular intrahepatic portosystemic shunt (TIPS) is considered to be a rescue option for variceal bleeding unresponsive to pharmacological and endoscopic treatment. However, TIPS has major disadvantages, such as stenosis and occlusion of the shunt, high rebleeding rates, and induction of hepatic encephalopathy [3], and might be ineffective for gastric varices with a gastrorenal shunt because of low portosystemic gradients [4].

Role of percutaneous transhepatic obliteration for special types of varices with portal hypertension

The treatment of special types of varices with portal hypertension has not yet been established. We were able to control 13 cases of special types of varices by percutaneous transhepatic obliteration (PTO). These 13 cases consisted of 2 esophagojejunal varices after total gastrectomy for gastric cancer, 1 stoma varices after abdominoperineal excision for rectal cancer, 2 mesenteric varices with encephalopathy, 1 gastric variceal rupture, 1 gastrorenal and gastroazygos shunt with encephalopathy, 3 giant bar-type esophageal varices, 2 isolated gastric varices with gastropericardiac shunts, and 1 isolated gastric varices with gastrophrenic shunt. The special types of varices were successfully embolized in all cases and there were no complications. We conclude that the PTO is still an effective and safe treatment for special types of varices with portal hypertension.

Efficacy of balloon-occluded retrograde transvenous obliteration, percutaneous transhepatic obliteration and combined techniques for the management of gastric fundal varices

To evaluate the effect of three interventional treatments involving transvenous obliteration for the treatment of gastric varices, and to compare the efficacy and adverse effects of these methods. From 1995 to 2004, 93 patients with gastric fundal varices underwent interventional radiologic embolotherapy at our hospital. Of the 93 patients, 75 were treated with the balloon-occluded retrograde transvenous obliteration (BRTO) procedure; 8 were with the percutaneous transhepatic obliteration (PTO) procedure; and 10 were with the combined BRTO and PTO therapy. A follow-up evaluation examined the rates of survival, recurrence and rebleeding of the gastric varices, worsening of esophageal varices and complications in each group. The BRTO, PTO, and combined therapy were technically successful in 81% (75/93), 44% (8/18), and 100% (10/10) patients, respectively. Recurrence of gastric varices was found in 3 patients in the BRTO group and in 3 patients in the PTO group. Rebleeding was observed in 1 patient in the BRTO group and in 1 patient in the PTO group. The 1- and 3-year survival rates were 98% and 87% in the patients without hepatocellular carcinoma (HCC) in the BRTO group, 100% and 100% in the PTO group, and 90% and 75% in the combined therapy group, respectively. Combined BRTO and PTO therapy may rescue cases with uncontrollable gastric fundal varices that remained even after treatment with BRTO and/or PTO, though there were limitations of our study, including retrospective nature and discrepancy in sample size between the BRTO, PTO and combined therapy groups.

A case of rectal varices treated by Percutaneous transhepatic obliteration of varices (PTO)

A case of rectal varices treated by Percutaneous transhepatic obliteration of varices (PTO)

Percutaneous Trans-hepatic Obliteration for Bleeding Esophagojejunal Varices After Total Gastrectomy and Esophagojejunostomy

A 72-year-old man who had undergone a total gastrectomy with a Roux-en-Y esophagojejunostomy for gastric cancer 6 years earlier presented to our hospital with massive hematemesis and melena. Endoscopic examination indicated esophageal varices with cherry-red spots and hemorrhage arising from beyond the anastomosis. Abdominal contrast-enhanced computed tomography and angiography revealed a dilated vein in the elevated jejunal limb supplying the varices. Percutaneous trans-hepatic obliteration (PTO) of the varices through the jejunal vein was performed using microcoils, ethanolamine oleate, and gelatin sponge cubes. Ten days after the procedure, endoscopic examination revealed reduction and thrombosis of the varices. We consider PTO to be an effective alternative method for treating ruptured esophagojejunal varices after total gastrectomy.

Percutaneous transhepatic obliteration for isolated gastric varices with gastropericardiac shunt: case report

Management of isolated gastric varices with a gastropericardiac shunt (GPS) has not yet been established. We were able to control a case of isolated gastric varices with a GPS by percutaneous transhepatic obliteration (PTO) using a microcatheter. In this case, the main blood drainage route was not a gastrorenal shunt, so transvenous retrograde obliteration could not be performed and PTO using the microcatheter was applied. Percutaneous transhepatic splenic venography revealed that the gastric varices came from the posterior gastric vein and the main drainage route was a GPS. Gastric varices and their blood supply were superselectively embolized using platinum microcoils and absolute ethanol. Portal venous pressure did not change after PTO because the route from the left gastric vein to the azygos venous system was preserved. Computed tomography 7 days after PTO revealed that the gastric varices were completely obliterated by the thrombi. Plasma ammonia level, arterial ketone body ratio, and indocyanine green retention rate at 15 min were improved. We conclude that PTO using a microcatheter is a rational, effective, and safe therapy for isolated gastric varices with a GPS.

Balloon occluded retrograde transvenous obliteration and percutaneous transhepatic obliteration for ruptured duodenal varices after operation for rectal cancer with multiple liver metastasis: report of a case

We report a patient with duodenal varices oozing blood who had undergone low anterior resection of the rectum and resection of the liver tumor because of multiple liver metastasis from rectal cancer 80 months previously. Although endoscopic variceal ligation (EVL) was carried out for the ruptured duodenal varices, their bleeding persisted and hepatic encephalopathy also appeared. Finally, balloon occluded retrograde transvenous obliteration (BRTO) with percutaneous transhepatic obliteration (PTO) was carried out for the duodenal varices. Percutaneous transhepatic portography revealed detailed hemodynamics. Following PTO, the duodenal varices were stagnated by BRTO, and no complications were recognized. No re-bleeding episode has been observed since the treatment. In addition, the hepatic encephalopathy was also improved.

Symptomatic intrahepatic portosystemic venous shunt: embolization with an alternative approach.

Intrahepatic portosystemic venous shunt is relatively rare and not well recognized. Awareness of intrahepatic communications is important because they can cause encephalopathy, and most of these shunts can be completely cured by transcatheter embolization. In this study, we describe the angiographic findings and transcatheter embolization techniques using several approaches for the treatment of intrahepatic portosystemic venous shunt. Between 1989 and 2001, we treated 10 patients with symptomatic intrahepatic portosystemic venous shunt by performing transcatheter embolization with Gianturco coils, fibered platinum coils, detachable balloons, and detachable microcoils using one of three approaches to access the portal venous system: transileocolic obliteration (n = 2), percutaneous transhepatic obliteration (n = 4), or retrograde transcaval obliteration (n = 4). In all patients, complete obliteration or nearly complete obliteration was confirmed angiographically, and symptoms related to portal-systemic encephalopathy improved after treatment. Complications were observed in three patients: adhesive ileus in a patient treated by transileocolic obliteration and thrombosis of intrahepatic portal branches in two patients treated by percutaneous transhepatic obliteration. On angiography, two types of intrahepatic portosystemic venous shunt were seen: intrahepatic portal venous-hepatic venous communication and intrahepatic portal venous-perihepatic venous communication. Transcatheter embolization is effective for treatment of intrahepatic portosystemic venous shunt. Retrograde transcaval obliteration is the least invasive technique and is recommended as the first choice for treatment of portosystemic venous shunt except in patients with multiple shunts.

Percutaneous transhepatic obliteration combined with partial splenic embolization for the gastric varices; a case report

Percutaneous transhepatic obliteration combined with partial splenic embolization for the gastric varices; a case report

A case of huge gastric varices successfully treated with endoscopic injection sclerotherapy with occlusion of both supplying and draining veins with balloons

Gastric varices bleed less frequently but more severely than esophageal varices. Endoscopic treatment for gastric varices using sclerosants such as ethanol, ethanolamine oleate, and tissue adhesive agents has been reported,1-3 but no single effective method has yet been established. Other procedures for gastric varices such as surgical intervention, percutaneous transhepatic obliteration, transjugular intrahepatic portosystemic shunt (TIPS), and balloon-occluded retrograde transvenous obliteration (B-RTO) may be effective.4-9 However, these procedures cannot always be performed because patients may have poor hepatic function or a hemorrhagic diathesis and often have hepatocellular carcinoma or sometimes gastric varices without an associated gastro-renal shunt. We therefore have tried to treat such varices with endoscopic injection sclerotherapy together with percutaneous transhepatic obliteration with a balloon catheter, and, if the gastric varices have a gastro-renal shunt, with obliteration of the shunt with another balloon catheter. This procedure has the advantage that sclerosant is placed with the targeted varices, and that it can be also used to treat gastric varices safely regardless of variations in portal anatomy. In the present case, we used this procedure for giant gastric varices 15 mm in diameter with the gastro-renal shunt and obtained complete embolization of the varices with use of minimal sclerosant.