Retrograde Transvenous Obliteration Research Articles

Rectal varices treated by retrograde transvenous obliteration

Rectal varices treated by retrograde transvenous obliteration

Ендоваскулярні втручання в комплексній терапії пацієнтів із портальною гіпертензією і кровотечею з варикозно розширених вен

For today, endovascular procedures, such as embolization of splenic artery, transjugular intrahepatic shunt, and retrograde transvenous obliteration with balloon occlusion are widely applied in the treatment and prophylaxis of variceal bleeding in patients with portal hypertension. Splenomegaly with the development of hypersplenism is one of complications of portal hypertension in patients with liver cirrhosis, which can negatively be influenced on clinical course. Due to that, it can be assumed that the management of hypersplenism in patients with portal hypertension with the applying of splenic artery embolization, could be improve the results of treatment of this group of patients. Purpose - to summarize the own experience of the applying of splenic artery embolization in the complex therapy in patients with portal hypertension that complicated by the variceal bleeding. Materials and methods. This study based on the results of treatment of 36 patients, in which the embolization of splenic artery was applied in the complex management (conventional treatment and endoscopic ligation of varices). The classic method of “chronic” occlusion was used for the embolization. The embolization on the level of the initial portion of the main trunk of splenic artery was performed in 30 (83.3%) of patients. Due to the anatomical peculiarities of vasculature, embolization was performed on the level of middle part of splenic artery in 6 (16.7%) of patients. The effectiveness of the treatment was evaluated by the changes of complete blood count indices and ultrasonography results. Statistical analysis was performed using the program SPSS Statistic for Windows, version 15.0 (IBM Corp., Armonk, NY, USA). Results. The middle age of patients was 55.8±1.6 years. The middle value of Child-Turcotte-Pugh criterion was 2.44±0.08, and MELD score was 16.36±0.99 value. Conclusions. The applying of splenic artery embolization that combined with conventional therapy and endoscopic ligation of varices is appropriate and justified. Embolization of the splenic artery promotes to decrease of appearance of hypersplenism in patients with the portal hypertension with positive influence on follow-up clinical course. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

AASLD Practice Guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage.

AASLD Practice Guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage.

Antegrade Gastric Variceal Embolization Simultaneously With Tips in Treatment of Patients with Acute Gastric Variceal Bleeding Having Unfavorable Gastric Variceal Anatomy

Gastric varices bleed at a lower Porto systemic pressure, have more catastrophic consequences and associated with large Porto systemic shunts. Occluded retrograde Trans-venous obliteration (RTO) is the mainstay of therapy for gastric variceal bleeding refractory to endoscopic therapy. A favorable afferent (Kiyosue type 1) and efferent (Kiyosue type A) anatomy of gastric varices is required for successful and safe RTO. Complex modifications in the RTO procedure are required for unfavorable afferent and efferent anatomies with high failure rates. RTO is not feasible in a type D efferent anatomy. RTO may aggravate potential complications associated with portal hypertension (ascites, catastrophic esophageal variceal bleeding). Antegrade gastric variceal embolization in adjunct to TIPS placement offers a safe, easier and effective alternative to modified RTO for gastric varices with unfavorable afferent and efferent anatomy. Concomitant placement of a TIPS stent leads to portal decompression and diminishes the risks associated with aggravation of portal hypertension. In this review, we discuss the anatomic and hemodynamic classification of gastric varices and describe the advantages of antegrade embolization (+TIPS) over RTO for management of gastric variceal bleeding in patients with complex variceal anatomies.

Endoscopic variceal obturation and retrograde transvenous obliteration for acute gastric cardiofundal variceal bleeding in liver cirrhosis

Background/AimsWe retrospectively compared the effect of endoscopic variceal obturation (EVO) and retrograde transvenous obliteration (RTO) in acute cardiofundal variceal bleeding.MethodsPatients with acute cardiofundal variceal bleeding treated with EVO or RTO at two hospitals were included.ResultsNinety patients treated with EVO and 86 treated with RTO were analyzed. The mean model for end-stage liver disease score was significantly higher in EVO group than in RTO group (13.5 vs. 11.7, P = 0.016). The bleeding control rates were high (97.8% vs. 96.5%), and the treatment-related complication rates were low in both EVO and RTO groups (2.2% vs. 3.5%). During the median follow-up of 18.0 months, gastric variceal (GV) and esophageal variceal rebleeding occurred in 34 (19.3%) and 7 (4.0%) patients, respectively. The all-variceal rebleeding rates were comparable between EVO and RTO groups (32.4% vs. 20.8% at 2-year, P = 0.150), while the GV rebleeding rate was significantly higher in EVO group than in RTO group (32.4% vs. 12.8% at 2-year, P = 0.003). On propensity score-matched analysis (71 patients in EVO vs. 71 patients in RTO group), both all-variceal and GV rebleeding rates were significantly higher in EVO group than in RTO group (all P < 0.05). In Cox regression analysis, EVO (vs. RTO) was the only significant predictor of higher GV rebleeding risk (hazard ratio 3.132, P = 0.005). The mortality rates were similar between two groups (P = 0.597).ConclusionsBoth EVO and RTO effectively controlled acute cardiofundal variceal bleeding. RTO was superior to EVO in preventing all-variceal and GV rebleeding after treatment, with similar survival outcomes.

Retrograde transvenous obliteration for the prevention of variceal rebleeding in patients with hepatocellular carcinoma: a multicentre retrospective study

To evaluate the effectiveness and safety of retrograde transvenous obliteration (RTO) for the prevention of variceal rebleeding variceal rebleeding in patients with hepatocellular carcinoma (HCC). This multicentre retrospective study enrolled 79 patients with HCC who underwent RTO for the prevention of variceal rebleeding. Successful occlusion of the gastrorenal shunt and obliteration of the gastric varices were achieved in 74 patients, with a technical success rate of 93.7%. Of the remaining 74 patients (mean age, 64.9±10.3 years; 56 men), 66 (90.4%) had gastroesophageal varices and seven (9.6%) had isolated gastric varices. Thirty-two patients (43.8%) underwent balloon-occluded RTO, 40 patients (54.8%) underwent plug-assisted RTO, and one patient (1.4%) underwent coil-assisted RTO. No patients had major procedural complications. Rebleeding occurred in seven patients (9.6%) during the follow-up period. The 6-week and 1-year actuarial probabilities of patients remaining free of rebleeding were 90.8±3.6% and 88.6±4.1%, respectively. The median survival was 12.6 (95% confidence interval [CI] 8-17.3) months. The 6-week, 1-year, and 3-year actuarial probabilities of survival were 83.2±4.4%, 51.1±6.6%, and 32.7±7%, respectively. New or worsening ascites and oesophageal varices occurred in 12 (16.4%) and 13 patients (17.8%), respectively, during the follow-up period. Overt hepatic encephalopathy occurred in one patient (1.4%) during the follow-up period. The Child-Pugh score remained comparable to that at baseline at 1 and 3 months. RTO was effective and safe in preventing variceal rebleeding in patients with HCC.

Retrograde Transvenous Obliteration of Gastric Varices using Sodium Tetradecyl Sulphate: Technical Considerations and Results from a Single Institution Retrospective Study

Abstract Introduction Retrograde transvenous obliteration (RTO) with the assistance of a balloon (BRTO) or a vascular plug (PARTO) is an established method for treating gastric varices (GVs) secondary to portal hypertension. Most of the available studies on RTO have used lipiodol along with sclerosing agents like ethanolamine oleate or sodium tetradecyl sulfate (STS). We evaluated the safety and efficacy of RTO for treating GVs using STS as a sclerosant without lipiodol. Materials and Methods Sixteen patients (nine men, age range 16–74 years) were included in this retrospective study. Twelve patients presented with acute bleeding, two with chronic bleeding, one with large varices without bleeding, and one with refractory hepatic encephalopathy (HE). BRTO was attempted in 14 patients and PARTO in 2 patients. The technical and clinical success and complications of RTO were studied. Results The RTO procedure was technically successful in 14 (14/16, 87.5%) patients, with 13 (13/14, 93%) obtaining clinical success. One patient died due to the early recurrence of bleeding. Three patients had minor intraprocedural complications. Conclusion Retrograde gastric variceal obliteration using STS is safe and technically feasible with high technical and clinical success and low complication rate.

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.

Retrograde transvenous obliteration for the prevention of variceal rebleeding in patients with portal vein thrombosis: a multicenter study.

To evaluate the effectiveness of retrograde transvenous obliteration (RTO) for the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis (PVT). Consecutive cirrhotic patients with PVT who underwent RTO for the prevention of variceal rebleeding between January 2002 and June 2019 were included in this multicenter retrospective study. The primary outcome measure was rebleeding. The secondary outcome measures were survival, other complications of portal hypertension, liver function, and PVT. Forty-five patients (mean age, 66.0 ± 10.6years; mean Model for End-Stage Liver Disease (MELD) score, 13.9 ± 5.5) were included. The 1-year actuarial probability of remaining free of rebleeding was 92.8 ± 4.0%. The 6-week, 1-year, and 3-year actuarial probabilities of survival were 79.8 ± 6.0%, 48.8 ± 7.7%, and 46.1 ± 7.9%, respectively. MELD score (hazard ratio (HR), 1.09 (95% confidence interval (CI), 1.01-1.17); p = .013) and ascites (HR, 2.84 (95% CI, 1.24-6.55); p = .014) were identified as significant predictors of survival. The 1-year actuarial probabilities of remaining free of new or worsening ascites and esophageal varices were 81.2 ± 8.7% and 89.2 ± 6.0%, respectively. No patients had overt hepatic encephalopathy during follow-up. MELD score significantly increased by a mean of 3.8 (95% CI, 1.7-6.0) at 3months (p = .001). PVT had improved in 32.0%, worsened in 12.0%, and remained unchanged in 56.0% of patients at 3months. RTO may be effective for the prevention of variceal rebleeding in cirrhotic patients with PVT. • Retrograde transvenous obliteration may prevent variceal rebleeding in cirrhotic patients with portal vein thrombosis. • The risks of other complications of portal hypertension may not be high after retrograde transvenous obliteration in cirrhotic patients with portal vein thrombosis. • Portal vein thrombosis may improve in approximately one-third of cirrhotic patients within 3months after retrograde transvenous obliteration.

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.

Retrograde Transvenous Obliteration (RTO): A New Treatment Option for Hepatic Encephalopathy.

Hepatic Encephalopathy (HE) is a complication of liver disease, consisting of brain dysfunction often due to portosystemic shunting of blood flow in the liver. HE can range from minimal HE, presenting with normal neurological function, to overt HE, with neurological and neuropsychiatric abnormalities. Various clinical grading systems are used to differentiate HE to provide the appropriate treatments. Traditional treatment of HE aims to identify and resolve precipitating factors through targeting hyperammonemia and administering antibiotics or probiotics. While retrograde transvenous obliteration (RTO), including balloon-occluded retrograde transvenous obliteration, coil-assisted retrograde transvenous obliteration or plug-assisted retrograde tranvenous obliteration, is an established procedure to manage gastric varices, little is known about its potential to treat HE. RTO is a procedure to occlude a spontaneous portosystemic shunt, minimizing shunting of portal blood to systemic circulation. Though there is not a large study with HE patients who have undergone RTO; the results appear promising in reducing HE. Side effects, however, should be considered in the treatment of HE such as the transient worsening of portal hypertension and the formation of additional shunts. While additional studies are needed to assess the long-term success, RTO appears to be an effective alternative method to alleviate clinical symptoms of HE when pharmacological therapies and other conservative medical managements have failed.

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.

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.

Gastric Varices and Hepatic Encephalopathy: Treatment with Vascular Plug and Gelatin Sponge–assisted Retrograde Transvenous Obliteration—A Primary Report

To evaluate technical safety, clinical safety, and effectiveness of vascular plug-assisted retrograde transvenous obliteration (RTO) for treatment of gastric varices (GV) and hepatic encephalopathy (HE). This retrospective study was approved by the institutional review board; written informed consent was waived. From April 2009 to December 2011, 20 patients (13, GV; seven, HE) who had undergone vascular plug-assisted RTO were retrospectively evaluated. After retrograde transvenous placement of a vascular plug in the left adrenal vein or gastrorenal shunt, subsequent gelatin-sponge embolization of both gastrorenal shunt and GV was performed. Follow-up computed tomography (CT) and upper gastrointestinal tract endoscopy were performed; clinical and laboratory data were collected to evaluate primary (technical success, complications, clinical success) and secondary (change of liver function by using the Child-Pugh score, worsening of esophageal varices) end points. Laboratory data before and after vascular plug-assisted RTO were compared (paired-sample t test). Placement of the vascular plug and subsequent gelatin-sponge embolization were technically successful in all 20 patients, with no procedure-related complications. Follow-up CT within 1 week after vascular plug-assisted RTO showed complete thrombosis of GV and gastrorenal shunts in all patients. Clinical symptoms of HE completely resolved in all seven patients with HE; mean serum NH3 level of 127.4 μmol/L ± 58 (standard deviation) before vascular plug-assisted RTO decreased significantly to 28.1 μmol/L ± 9.8 within 1 week after vascular plug-assisted RTO (P = .002). Eighteen patients who underwent follow-up longer than 2 months showed complete obliteration of GV and gastrorenal shunts at CT and endoscopy. There were no cases of variceal bleeding or HE during mean follow-up of 422 days. Improvement in Child-Pugh score was observed in 12 of 18 (67%) patients 1 month after vascular plug-assisted RTO. Worsening of esophageal varices was observed in four (22%) patients at mean follow-up of 9.4 months. Vascular plug-assisted RTO is technically simple and safe and seems to be clinically effective for treatment of GV and HE.

逆行性経静脈的塞栓術とストーマ再造設を施行した回腸ストーマ静脈瘤の1例

症例は73歳女性．41歳時直腸癌に対し腹会陰式直腸切断術，57歳時多発結腸癌に対し結腸全摘術および回腸人工肛門造設術の既往あり．また合併症としてC型肝炎を認めた．68歳時より回腸ストーマ周囲より出血を繰り返すようになった．72歳時出血の量および頻度ともに悪化傾向を認め，腹部造影CT検査で回腸ストーマ周囲に静脈瘤の形成を認めた．逆行性経静脈的塞栓術を施行したが，1年後に再出血をきたしたためストーマ再造設を施行した．現在軽度の出血を繰り返すが，保存的に軽快するため経過観察中である．門脈圧亢進症の原因として，ウイルス性肝炎が多い本邦においては，肝予備能および生命予後の点から過大侵襲を避けた治療選択が重要である．

Balloon‐occluded retrograde transvenous obliteration: One step beyond obliteration of gastric varices

See article in J. Gastroenterol. Hepatol. 2012; 27: 137–141.

Portal hemodynamics and clinical outcomes of patients with gastric varices after balloon‐occluded retrograde transvenous obliteration

Long-term hemodynamic effects and clinical outcomes after balloon-occluded retrograde transvenous obliteration (B-RTO) remain unclear. The purpose of this study was to evaluate long-term clinical results and effects on portal hemodynamics after B-RTO for the treatment of gastric varices with spontaneous gastrorenal shunt. A total of 21 patients with cirrhosis and gastric varices treated by B-RTO were evaluated. The cumulative survival rate was calculated, portal blood flow was measured by Doppler ultrasonography, and liver function was estimated on the basis of Child-Pugh classification before and 1 year after B-RTO. Gastric varices disappeared or decreased markedly in size in all patients. Overall cumulative survival rates at 1, 3 and 5 years were 90.48, 71.11 and 53.71%, respectively. Portal blood flow increased significantly from 681.9 +/- 294.9 to 837.0 +/- 279.1 ml/min (P = 0.0125) after B-RTO. Child-Pugh score was not significantly changed (P = 0.755) after obliteration, but serum albumin was elevated significantly from 3.49 +/- 0.49 to 3.75 +/- 0.53 g/dl (P = 0.0459). The ascites score was significantly increased (P = 0.0455) after B-RTO, but all cases of ascites could be controlled with medication. Balloon-occluded retrograde transvenous obliteration is a safe and effective treatment for gastric varices with gastrorenal shunt. Portal blood flow and serum albumin parameters are increased, and liver function is unchanged after B-RTO.

Successful Treatment of Mesenteric Varices After Living Donor Liver Transplantation with Retrograde Transvenous Obliteration Via an Abdominal Wall Vein

Balloon-occluded retrograde transvenous obliteration is an established treatment for gastric varices; it has been used more rarely to treat mesenteric varices. We report a 12-year-old girl who had received a living donor liver transplant and suffered melena due to ruptured mesenteric varices. We addressed treatment of the mesenteric varices by retrograde transvenous obliteration of an abdominal wall collateral vein detected by superior mesenteric arteriography.

GASTRIC FUNDIC VARICES: HEMODYNAMICS AND NON‐SURGICAL TREATMENT

The hemodynamics and non‐surgical treatment of gastric fundic varices (FV) are reviewed. FV are more frequently supplied by the short and posterior gastric veins than esophageal varices (EV), and are formed mostly by large spontaneous shunts in which the gastric or splenic vein is continuous with the left renal vein via the inferior phrenic veins and the suprarenal vein (so‐called gastric‐renal shunt). Concomitant collaterals such as EV, para‐esophageal vein, and para‐umbilical vein were also observed in nearly 60% of FV. Endoscopic injection sclerotherapy (EIS) with Histoacryl is thought to be the most approved treatment for hemorrhage from FV, but repeated treatment for residual FV and care for ensuing hepatic failure are required. Balloon‐occluded retrograde transvenous obliteration (B‐RTO) is a notable interventional radiological procedure specially developed for the elective or prophylactic treatment of FV. If the procedure is technically successful, long‐term eradication of treated FV is found in most patients without recurrence. B‐RTO includes another significance, obliteration of the unified portal‐systemic shunt. Follow‐up abdominal CT scan revealed a high incidence of long‐term obliteration of the gastric‐renal shunt after B‐RTO. Benefits such as elevation of serum albumin, improvement in 15‐min retention rate of indocyanine green, decrease in blood ammonia levels, and improvement of encephalopathy are sometimes observed.

Endovascular obliteration of bleeding duodenal varices in patients with liver cirrhosis

The purpose of this paper is to describe our experience with endovascular obliteration of duodenal varices in patients with liver cirrhosis and portal hypertension. Balloon-occluded transvenous retrograde and percutaneous transhepatic anterograde embolizations were performed for duodenal varices in five patients with liver cirrhosis, portal hypertension, and decreased liver function. All patients had undergone previous endoscopic treatments that failed to stop bleeding and were poor surgical candidates. Temporary balloon occlusion catheters were used to achieve accumulation of an ethanolamine oleate-iopamidol mixture inside the varices. Elimination of the varices was successful in all patients. Retrograde transvenous obliteration via efferent veins to the inferior vena cava was enough to achieve adequate sclerosant accumulation in three patients. A combined anterograde-retrograde embolization was used in one patient with balloon occlusion of afferent and efferent veins. Transhepatic embolization through the afferent vein was performed in one patient under balloon occlusion of both efferent and afferent veins. There was complete variceal thrombosis and no bleeding was observed at follow-up. No major complications were recorded. Endovascular obliteration of duodenal varices is a feasible and safe alternative procedure for managing patients with portal hypertension and hemorrhage from this source.