Successful Balloon-occluded Retrograde Transvenous Obliteration Research Articles

Balloon-occluded retrograde transvenous obliteration for treatment of gastric varices.

Rupture of gastric varices (GVs) can be fatal. Balloon-occluded retrograde transvenous obliteration (BRTO), as known as retrograde sclerotherapy, has been widely adopted for treatment of GVs because of its effectiveness, ability to cure, and utility in emergency and prophylactic treatment. Simplifying the route of blood flow from GVs to the gastrorenal shunt is important for the successful BRTO. This review outlines BRTO indications and contraindications, describes basic BRTO procedures and modifications, compares BRTO with other GVs treatments, and discusses various combination therapies. Combined BRTO and partial splenic embolization may prevent exacerbation of esophageal varices and shows promise as a treatment option.

Ectopic Ascending Colonic Variceal Bleeding Treated with Balloon-Occluded Retrograde Transvenous Obliteration in a Decompensated Liver Cirrhosis Patient—A Hepatology Perspective

Ectopic colonic varices development from liver cirrhosis and portal hypertension is uncommon. They are part of the spectrum of portal hypertensive colopathy. Colonic variceal bleeding remains a rare cause of lower gastrointestinal tract (GI) bleeding. Due to the paucity of cases, there are no well-established conventional treatments for bleeding colonic varices. Different treatments have been reported. Here, we report a case of a 55-year-old gentleman, with a history of alcoholic liver cirrhosis, presenting with severe lower GI bleeding and symptomatic anaemia. An esophagogastroduodenoscopy revealed large esophageal varices with high-risk bleeding stigmata requiring endoscopic variceal ligation. A cross-sectional computed tomography scan showed colonic portosystemic shunts. In light of this and that the severe lower GI bleeding seemed out of proportion to the esophageal varices seen on upper endoscopy, an urgent unprepped colonoscopy was performed which revealed possible bleeding diverticula disease which required endoscopic mechanical hemoclip therapy. However, despite this, patient had recurrence of lower GI bleeding prompting a second colonoscopy. This relook colonoscopy showed ectopic ascending colon varices with high-risk bleeding stigmata. High-dose intravenous vasoactive agent somatostatin (500 mcg/hour) and subsequently terlipressin (2 mg every 4 hours) were used. The patient subsequently underwent successful balloon-occluded retrograde transvenous obliteration (B-RTO) and sclerotherapy. The non-selective beta-blocker (NSBB) carvedilol was started and bridged together with the vasoactive agent until stabilisation of portal hypertension. This difficult case illustrates the dynamic nature of portal hypertensive bleeding. It also highlights the presence of confounding non-variceal pathology complicating diagnosis of portal hypertensive colonic variceal bleeding, and that ectopic ascending colonic variceal bleeding can be treated successfully with B-RTO and sclerotherapy, with meticulous titration of high-dose vasoactive agents and NSBB, in a decompensated alcoholic liver cirrhosis patient.

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.

2011 Jejunal Varices: A Diagnostic and Therapeutic Nightmare!

INTRODUCTION: Gastrointestinal hemorrhage is a common complication among cirrhotic patients with portal hypertension, due to the development of bleeding varices. While esophagus and stomach are the most common location for development of varices, it can also rarely occur in ectopic locations, such as the jejunum, ileum, rectum and duodenum. Here, we report a case of a patient with severe gastrointestinal hemorrhage due to a bleeding jejunal varix. CASE DESCRIPTION/METHODS: A 55-year-old male with a history of hypertension, splenectomy, and alcoholic cirrhosis had presented initially to an outside ED with complaints of bright red blood per rectum. At admission, he required multiple infusions of pRBCs, and several upper endoscopies due to refractory bleeding with unclear source. Initial endoscopies showed non-bleeding esophageal varices, for which he underwent ligation banding. However, he continued to deteriorate, developing recurrent melena, hypotension, and syncope. On admission to our hospital, he had a repeat upper endoscopy, lower endoscopy, CT angiography and tagged red blood cell study; but we were unable to localize the source of the bleeding. He continued to deteriorate, and also developed a PEA arrest in the setting of a profuse bright red blood per rectum, requiring massive transfusion protocol. After successful resuscitation, he underwent a small bowel enteroscopy, which finally revealed a bleeding jejunal varix. However, the varix was not amenable to any endoscopic intervention. Subsequently, he underwent a successful balloon-occluded retrograde transvenous obliteration (BRTO) of varix. Patient’s condition stabilized and after adequate recovery, he was extubated. DISCUSSION: Early diagnosis of ectopic varices is difficult to achieve due to low likelihood of presentation and low sensitivity to various diagnostic tests. Due to its low prevalence, there are no protocols for its management. As in our patient, endoscopic intervention such as sclerotherapy and band ligation can be difficult due to the narrow lumen of the small bowel. Alternatively, BRTO and TIPS are also considered effective therapeutic options. However, due to his poor liver function, BRTO was a better alternative. In conclusion, through this case report, we want to emphasize the importance of early recognition and appropriate management of ectopic varices due to its potential for massive, even fatal hemorrhage.

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 >3.5 cm in five. Two patients were having both proximal gastrorenal and distal splenorenal shunts. The ISD was >3.5 cm in two patients with failed initial femoral approach and < 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.

Educational ExhibitAbstract No. 353 - Technique and tools needed for successful balloon-occluded retrograde transvenous obliteration (BRTO)

Educational ExhibitAbstract No. 353 - Technique and tools needed for successful balloon-occluded retrograde transvenous obliteration (BRTO)

Protective Value of TIPS Against the Development of Hydrothorax/Ascites and Upper Gastrointestinal Bleeding after Balloon-Occluded Retrograde Transvenous Obliteration (BRTO)

The objective of this study was to evaluate the incidence of post-balloon-occluded retrograde transvenous obliteration (BRTO) ascites/hepatic hydrothorax and rebleeding rate (variceal and non-variceal) in the presence and absence of a transjugular intrahepatic portosystemic shunt (TIPS). A retrospective audit of consecutive patients undergoing BRTO was performed (August 2007-October 2010). The population was divided into two groups: patients who underwent BRTO only (BRTO-only group) and those who underwent BRTO in the presence of TIPS (BRTO+TIPS group). Post-BRTO rebleeding was categorized for the source of bleeding. Ascites and/or hepatic hydrothorax were categorized according to clinical severity. Comparisons, utilizing the Kaplan-Meier method, between both groups were made for patient survival, incidence of ascites/hydrothorax, and rebleeding. Thirty-nine patients underwent BRTO (three technical failures of BRTO-only group). Of the 36 technically successful BRTO procedures, 27 patients (75%) underwent BRTO-only and 9 patients (25%) underwent BRTO in the presence of a TIPS. Pre-BRTO ascites/hydrothorax resolved in BRTO-only vs. BRTO+TIPS in 7% (N=2/27) and 56% (N=5/9), respectively (P=0.006). The ascites/hydrothorax free rate at 6, 12, and 24 months after BRTO for BRTO-only vs. BRTO+TIPS was 58%, 43%, 29%, and 100%, 100%, 100%, respectively (P=0.01). Recurrent hemorrhage for BRTO-only vs. BRTO+TIPS groups, and for the same time periods was 9%, 9%, 21% vs. 0%, 0%, 0%, respectively (P=0.03). The 1-year patient survival of both groups (80-88%) was similar (P>0.05). This study concludes that the presence of TIPS has a protective value against the development of post-BRTO ascites/hydrothorax as well as recurrent hemorrhage but this does not translate to improved patient survival.

8:56 AM Abstract No. 124 - Effects of high viscosity and conventional sclerosants on complication rates and MELD in BRTO

Purpose 10% Ethanolamine oleate is the international standard sclerosing agent in balloon-occluded retrograde transvenous obliteration (BRTO) but its lack of availability in this concentration limits its use in the US. Our goal is to describe our initial experience, complication rates and effects on liver function utilizing high viscosity sclerosant (HVS) mixture versus conventional sclerosant. Materials and Methods We performed a retrospective analysis of nine patients in which successful BRTO was performed in the setting of acute endoscopicaly proven bleeding isolated gastric varices (IGV) from 11/10 - 9/12. The primary sclerosant used was 3% STS+Gel foam+ IV contrast solidified to a honey consistency, other sclerosants used were absolute alcohol and STS + Ethiodol (ETL). Results We performed 12 successful BRTO procedures; three were treated with absolute alcohol (ETOH), two with STS+etl and four patients treated with HVS. There were 3-grade (G) 1, 2 -G2, 3-G3 and 1- G4. Technical success rate (complete obliteration of GV) was 9 of 9 (100%). Initial clinical success rate (absence of re-bleeding in 7 days) was 100% (9/9). There were no cases of recurrent variceal bleeding requiring either TIPS or surgical intervention with a mean clinical follow-up period of 1.8 months (range, 2 to 20 weeks). Complications occurred in 3 of 9 (33%) patients; 1 death (ETOH) and 2 non target embolizations (ETOH and sts+etl) with subsequent venous thrombosis complications. No complications were associated with the HVS. Mean cohort pre-MELD (prm), post-Meld (next day follow up) (pom) and intermediate term follow-up MELD (ITFM) (mean: 1.8 mo): 14, 15.5 and 12.3. Mean prm, pom and itfm (ETOH): 16, 17 and 12. Mean prm, pom and itfm (sts+etl): 10.7, 10.1 and 8. Mean prm, pom and itfm (HVS): 14, 17 and14.5. The percentage improved MELD with ETOH, sts+etl and HVS: 29.3, 20.5 and 15.3 utilizing the fischer exact test and student t test trend of MELD over time is highly correlative (R=0.9 and p Conclusion HVS while not as a robust hepatoprotective sclerosant, in the short term appears to be effective in short term variceal obliteration with low complication rates.

Carbon Dioxide (CO2) vs Iodinated Contrast Digital Subtraction Angiography during Balloon-occluded Retrograde Transvenous Obliteration (BRTO) Using Foam Sclerosant for Gastric Varices

PurposeTo compare the visualization of the target gastric varices (GV) on balloon-occluded retrograde transvenous venography (BRTV) using iodinated contrast material vs carbon dioxide (CO2) in preparation for subsequent balloon-occluded retrograde transvenous obliteration (BRTO) using foam sclerotherapy. Materials and MethodsIn 16 consecutive patients with nonruptured GV, BRTV was performed first using iodinated contrast material and then with CO2. BRTV was repeated whenever there were changes in the catheter or patient position or when coil embolization of collaterals was needed. Each visualization grade of GV (grade 1=GV only; grade 2=GV >collaterals; 3=GV<collaterals; grades 4–5=collaterals only) was determined by two observers in consensus. During foam BRTO, the GV visualization grade was recorded again and confirmed by C-arm computed tomography (CT). ResultsIn 38 pairs of BRTV, GV grades were significantly (P<.0001) lower (ie, favoring BRTO) on CO2 BRTV (mean±standard deviation, 1.8±0.8) than on iodine BRTV (3.4±0.8). GV grades on foam BRTO (1.4±0.7) were similar to the grades obtained on the most recent CO2 BRTV (1.3±0.5) but were significantly smaller (P<.0001) than on iodinated BRTV (3.1±0.9). GV were opacified by foam on initial C-arm CT in 14 patients (87.5%), and complete thrombosis of GV was obtained without any complication in all 16 patients (100%). CO2 reached the GV even when iodinated contrast material could not (grade 4) in seven of our 16 patients (43.8%), leading to successful BRTO. ConclusionsCO2 BRTV visualized GV better than did iodine BRTV and changed the management of more than 40% of patients by enabling successful foam BRTO in patients in which conventional liquid BRTO could not be performed.

Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Technical Results and Outcomes

Variceal bleeding is one of the major complications of portal hypertension. Gastric variceal (GV) bleeding is less common than esophageal variceal (EV) bleeding, however, is associated with a high morbidity and mortality. Balloon-occluded retrograde transvenous obliteration (BRTO) is an established procedure for the management of gastric varices in Japan and has shown promising results in the past decade. The technical success rate, intent-to-treat (including technically failed BRTO-procedures) obliteration rate, and the obliteration rate of gastric varices of technically successful BRTO procedures was 91% (79-100%), 86% (73-100%), and 94% (75-100), respectively. BRTO is successful in controlling active gastric variceal bleeding in 95% of cases (91-100%) and in significantly reducing or resolving encephalopathy in 100% of cases. However, BRTO diverts blood into the portal circulation and increases the portal hypertension, thus aggravating esophageal varices with their potential for bleeding. The 1-, 2-, and 3-year esophageal variceal aggravation rates are 27-35%, 45-66%, and 45-91%, respectively. The gastric variceal rebleed rate of successful BRTO procedures, the intent-to-treat gastric variceal rebleed rate, and the global (all types of varices) variceal rebleed rate are 3.2-8.7%, 10-20%, and 19-31%, respectively. However, the advantage of diverting blood into the portal circulation and potentially toward the liver is improved hepatic function and possible patient survival. Unfortunately, the improved hepatic function is transient (for 6-12 months); however, it is preserved in the long-term (1-3 years). Patient 1-, 2-, 3-, and 5-year survival rates are 83-98%, 76-79%, 66-85%, and 39-69%, respectively. Patient survival is determined by baseline hepatic reserve and the presence of hepatocellular carcinoma.

Successful Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Varix Mainly Draining into the Pericardiophrenic Vein

Two cases of gastric varices were treated by balloon-occluded retrograde transvenous obliteration via the pericardiophrenic vein at our hospital, and both were successful. One case developed left hydrothorax. Gastric varices did not bled and esophageal varices were not aggravated in both cases for 24-30months thereafter. These outcomes indicate the feasibility of balloon-occluded retrograde transvenous obliteration via the pericardiophrenic vein.

副流出路に対しマイクロバルーンカテーテル併用によるダブルバルーン下逆行性経静脈的塞栓術が有用であった孤立性胃穹窿部静脈瘤の1例

症例は43歳女性．2005年8月飲酒後，吐血し，救急車にて某院搬送入院．上部消化管内視鏡にて孤立性胃穹窿部静脈瘤からの出血を認めたが，自然止血にて経過観察していた．再出血の可能性を認め，バルーン下逆行性経静脈的塞栓術目的に当院へ紹介転院となった．造影CTにて胃内腔へ突出する胃静脈瘤とそれに連続する胃腎短絡路を認めた．胃腎短絡路の存在からバルーン下逆行性経静脈的塞栓術可能と判断し，血管造影施行．右内頸静脈により6Frバルーンカテーテルを胃腎短絡路に挿入，逆行性造影を施行したところ，造影剤は通常より左側の細い胃腎短絡路より流出し，胃静脈瘤本体への造影剤の停滞は不十分であった．そこで，右大腿静脈から6Frシェファードフックカテーテルを左腎静脈に挿入し，マイクロバルーンカテーテルを細い短絡路に挿入し，閉塞下に造影したところ，十分な静脈瘤血行路の描出が得られ，閉塞が可能となり，2カ所の閉塞により胃静脈瘤への造影剤の停滞が十分であると判断し，5%EOIを注入し塞栓可能となった．術後CTにても短絡路は消失し，胃静脈瘤は消失した．

Successful balloon-occluded retrograde transvenous obliteration for ruptured gastric fundal varices in a patient with Child-Pugh C cirrhosis: case report and literature review.

Successful balloon-occluded retrograde transvenous obliteration for ruptured gastric fundal varices in a patient with Child-Pugh C cirrhosis: case report and literature review.

Transcatheter obliteration of gastric varices. Part 1. Anatomic classification.

Since its introduction in the mid-1990s, balloon-occluded retrograde transvenous obliteration (BRTO) has become widely accepted in Japan as a minimally invasive, highly effective treatment for gastric varices. Sufficient filling and stagnation of the sclerosing agent in the entire variceal complex is essential for successful BRTO of gastric varices. However, the success of BRTO in this context also requires familiarity with the hemodynamic features of the varices, including the patterns of their afferent and draining veins, which affect the degree of difficulty in performing BRTO. Thus, accurate assessment of the hemodynamic pattern before and during each procedure is essential for successful treatment. Sixty cases of gastric varices that were successfully treated with transcatheter techniques over the past 5 years were reviewed and analyzed. From this study, a classification system for gastric varices was developed that is based on the hemodynamic pattern of the varices.