Transvenous Obliteration Research Articles

Variceal Hemorrhage: Decompression, Obliteration, or Both?

AbstractVariceal hemorrhage is a morbid condition that frequently mandates the involvement of interventional radiology to achieve successful and sustained hemostasis. Primary image-guided therapies for variceal hemorrhage include a transjugular intrahepatic portosystemic shunt and transvenous obliteration. Knowledge of variceal pathophysiology and anatomy, current techniques, and the evidence supporting therapeutic selection is paramount to successful patient outcomes. The purpose of this review is to provide the reader a framework of the available literature on image-guided management of bleeding varices to assist in clinical management.

An Ostomy Bag Filled With Blood

A 68 year old man with colorectal cancer s/p diverting ileostomy, HCV cirrhosis, and gastritis, presented with an ostomy bag filled with blood. The patient reported bright red blood from the ileostomy for 5 days and generalized abdominal pain. He was hypotensive and tachycardic with a hemoglobin (Hgb) of 5.1. CT of the abdomen showed right lower quadrant ileostomy with non-obstructed loops of small bowel herniating through the ostomy site, mesenteric vein enhancement, and ascites. Peritoneal fluid sampling was consistent with spontaneous bacterial peritonitis. The source of bleeding was unclear with potential sources in the upper GI tract, varices, or ileostomy. Twelve hours after admission, the patient became hypotensive with his colostomy bag filled with blood again. A parastomal superficial pulsatile vessel was suture ligated, but was complicated by an expanding hematoma. Bedside ultrasound demonstrated prominent superficial veins and an artery. As the patient was a poor surgical candidate, interventional radiology (IR) assessed the patient for recurrent parastomal bleeding with a jet of non-pulsatile bright red blood thought to be from parastomal varices. IR performed venography and variceal sclerosis of parastomal varices using sodium tetradecyl sulfate. The parastomal variceal bleeding stopped and his Hgb remained stable. He was discharged to a long-term care facility. Defined as ectopic extraperitoneal mesenteric varices associated with ileostomies and colostomies due to the juxtaposition of intestinal veins with systemic veins of the anterior abdominal wall, stomal or parastomal varices develop in the setting of portal hypertension and can cause fatal hemorrhage. Stomal varices occur in up to 50% of patients with a stoma and concurrent portal hypertension, with a 27% risk of bleeding. Exam findings are a “raspberry appearance” of the stoma and peristomal caput medusae. Ectopic varices should be suspected in patients with GI bleeding and portal HTN who have undergone luminal evaluation without discovery of a bleeding source. Venous phase mesenteric angiography aids in diagnosis. Focally bleeding stomal varices can be controlled with manual compression, suture ligation, or transvenous obliteration with sclerosant. Complications of injection sclerotherapy include mucosal ulceration and stricturing of the stomal orifice. TIPS is preferred for secondary prevention of stomal variceal bleeding.

Ectopic Varices: Anatomical Classification, Hemodynamic Classification, and Hemodynamic-Based Management

Ectopic varices are dilated splanchnic (mesoportal) veins/varicosities and/or are dilated portosystemic collaterals that can occur along the entire gastrointestinal tract outside the common pathologic variceal sites. Ectopic varices are complex and highly variable entities that are not fully understood. Ectopic varices represent 2%-5% of a gastrointestinal tract variceal bleeding. However, ectopic varices have a 4-fold increased risk of bleeding when compared with esophageal varices and can have a mortality rate as high as 40%. All treatment strategies and techniques have been utilized in managing these potentially mortal varices and have shown poor outcomes. The debate of whether to manage these varices by decompression with a transjugular portosystemic shunt, or other portosystemic shunts, vs transvenous obliteration is unresolved. The rebleed rates after transjugular portosystemic shunt decompression are 20%-40%. The rebleed rates after transvenous obliteration and the mortality rate at 3-6 months are 30%-40% and 50%-60%, respectively. Hemodynamically from an etiology standpoint, there are 2 types: occlusive (type-b) and nonocclusive (oncotic or type-a). Hemodynamically from a vascular-shunting standpoint, there could be a component of portoportal or portosystemic shunting or both with varying dominance. This is the basis of the new classification system described herein. Management strategies (decompression vs sclerosis) are discussed. The ideal management strategy is a treatment that leads to prompt hemostasis but also addresses the etiology or hemodynamics of the ectopic varices. It is the hope that with better understanding, description, and categorization of ectopic varices comes a more systematic approach to this rare but menacing problem.

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.