Recurrence Of Varices Research Articles

Technique and early results of endovenous laser ablation in morphologically complex varicose vein recurrence after small saphenous vein surgery.

Recurrences after varicose vein treatment occur frequently and represent a significant health and economic problem. In contrast to primary treatments of superficial truncal venous insufficiency, their management is often more difficult. Here we assessed the technical feasibility and early results of endovenous laser ablation (EVLA) for recurrences with stumps or subfascial meandering varices after small saphenous vein (SSV) surgery. This single-center retrospective study included 45 consecutive EVLA procedures from July 2019 to December 2021 in 40 patients (19 male, 21 female, mean age 62.8 ± 12.7 years). Patients had clinically relevant recurrent varicose veins after SSV surgery, with clinical, etiologic, anatomic and pathophysiologic (CEAP) classification stage of C2S or higher. We categorized the recurrences morphologically according to duplex sonographic criteria. Ablations were done with a 1470 nanometers laser and dual ring radial fibers and aimed at thermal closure as proximal as possible to the upper inflow. Analyses were performed by descriptive statistics and the Kaplan-Meier method. The primary outcome analyzed was the technical success, defined by thermal occlusion not requiring re-intervention during the observation period. The secondary outcome was the occurrence of postoperative complications. A complex morphology with residual stumps or tortuous venous connections to the popliteal vein was present in 35 cases (77.8%). Immediate technical success at the first postoperative visit after a median of 11 days (interquartile range 8-13 days) was 97.8%. During the follow-up period (median 77 days, interquartile range 13-256 days), 6 limbs (13.3%) required redo EVLA due to symptomatic persistent or newly presenting reflux. The median freedom from re-recurrence was 791 days. Otherwise, no medical or surgical complications requiring specific treatment were observed, particularly no endothermal heat-induced thrombosis (EHIT) or other thrombotic complications, and no nerve damage. According to our pilot data, EVLA is technically feasible for complex popliteal variceal recurrence, although the success rate appears substantially lower than for primary treatment of truncal venous insufficiency.

Efficacy and safety of variceal embolization for primary prophylaxis in cirrhosis patients with challenges in standard treatments: preliminary results.

Nonselective beta blockers (NSBBs) or endoscopic therapies are currently recommended by guidelines for preventing the first variceal bleed in patients with high-risk varices. However, there is a lack of detailed treatment strategies for patients who are intolerant to both NSBBs and endoscopic approaches. Our study aimed to assess the efficacy and safety of variceal embolization as a primary prophylaxis method in cirrhosis patients who are not suitable candidates for NSBBs or endoscopic treatments. The study included 43 cirrhotic patients with high-risk varices who were candidates for primary prophylaxis against variceal bleeding. These patients underwent variceal embolization at the Xijing Hospital between January 2020 and June 2022. The primary endpoint was the occurrence of bleeding from varices, and the secondary endpoints were the recurrence of varices and the emergence of complications. The procedure of variceal embolization had a success rate of 93.0% (40 out of 43 patients). Over a 2-year follow-up period, the rate of variceal bleeding was 11.6% (5 out of 43 patients), the recurrence rate of varices was 14.0% (6 out of 43 patients), and the rate of severe complications was limited to 2.3% (1 out of 43 patients). Variceal embolization is a viable primary prophylactic intervention for cirrhotic patients who are at risk of variceal bleeding when standard treatments, such as NSBBs or endoscopic therapies, are difficult to perform.

The Value of Follow-Up Liver Stiffness Changes Measured by Virtual Touch Quantification Elastography for Predicting Recurrence of Gastroesophageal Varices after Endoscopic Injection Sclerotherapy on Cirrhotic Patients.

Recurrence of gastroesophageal varices (GEVs) after sclerotherapy is a public health problem. However, mass screening of recurrence of GEVs through gastroscopy is a high-cost procedure. We aim to evaluate the changes in liver stiffness (LS) over time after endoscopic injection sclerotherapy (EIS) and determine its value in predicting the recurrence of GEVs. One hundred and thirty-five patients with GEVs who underwent EIS treatment were included in this study. The patients were divided into two groups, namely, the nonrecurrence and recurrence groups, based on endoscopic findings at 6 months after discharge. LS measurements were obtained on five occasions. Repeated measure analysis of variance was employed to assess LS differences at different time points and compare them between the two groups. The LS values during the 6-month postdischarge period were consistently higher than the baseline value (measured on the day of hospitalization). The recurrence group demonstrated sustained elevated LS levels throughout the 6-month follow-up period, while the nonrecurrence group showed a gradual decline in LS. The difference in LS trend between the two groups was statistically significant (P = 0.04). The area under the curve (AUC) values for LS differences were 0.806, with a corresponding 95% confidence interval (CI) of 0.640-0.918 and a cut-off value of 0.556, indicating their potential utility in predicting GEV recurrence. Longitudinal assessment of LS values in post-EIS patients can provide valuable information for predicting the recurrence of GEVs.

CT venography combined with ultrasound-guided minimally invasive treatment for recurrent varicose veins: a pilot paired-design clinical trial

AimTo compare 1-year outcomes of computed tomography venography (CTV) combined with ultrasound-guided minimally invasive treatment with ascending phlebography and ultrasound-guided treatment for recurrent varicose veins. Materials And MethodsConsecutive patients with unilateral recurrent varicose veins were matched by gender, age, C classification, and degree of obesity, and randomised in a 1:1 ratio to receive either CTV (CTV group) or ascending phlebography (control group) combined with ultrasound-guided minimally invasive treatment. Patients were followed up by clinical and ultrasound examination. Follow-up was scheduled at 1 week, and 3, 6, and 12 months. The primary outcome measure was the Venous Clinical Severity Score (VCSS) at 12 months. Measures of secondary outcome included Chronic Insufficiency Venous International Questionnaire-20 (CIVIQ-20) score, recurrence of varicose vein or ulcer during 12 months, ulcer healing time, detection and location of treated veins. ResultsEighty patients were enrolled. Median VCSS in the CTV group was lower than it in the control group (p=0.04) and the CIVIQ-20 score was higher than the control group (p=0.02). By 12 months, no symptomatically recurrent varicose veins or ulcers had occurred. The ulcer healing time in CTV group was shorter (p<0.01). A greater number of patients had treated veins detected using CTV than by ascending venography (p=0.01), especially among patients with recurrence reflux veins in the groin, perineum, and vulva (p<0.01). ConclusionCTV combined with ultrasound may be more helpful than ascending phlebography combined with ultrasound to improve treatment efficacy for recurrent varices. These results should be verified by an future study with more patients and long-term follow-up.

The role of variceal bleeding primary prophylaxis in the management of extrahepatic portal vein obstruction in children

Extrahepatic portal vein obstruction is a major cause of pediatric symptomatic portal hypertension and can lead to profuse variceal hemorrhaging. Purpose - to evaluate the role of primary prophylaxis of the variceal bleeding in children with extrahepatic portal vein obstruction. Materials and methods. A one-center prospective cohort clinical study involved 120 patients with extrahepatic portal vein obstruction who underwent primary or secondary variceal bleeding prophylaxis in 2016-2021. The laboratory, ultrasound, and endoscopy data before and after treatment were collected and evaluated. Results. Variceal bleeding episodes occurred in 5.8% (n=3) of patients who underwent primary prophylaxis and rebleeding occurred in 27.9% (n=19) of those who underwent secondary prophylaxis. Bleeding episodes occurred less frequently in patients from primary prophylaxis group (p=0.013). In patients treated endoscopically (n=53, 44.17%) Variceal bleeding appeared less frequently (n=3, 5.66%) after treatment compared to patients who underwent surgery (n=67 (55.83%), 19 had rebleeding (28.35%)) (p=0.001). In 69.17% patients (n=83) esophageal varices eradication was achieved: in 53.01% (n=44) patients from the primary prophylaxis group and 46.99% (n=39) from the secondary prophylaxis group. Bleeding episodes occurred less frequently after the eradication achievement (p&lt;0.001). The primary prophylaxis led to varices eradication more often than secondary (p=0.003). The varices recurrence episodes rates after the eradication achievement were not different between groups (p=0.51). Conclusions. Primary prophylaxis can reduce the bleeding risk in extrahepatic portal vein obstruction with high risk of variceal bleeding. The prophylaxis by endoscopic variceal banding is an important bridge in the treatment for pediatric patients with portal hypertension that along with portosystemic shunting could potentially improve prophylactic treatment results. The Committee on Clinical Investigation of Bogomolets National Medical University approved this study (Protocol No.141, 27.01.2021). All the studies were conducted according to implemented guidelines in consideration of GCP-ICH and Declaration of Helsinki. The written informed consent of all participants’ parents/guardians was achieved. No conflict of interests was declared by the authors.

Partial splenic embolization combined with endoscopic therapies and vasoconstrictive drugs reduces rebleeding in cirrhosis patients with acute variceal bleeding and hypersplenism: a multicenter randomized controlled trial.

This study aimed to compare the efficacy of partial splenic embolization (PSE) combined with endoscopic therapy and endoscopic therapy alone in cirrhosis patients with acute variceal bleeding (AVB) and hypersplenism. Cirrhosis patients with AVB who visited three hospitals from June 2016 to June 2022 were prospectively enrolled and randomly allocated to either the endoscopic therapy combined with PSE group (EP group) or the endoscopic intervention group (E group) in a 1:1 ratio. The primary endpoint of the study was re-bleeding of varices during follow-up, and the secondary endpoints were the recurrence of varices, death, and adverse events. One hundred and fourteen patients were prospectively included, of whom 110 completed the trial. The risk of variceal re-bleeding (19.3% vs. 40.4% (23/57), p = 0.013) and variceal recurrence (28.1% vs. 63.2%, p < 0.001) five years after treatment was significantly lower in the EP group than in the E group, and the EP treatment was the only significant independent risk factor affecting variceal re-bleeding and variceal recurrence in patients. The mortality rate was comparable between the EP and E groups. Peripheral blood counts and liver function all improved significantly in the EP group compared to the E group during the follow-up (p < 0.05). The rates of variceal re-bleeding and recurrence were significantly lower in cirrhosis patients with AVB and hypersplenism after combined endoscopic and PSE treatment compared to those who were provided endoscopic treatment only. The peripheral blood counts and liver function were also improved significantly in EP group (NCT02778425).

Effect of nursing instructions on esophageal varices recurrence after endoscopic band ligation.

effect of nursing instructions on esophageal varices recurrence after endoscopic band ligation.

Long-Term Prognosis and Related Factors in Patients with Cirrhosis Treated with Balloon-Occluded Retrograde Transvenous Obliteration

Introduction: Balloon-occluded retrograde transvenous obliteration (BRTO) was developed as an effective treatment for gastric varices in patients with cirrhosis. Because liver fibrosis in these patients is assumed to be advanced, their prognosis is expected to be poor. In this study, we investigated the prognosis and characteristics of the patients. Methods: We enrolled 55 consecutive patients with liver cirrhosis treated with BRTO between 2009 and 2021 at our department. To evaluate factors related to variceal recurrence and long-term prognosis, survival analysis was performed on 45 patients, excluding those who died within 1 month, had an unknown prognosis, or whose treatments were converted to other treatments. Results: During a mean follow-up period of 2.3 years, esophageal varices recurred in 10 patients and could be treated endoscopically. Non-alcoholic steatohepatitis (NASH) was related to the variceal recurrence (hazard ratio [HR] = 4.27, 95% CI: 1.17–15.5, p = 0.028). The survival rate after the procedure at 1, 3, and 5 years was 94.2%, 74.0%, and 63.5%, respectively, and 10 patients died of hepatocellular carcinoma (n = 6), liver failure (n = 1), sepsis (n = 1), and unknown reasons (n = 2). The estimated glomerular filtration rate (eGFR) level was proved to be a significant poor prognostic factor (HR = 0.96, 95% CI: 0.93–0.99, p = 0.023). The comorbid hypertension (HTN) was the main cause of low eGFR, and HTN was also significantly related to survival (HR = 6.18, 95% CI: 1.57–24.3, p = 0.009). Most of the patients with HTN were treated with calcium channel blocker and/or angiotensin receptor blocker. Conclusion: The clinical course of patients with cirrhosis treated with BRTO was dependent on the metabolic factors including renal function, comorbid HTN, and NASH.

Efficacy and Technical Feasibility of Plug-Assisted Retrograde Transvenous Obliteration of Gastric Varices via Pathways Other than the Gastrorenal Shunt

To evaluate the efficacy and technical feasibility of plug-assisted retrograde transvenous obliteration of gastric varices via pathways different from the typical gastrorenal shunt. We retrospectively reviewed the medical records of 130 patients who underwent plug-assisted retrograde transvenous obliteration for gastric varices between 2013 and 2022. Eight patients underwent plug-assisted retrograde transvenous obliteration via different pathways. We evaluated the types of portosystemic shunts in these patients, the procedure technical and clinical success rates, and clinical outcomes. In these eight patients (6 males, 2 females; mean age = 60 ± 6years), the most common type of portosystemic shunt was a gastrocaval shunt (n = 7). Five patients had a gastrocaval shunt only; two had coexisting gastrocaval and gastrorenal shunts. One patient had a pericardiacophrenic shunt without a gastrorenal or gastrocaval shunt. The mean procedure time was 55min. For patients with a gastrocaval shunt alone (n = 5), the mean procedure time was 40.8min. The technical and clinical success rates were 100%. No major complication related to the procedure occurred. An initial follow-up computed tomography was performed within 2-3weeks in all patients and revealed complete thrombosis of the gastric varices. Subsequent follow-up computed tomography (interval: 2-6months) was performed in seven patients and showed complete disappearance of the gastric varices in all patients. During the follow-up period (range: 42days-6.25years), no patients experienced rebleeding or recurrence of gastric varices. Plug-assisted retrograde transvenous obliteration via alternative portosystemic shunts is effective and technically feasible in the treatment of gastric varices.

Balloon-Occluded Esophageal Variceal Obliteration Procedure: A Novel Technique Report from Three Centers.

Introduction: Esophageal variceal bleeding (EVB) is a potentially fatal complication of cirrhosis. The purpose of the present study was to evaluate the safety and efficacy of a novel technique of balloon-occluded esophageal varices (EVs) obliteration (BEVO) for EVs classified as F2 (medium size, F2-EVs) and F3 (large size, F3-EVs). Materials and Methods: Between December 2020 and December 2021, a total of 73 consecutive patients with EVs were treated using BEVO. An injection of sclerosant was administered via direct puncture of the varices during balloon occlusion. Immediate postprocedural Doppler endoscopic ultrasonography (EUS) was conducted to evaluate the blood flow in the EVs. Several factors, including the technical success, controlling of acute bleeding, intraoperative bleeding at the injection site, variceal eradication, variceal recurrence, and BEVO-related complications, were assessed. Results: BEVO was successfully performed in all patients. Immediate hemostasis was achieved in 100% (25/25) of patients with active EVB. The incidence of injection site intraoperative bleeding presenting as oozing and spurting bleeding was 76.71% (56/73) and 8.22% (6/73), respectively. Based on Doppler EUS and endoscopic examination, EVs were completely eradicated in 71 out of 73 patients (97.26%) after three sessions. A total of 3 (4.11%) patients were diagnosed with EV recurrence during follow-up after complete EV eradication. Retrosternal chest discomfort (13.70%; 10/73) and abdominal bloating (2.74%; 2/73) were spontaneously relieved after a few days. No serious BEVO-related complications were observed. Discussion: BEVO is a convenient and effective treatment for obliterating F2 and F3 EVs. Clinical Trial Registration No. ChiCTR2000039974.

Esophageal variceal ligation plus sclerotherapy vs. ligation alone for the treatment of esophageal varices.

BackgroundThis study aimed to evaluate the efficacy and adverse events of esophageal variceal ligation (EVL) vs. EVL combined with endoscopic injection sclerosis (EIS) in the therapy of esophageal varices.MethodsPatients from January 2017 to August 2021 who received EVL alone (control group) or EVL plus EIS (intervention group) were enrolled in this retrospective study. Efficacy, including rebleeding (clinically hematemesis or melena, confirmed by endoscopy as esophagogastric varices bleeding), variceal recurrence rate (the presence of esophagogastric varices which is needed to be treated again) the number of sessions performed to complete eradication of varices, and safety (adverse events) were compared. The variceal recurrence-associated factors were derived by univariate and multivariate logistic regression analyses.ResultsThe variceal recurrence and rebleeding rate in the intervention group showed significantly lower than the control group (2.6% vs 10.3%, P = 0.006 and 20.7% vs 37.5%, P = 0.029, P = 0.006, respectively, in the 12-month follow-up). The adverse events (fever, chest pain, swallowing, and esophageal stricture) showed no significant difference between the two groups (P > 0.05). Further research showed that the efficacy of the intervention group was better than the control group only achieved in prophylactically endoscopic treatment patients. The diameter of esophageal varices and gastric varices co-exist showed significant effects on variceal recurrence in intervention group [odds ratio (OR) = 15.856; 95% confidence interval (CI), 1.709–160.143; P = 0.016 and OR = 4.5; 95% CI, 1.42–20.028; P = 0.021; respectively].ConclusionsThe intervention group may obtain lower recurrence, rebleeding rate, and fewer sessions performed to complete eradication of varices (number of sessions) and similar incidence of adverse events, especially for prophylactically treatment. Among the intervention group, the diameter of esophageal varices and gastric varices were closely associated with variceal recurrence.

A Case of Recurrent Varices after Surgery (REVAS) of the Lateral Small Saphenous Vein Just Near the Lateral Sural Cutaneous Nerve Treated with Cyanoacrylate Closure

A Case of Recurrent Varices after Surgery (REVAS) of the Lateral Small Saphenous Vein Just Near the Lateral Sural Cutaneous Nerve Treated with Cyanoacrylate Closure

Efficacy and Safety of Endoscopic Primary Prophylaxis of Bleeding in Children With High-Risk Gastroesophageal Varices.

Primary prophylaxis of bleeding is debated in children with gastroesophageal varices; one of the reasons is the limited number of studies concerning its efficacy and safety. We report our experience with endoscopic primary prophylaxis. From 2006 to 2019, 145 children (median age, 3.5 years; cirrhosis, n = 116) with high-risk gastroesophageal varices underwent primary prophylaxis (banding, n = 114; sclerotherapy n = 31, primarily in smaller children). We observed the eradication of varices in 93% of children after a mean of 6 months, at least one recurrence of varices in 45% after eradication, and gastrointestinal bleeding in 17% of children. Irrespective of the cause of portal hypertension, grade 3 esophageal varices, presence of gastric varices along the cardia and a lower composite score of endoscopic severity were associated with a worse probability of eradication, a longer time to eradication and a lower risk of a first recurrence and of bleeding following the procedure, respectively. Ten-year probabilities of overall survival and of bleeding-free survival were 95% and 75%, respectively. Endoscopic primary prophylaxis of variceal bleeding is reasonably effective and safe in children with high-risk gastroesophageal varices. Worse results are observed in children with more advanced endoscopic features. This pleads for endoscopic screening in children with portal hypertension and early detection of varices warranting primary prophylaxis.

Minimally invasive ways to treat and prevent gastroesophageal portal bleeding

Aim. To analyze the results of minimally invasive techniques to prevent and treat gastroesophageal bleeding in patients with cirrhosis.Materials and methods. The study included 997 patients with liver cirrhosis: Child-Pugh class A – 21.7%; class B – 48.8%; class C – 29.5%. Esophageal varices of Grades III–IV were diagnosed in 95.5% of the patients, while gastric varices were observed in 17.4% of the patients. The following methods were used: endoscopic ligation, endoscopic sclerotherapy, TIPS, laparoscopic azygoportal disconnection, and distal splenorenal anastomosis.Results. Following endoscopic procedures aimed at preventing the onset of gastroesophageal bleeding, variceal recurrence and bleeding were observed in 35.9% and 18.6% of cases, respectively. The efficacy of endoscopic ligation in case of bleeding amounted to 91.2%. Multiple endoscopic procedures provided means to treat esophageal and gastric varices in 56.2% of the patients. Rebleeding was observed in 9.3% of the patients, while esophageal and gastric varices persisted in 34.3% of the patients. TIPS was found to significantly reduce portal pressure and the grade of varices, with encephalopathy developing in 41.4% of the patients. In the long-term period, stent dysfunction was diagnosed in 22.5% of cases, while bleeding recurred in 10%. Laparoscopic azygoportal disconnection contributed to the regression of esophageal and gastric varices. In the long-term period, bleeding recurred in 42.3% of cases. Laparoscopic distal splenorenal anastomosis reliably prevented the recurrence of bleeding. No shunt thrombosis or lethal outcomes were observed, while the incidence of encephalopathy amounted to 14.7%.Conclusion. A sufficient number of minimally invasive methods are currently available in the treatment and prevention of gastroesophageal portal bleeding. A case-specific approach to the choice of measures aimed at treating and preventing gastroesophageal bleeding in patients with cirrhosis is required, taking into account the degree of decompensation of portal hypertension and the severity of liver dysfunction.

Impact of endoscopic ultrasound examination for deep esophageal collateral veins evaluation in liver cirrhosis patients prior to endoscopic treatment: A case series

AbstractAimThe presence of esophageal collateral veins (ECV) has been reported to be associated with the recurrence of esophageal varices (EV) and bleeding in liver cirrhotic (LC) patients. This study aimed to see the potential clinical value of deep collateral veins assessment using endoscopic ultrasound (EUS) in liver cirrhotic patients with EV.MethodsDuring 6 months period, a prospective study is conducted, where we identified LC patients who were admitted for esophagogastroduodenoscopy (EGD) screening at the Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Jakarta. ECV was examined using EUS. Patients were excluded if they had (1) liver malignancy, (2) history of ligation or glue injection, or (3) portal or splenic vein thrombus. We collected demographic data, medical history, data pertaining to use of nonselective beta blocker (NSBB), and laboratory, imaging, and endoscopy results. EGD was performed using a gastroscope (EG29‐i10, 3.2 mm Pentax Medical) while EUS was performed using a linear array echoendoscope (EG‐3870UTK, 3.8 mm, Pentax Medical) before band ligation or glue injection.ResultsThere were 20 LC patients included in this study, where 15 (75%) of patients were classified with Child–Pugh (CP)‐A and five (25%) of patients with CP‐B. The most common aetiologies were hepatitis B in seven (35%) patients and hepatitis C in nine (45%) patients. The EV with peri‐ or para‐esophageal veins (PEEV or PAEV) were detected in 65% of patients. None of the LC patients with no EV showed the presence of ECV. PEEV or PAEV were detected in grades 1–3 EV.ConclusionEUS examination can give a better evaluation before managing gastroesophageal varices through deep ECV detection in LC patients.

Comparison of the Covered Self-Expandable Viatorr CX Stent with the Covered Balloon-Expandable BeGraft Peripheral Stent for Transjugular Intrahepatic Portosystemic Shunt (TIPS) Creation: a Single-Centre Retrospective Study in Patients with Variceal Bleeding.

This study compares the safety and efficacy of the ePTFE-covered self-expansible nitinol stent (VIATORR® Controlled Expansion, Gore, Flagstaff, USA) with the ePTFE-covered, balloon-expandable, metallic stent (BeGraft peripheral, Bentley, Hechingen, Germany) for the creation of the transjugular intrahepatic portosystemic shunt (TIPS). From September 2016 to December 2020, 72 consecutive patients receiving TIPS for acute variceal bleeding (rescue and early TIPS, n = 15) or for prophylaxis of variceal rebleeding (n = 57) were enrolled. The main contraindications were patients with vascular liver disease (portal vein thrombosis and Budd-Chiari syndrome). Forty patients (55.6%) received a Viatorr CX stent and 32 patients (44.4%) a BeGraft peripheral stent. Safety endpoints were technical and clinical adverse events and early deaths within 30days after TIPS implantation. Efficacy endpoints were rebleeding rates, recurrence of large varices requiring endoscopic band ligation, or TIPS revision. Groups receiving the Viatorr CX or BeGraft peripheral stent were comparable in all respects except the TIPS indication for acute variceal bleeding (5% vs. 25%, p = 0.015). All patients had a successful intervention, and the physical variables of stent implantation (intervention and fluoroscopy time, reduction of the portosystemic pressure gradient) as well as adjunctive embolization of varices were similar in both groups. Severe clinical complications (Viatorr CX: 5% vs. BeGraft peripheral: 3.1%, p = 0.692), post-TIPS hepatic encephalopathy (12.5% vs. 18.8%, p = 0.743) and death (5% vs. 0%, p = 0.793) were not different between Viatorr CX and BeGraft peripheral groups. With respect to efficacy, freedom from rebleeding and from variceal band ligation during follow-up (100% vs. 100%, p = 1.0), as well as the need for shunt revision (10.5% vs. 18.8%, p = 0.327), was comparable. Compared to the present gold standard, the Viatorr CX stent, the balloon-expandable BeGraft peripheral stent, showed similar results with respect to safety and efficacy.

Risk Factors for Esophageal Collateral Veins in Cirrhosis with and without Previous Endoscopic Esophageal Variceal Therapy.

Background Portosystemic collateral vessels are a sign of portal hypertension in liver cirrhosis. Esophageal collateral veins (ECVs) are one major type of portosystemic collateral vessels, which increase the recurrence of esophageal varices and bleeding after variceal eradication. However, the risk factors for ECVs were still unclear. Methods We retrospectively screened cirrhotic patients who had contrast-enhanced computed tomography (CT) images to evaluate ECVs and upper gastrointestinal endoscopic reports to evaluate gastroesophageal varices at our department. Univariate and multivariate logistic regression analyses were performed to explore the independent risk factors for ECVs. Odds ratios (ORs) were calculated. Subgroup analyses were performed in patients with and without previous endoscopic variceal therapy which primarily included endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS). Results Overall, 243 patients were included, in whom the prevalence of ECVs was 53.9%. The independent risk factors for ECVs were hepatitis C virus infection (OR = 0.250, p = 0.026), previous EVL (OR = 1.929, p = 0.044), platelet (OR = 0.993, p = 0.008), and esophageal varices needing treatment (EVNTs) (OR = 2.422, p = 0.006). The prevalence of ECVs was 60.8% (73/120) in patients undergoing EVL, 50% (10/20) in those undergoing EIS, and 47.5% (48/101) in those without previous endoscopic variceal therapy. The independent risk factors for ECVs were the use of nonselective beta-blockers (OR = 0.294, p = 0.042) and EVNTs (OR = 3.714, p = 0.006) in subgroup analyses of patients with and without previous endoscopic variceal therapy, respectively. Conclusions The presence of ECVs should be closely associated with the severity of portal hypertension in liver cirrhosis. Risk of ECVs might be increased by previous EVL.

Management of varices and variceal hemorrhage in liver cirrhosis: a recent update.

Cirrhosis consists of two main stages: compensated (asymptomatic) and decompensated, the latter with a higher mortality. Variceal hemorrhage, together with ascites or encephalopathy, or both, are events that define cirrhosis decompensation and are driven by portal hypertension. The approach and management of patients with compensated cirrhosis has been mostly focused on preventing variceal hemorrhage in those who have high-risk varices on endoscopy. Recent studies suggest a paradigm shift aimed at preventing all decompensating events, not only variceal hemorrhage, in patients with cirrhosis and clinically significant portal hypertension identified via noninvasive measures such as liver stiffness and platelet count. In these patients, nonselective beta-blockers have been shown to prevent ascites (the most common decompensating event) and variceal growth. Variceal hemorrhage has a high mortality rate and even though advances in diagnostic approach and standard of care over the past decades have led to a decrease in mortality, it is still high with a 6-week mortality rate of 15–20%. Survival has improved with the preemptive placement of the transjugular intrahepatic portosystemic shunt in patients at high risk of failing standard therapy. In this review, we provide an overview of the pathophysiology and bases for therapy of portal hypertension and varices, the diagnostic approach and management of compensated cirrhosis with clinically significant portal hypertension, and the management of acute variceal hemorrhage as well as prevention strategies for variceal hemorrhage recurrence.

Balloon-compression endoscopic injection sclerotherapy for the treatment of esophageal varices.

Video 1Balloon-compression endoscopic injection sclerotherapy for the treatment of esophageal varices. A 50-year-old man with schistosomiasis-induced liver fibrosis presented with melena and hematemesis. The bleeding stopped after intravenous administration of somatostatin and ceftriaxone for 4 days. Balloon-compression endoscopic injection sclerotherapy (bc-EIS) was performed with the patient under general anesthesia to prevent rebleeding. The novel device for bc-EIS is composed of a syringe, a stopcock, a catheter, and an inflatable balloon. In the majority of patients with cirrhosis, the blood flow from the coronary vein drains into the azygos and hemiazygos venous system through esophageal and para-esophageal varices, and eventually back to the inferior vena cava. With compression of proximal esophageal and para-esophageal varices via an inflated balloon, sclerosant can be retained at the injection site, rather than flowing back to the inferior vena cava. Endoscopy revealed the presence of moderately enlarged, beady esophageal varices with red wale signs in the middle and lower esophagus. An inflatable balloon was fixed to an endoscope at a distance of 3 cm from its distal end. When the end of the endoscope was introduced to the target varices, 20 mL of air was injected into the balloon through a thin catheter, making its outer diameter expand to 3.5 cm. A disposable endoscopic injection needle then entered the base of the variceal columns near the cardia. When blood flowed back into the needle, a mixture of Lauromacrogol and methylene blue was intravariceally administered. Minor bleeding at the injection site was stopped through brief compression with the needle sheath. The second injection was performed following the aforementioned procedure. Follow-up endoscopy at 1 month, 4 months, and 7 months revealed the progression from thrombosed blue varices to complete eradication of esophageal varices. Endoscopic ultrasonography also showed the absence of blood flow in the varices after treatment. To date, bc-EIS has been performed successfully on 28 patients with esophageal varices. Variceal eradication was obtained in 17 patients with 1 session, 10 patients with 2 sessions, and 1 patient with 3 sessions. Two patients showed recurrence of esophageal varices on routine follow-up endoscopy and were re-treated with bc-EIS successfully. There were no severe complications during the follow-up period. With the sclerosant retained at injection sites after balloon compression, bc-EIS enables complete eradication of esophageal varices and lowers the risk of recurrence. The blockade of sclerosant also decreases the incidence of complications related to large-volume injection of sclerosant, such as embolization, ulceration, and perforation. In conclusion, bc-EIS appears to be an effective and safe approach for the treatment of esophaeal varices. Further research is underway to determine its suitability for large-scale clinical application.

Prognostic and recurrence factors after endoscopic injection sclerotherapy for esophageal varices: Multivariate analysis with the propensity score matching: Multivariate analysis with propensity score matching.

Peri-esophageal collateral veins have been reported to be associated with the recurrence of esophageal varices (EVs). In this study, we retrospectively analyzed whether endoscopic ultrasonography (EUS) findings obtained just before endoscopic injection sclerotherapy (EIS) are associated with the success rate of intravariceal injection, recurrence rate of EVs, and overall survival rate (OS) of patients. Furthermore, we investigated the independent predictors associated with these factors by multivariate analysis. A total of 91 patients with risky EVs treated by EIS were analyzed. The primary endpoint was to identify independent predictors associated with the success rate of intravariceal injection, recurrence rate, and OS by multivariate analysis, to confirm the usefulness of EUS examination. The secondary endpoint was to clarify differences in recurrence rate and OS between patients who underwent additional argon plasma coagulation (APC) and those who did not, by the propensity score matching method. Luminal diameter of EVs and F factor were predictors of the success rate of intravariceal injection. APC was predictor of OS and recurrence of EVs. EUS findings were not associated with these factors. Propensity score matching (APC, 23; without APC, 23) showed that recurrence rate was significantly improved in the APC group (P = 0.050) and that OS had the tendency to be higher in the APC group (P = 0.068). Endoscopic ultrasonography findings before EIS were associated with successful intravariceal injection but were not associated with recurrence rate or OS. Additional APC could improve OS and reduce the recurrence of EVs.