Worsening Of Esophageal Varices Research Articles

Endoscopic Cyanoacrylate Injection Versus Balloon‐Occluded Retrograde Transvenous Obliteration for Prevention of Gastric Variceal Bleeding: A Randomized Controlled Trial

Background and Aims The optimal treatment for gastric varices (GVs) is a topic that remains open for study. This study compared the efficacy and safety of endoscopic cyanoacrylate injection and balloon‐occluded retrograde transvenous obliteration (BRTO) to prevent rebleeding in patients with cirrhosis and GVs after primary hemostasis. Approach and Results Patients with cirrhosis and history of bleeding from gastroesophageal varices type 2 or isolated gastric varices type 1 were randomized to cyanoacrylate injection (n = 32) or BRTO treatment (n = 32). Primary outcomes were gastric variceal rebleeding or all‐cause rebleeding. Patient characteristics were well balanced between two groups. Mean follow‐up time was 27.1 ± 12.0 months in a cyanoacrylate injection group and 27.6 ± 14.3 months in a BRTO group. Probability of gastric variceal rebleeding was higher in the cyanoacrylate injection group than in the BRTO group (P = 0.024). Probability of remaining free of all‐cause rebleeding at 1 and 2 years for cyanoacrylate injection versus BRTO was 77% versus 96.3% and 65.2% versus 92.6% (P = 0.004). Survival rates, frequency of complications, and worsening of esophageal varices were similar in both groups. BRTO resulted in fewer hospitalizations, inpatient stays, and lower medical costs. Conclusions BRTO is more effective than cyanoacrylate injection in preventing rebleeding from GVs, with similar frequencies of complications and mortalities.

Development or worsening of esophageal varices in patients with cirrhosis after DAA-induced HCV clearance

Development or worsening of esophageal varices in patients with cirrhosis after DAA-induced HCV clearance

Balloon-Assisted Percutaneous Transhepatic Antegrade Embolization with 2-Octyl Cyanoacrylate for the Treatment of Isolated Gastric Varices with Large Gastrorenal Shunts

Aims To evaluate the safety and effectiveness of percutaneous transhepatic antegrade embolization (PTAE) with 2-octyl cyanoacrylate assisted with balloon occlusion of the left renal vein or gastrorenal shunts (GRSs) for the treatment of isolated gastric varices (IGVs) with large GRSs. Methods Thirty patients with IGVs associated with large GRSs who had underwent PTAE assisted with a balloon to block the opening of the GRS in the left renal vein were retrospectively evaluated and followed up. Clinical and laboratory data were collected to evaluate the technical success of the procedure, complications, changes in the liver function using Child-Pugh scores, worsening of the esophageal varices, the rebleeding rate, and survival. Laboratory data obtained before and after PTAE were compared (paired-sample t-test). Results PTAE was technically successful in all 30 patients. No serious complications were observed except for one nonsymptomatic pulmonary embolism. During a mean follow-up of 30 months, rebleeding was observed in 4/30 (13.3%) patients, worsening of esophageal varices was observed in 4/30 (13.3%) patients, and newly developed or aggravated ascites were observed on CT in 3/30 (10%) patients. Significant improvement was observed in Child-Pugh scores (p=0.009) and the international normalized ratio (INR) (p=0.004) at 3 months after PTAE. The cumulative survival rates at 1, 2, 3, and 5 years were 96.3%, 96.3%, 79.9%, and 79.9%, respectively. Conclusion Balloon-assisted PTAE with 2-octyl cyanoacrylate is technically feasible, safe, and effective for the treatment of IGV associated with a large GRS.

Abstract No. 494 - Towards a turning point in gastric varices treatment: modified balloon-occluded retrograde transvenous obliteration

Abstract No. 494 - Towards a turning point in gastric varices treatment: modified balloon-occluded retrograde transvenous obliteration

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.

Splenic Vein Embolization Using Coil Anchors and Prophylactic Occlusion of a Hepatofugal Collateral for Hepatic Encephalopathy due to Splenorenal Shunt: Technical Note and Literature Review

Purpose. Interventional treatment strategies for patients with encephalopathy due to splenorenal shunt remain controversial. Portosplenic blood flow separation by occluding the splenic vein could avoid the complication of severe portal hypertension, but it would require repeated reintervention due to recurrence of symptoms. This paper describes occlusion of the splenic vein using coil anchors and prophylactic embolization of a collateral hepatofugal vessel with no recurrence of hyperammonemia. Materials and Methods. A 51-year-old woman with severe cirrhosis had hepatic encephalopathy due to a large splenorenal shunt. The serum ammonia level was 132 μg/dL. Via a transileocolic approach, the splenic vein was completely embolized with 0.035-inch metallic coils using coil anchors while preserving the splenorenal shunt. In addition, one of the collateral vessels of the portal vein, the retrogastric vein, was also embolized prophylactically. Results. After this procedure, the serum ammonia level decreased immediately to 24 μg/dL. The portal venous pressure increased by only 1.5 mmHg. Hepatic encephalopathy had not been observed for 25 months after the procedure, and neither retention of ascites nor worsening of esophageal varices and liver function was observed. Conclusion. This procedure appears to be safe and effective for hepatic encephalopathy caused by a splenorenal shunt.

Balloon-occluded retrograde transvenous obliteration for intractable gastric variceal bleeding

Balloon-occluded retrograde transvenous obliteration (BRTO) is an interventional radiologic technique that obliterates gastric varices (GV) from draining veins under balloon occlusion. A 54-year-old man presented with Stage IV hepatocellular carcinoma and tumor thrombi in main portal vein. Intractable GV bleeding had no response to repeated endoscopic sclerotherapy and pharmacotherapy well. Additionally, his medical condition could not allow transjugular intrahepatic portosystemic shunt or surgical portal decompression. Due to spontaneous gastrorenal shunt proved with abdominal computed tomography, we conducted BRTO to prevent further bleeding. The immediate postprocedural venogram showed total occlusion of the gastrorenal shunt and no visualization of the GV. Follow-up endoscopy was performed at 1 month, 2 months, and 4 months after BRTO. It revealed shrinkage of gastric varices and no worsening of esophageal varices after 4 months of BRTO. The patient was free from repeated GV bleeding for 4 months. Our experience proved BRTO could be the other effective treatment for intractable GV bleeding.

Management of gastric fundal varices

I read with great interest the guideline for the prevention and management of gastroesophageal varices and variceal hemorrhage in patients with cirrhosis that was approved by the American Association for the Study of Liver Diseases and the American College of Gastroenterology.1 This guideline recommends that the use of a transjugular intrahepatic portosystemic shunt (TIPS) should be considered in patients in whom hemorrhage from fundal varices (FV) cannot be controlled or in whom bleeding recurs despite combined pharmacological and endoscopic therapy. It has been reported that esophageal varices rarely bleed when the hepatic venous pressure gradient (HVPG) is <12 mm Hg or after reduction of the HVPG by 20%, but the hemodynamics of FV are very different from those of esophageal varices or other types of gastric varices. Watanabe et al.2 studied a series of patients with FV and found that most of these varices were associated with a well-developed gastrorenal shunt and that superior mesenteric venous flow was diverted away from the liver and directed into the gastrorenal shunt via the feeding veins for these varices. Accordingly, the HVPG of large FV is quite low, whereas collateral flow into the varices is abundant. In addition, these patients are highly likely to develop hepatic encephalopathy. Tripathi et al.3 reported that bleeding from FV can occur even when the HVPG is <12 mm Hg and that TIPS improves the mortality rate only in patients who suffer from bleeding at an HVPG ≥ 12 mm Hg. This suggests that decompressive procedures such as TIPS are not likely to provide much benefit for FV patients who have a major shunt and low HVPG.4 Obliteration of such FV in a safe manner could therefore be justified. Balloon-occluded retrograde transvenous obliteration (B-RTO) is a radiologic technique using ethanolamine oleate (a common sclerosant) that was developed in Japan for the treatment of FV associated with a gastrorenal shunt.5 B-RTO is similar to TIPS but is less invasive and technically easy for interventional radiologists to perform. B-RTO can achieve excellent long-term prevention of bleeding with few major complications (fever, hemoglobinuria, and worsening of esophageal varices).6, 7 Ninoi et al.8 reported that transcatheter sclerotherapy (including B-RTO) might achieve better control of gastric variceal bleeding than TIPS, and they also suggested that transcatheter sclerotherapy could contribute to a higher survival rate compared with TIPS (class I, level B). The main limitation of B-RTO in the emergency setting seems to be the requirement for temporary control of bleeding with or without use of cyanoacrylate.9 In Japan, B-RTO is a recommended therapeutic option for the treatment of patients who have FV associated with a gastrorenal shunt, regardless of their HVPG or the size of their varices. Multidetector row computed tomographic angiography can accurately assess the presence of a gastrorenal shunt.10 Prospective randomized trials comparing cyanoacrylate with B-RTO are warranted. Akio Matsumoto*, * Department of Internal Medicine, Kumiyama Minami Hospital, Kumiyama-cho, Japan.

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.

Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices with Gastrorenal Shunt: Long-Term Follow-Up in 78 Patients

Our aim was to evaluate the long-term clinical results after balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices with spontaneous gastrorenal shunt. A total of 78 patients with cirrhosis and with gastric varices, successfully treated by B-RTO, were enrolled in this study. Recurrence and bleeding of gastric varices and worsening of esophageal varices were endoscopically evaluated. Univariate and multivariate analyses were used to assess the prognostic factors for worsening of esophageal varices and survival. Recurrence of gastric varices was found in two patients; the 5-year recurrence rate was 2.7%. Bleeding of gastric varices occurred in only one patient after B-RTO; the 5-year bleeding rate was 1.5%. Worsening of esophageal varices was observed in 29 patients, and the worsening rates at 1, 3, and 5 years were 27%, 58%, and 66%, respectively. These esophageal varices were endoscopically treated to prevent rupture. Multivariate analysis showed the presence of esophageal varices before B-RTO was a prognostic factor for worsening (relative risk, 4.956). At a median follow-up of 700 days (range, 137-2,339 days), the survival rates at 1, 3, and 5 years were 93%, 76%, and 54%, respectively. The prognostic factors associated with survival were presence of hepatocellular carcinoma (relative risk, 24.342) and the Child-Pugh classification (relative risk, 5.780). B-RTO is an effective method for gastric varices with gastrorenal shunt and provides lower recurrence and bleeding rates. We believe that B-RTO can become a standard treatment for gastric varices with gastrorenal shunt, although treatment of worsened esophageal varices may be necessary after B-RTO.

Selective Embolization of the Splenic Vein in Patients with Hepatic Encephalopathy and Splenorenal Shunt

Obliteration of portal-systemic shunts is effective for portosystemic encephalopathy but is often associated with complications such as retention of ascites and worsening of esophageal varices. Selective embolization of the splenic vein was performed on six patients with hepatic encephalopathy and splenorenal shunts. Hepatic encephalopathy was not observed in four patients after the procedure. Neither retention of ascites nor rupture of esophageal varices was observed because postoperative elevation of portal venous pressure was not as great as that seen when shunt obliteration is performed. This procedure can be an effective and safe treatment option for hepatic encephalopathy with a splenorenal shunt.

Long-term Results of Balloon-Occluded Retrograde Transvenous Obliteration for the Treatment of Gastric Varices and Hepatic Encephalopathy

To evaluate the long-term results of balloon-occluded retrograde transvenous obliteration (B-RTO) for the treatment of gastric varices (GV) and hepatic encephalopathy. A total of 43 patients who had undergone B-RTO were evaluated, 32 with GV, two with hepatic encephalopathy, and nine with both. All but one had been consecutively followed up with gastrointestinal endoscopy for more than 1 year (3-60 months; mean, 30.44 months). Collateral veins of gastric varices were graded using balloon-occluded retrograde left adrenal venography. The relation of both worsening of esophageal varices (EV) and improved Child-Pugh score after B-RTO to the grades of collateral vein development was analyzed. The relapse-free survival and the prognostic factors for survival after B-RTO were also assessed. GV disappeared or decreased markedly in size, and hepatic encephalopathy was completely cured in all patients. Improvement in Child-Pugh score was observed in 21 patient (50.0%) 6 months after B-RTO, but in only 11 patients (25.6%) 1 year after B-RTO. Worsening of EV was seen in eight patients and was related to a worsened grade of collateral veins. Cumulative relapse-free survival rate was 90.8% at 1 year and 87.4% at 3 years after B-RTO. The most significant prognostic factor was Child-Pugh classification (relative risk: 4.16) B-RTO is a safe and effective treatment for patients with GV and hepatic encephalopathy. The most important prognostic factors are the extent of Child-Pugh classification.