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Above and beyond TIPS: procedural challenges and alternative techniques
S278
Posters and Exhibits
Learning Objectives: To understand the technique and potential anatomic variants in BRTO. To review the most common procedural complications and provide some tips to avoid them. To illustrate some unusual complications related to the technique. Background: BRTO has been used to treat bleeding gastric varices in Asia for over 20 years. The technique is gaining momentum in the West, however, several modifications to the technique are necessary in the US due to different embolization agents and procedural materials available in this country. Many of the procedural complications are related to the use of inadequate materials or poor understanding of the anatomy of the gastrorenal shunts. The purpose of this exhibit is to review the common and unusual procedural and post procedural complications after BRTO for the treatment of bleeding gastric varices. Clinical Findings/Procedure Details: Procedural complications: step by step review of the basic technique and potential complications. Post procedural complications: what to expect and what to worry about. Tips to prevent complications: lessons learned with BRTO in the last 5 years. Conclusions: BRTO is a very useful minimally invasive technique for the treatment of bleeding gastric varices. Most of the procedural complications can be avoided by adequate selection of the embolization agent, the occlusion balloon and with good understanding of the possible variations of the technique that are available in challenging cases.
Educational Exhibit
Abstract No. 635
Advanced techniques for gastric variceal obliteration: transhepatic and transsplecnic routes
Posters and Exhibits
A. Kumar1, M. Kolber2, P. Shukla2, T. Markowitz1; 1New York, NY; 2Mount Sinai Beth Israel, New York, NY Learning Objectives: This exhibit will review the use of advanced techniques for gastric variceal embolization. We will provide a case-based illustration of the use of transhepatic and transplenic access for balloon occluded transvenous obliteration of gastric varices, in particular in patients with partial splenic vein thrombosis and absent splenorenal shunt. Background: Hemorrhage from gastric varices can be a major cause of morbidity and mortality in patients with portal hypertension. Balloon occluded retrograde transvenous obliteration (BRTO) has been increasingly used in management of isolated gastric varices with favorable outcomes. Traditionally, this procedure is performed via a splenorenal shunt draining to the left renal vein. However, approximately 12% of patients with gastric varices require alternative routes of access. This is especially the case in patients with partial splenic vein thrombosis causing portal hypertension. Clinical Findings/Procedure Details: A case based illustration of transhepatic and transsplenic access for gastric variceal sclerosis will be provided. The exhibit will discuss preprocedure imaging, review variant anatomy, procedural details, tips to avoid common pitfalls, and potential post procedural complications. Conclusions: Modifications to the traditional BRTO technique are often required for gastric variceal sclerosis when variant anatomy is encountered. Careful evaluation of
’
JVIR
pre-procedural imaging and understanding of intraprocedural challenges are essential for successful treatment of gastric varices using transsplenic and transhepatic routes.
Educational Exhibit
Abstract No. 636
Above and beyond TIPS: procedural challenges and alternative techniques A. Patel1, M. Chamarthy2, A. Pillai2, P. Sutphin3, M. Reddick2, S. Kalva4; 1University of Texas Southwestern, Dallas, TX; 2Coppell, TX; 3Dallas, TX; 4 University of Texas Southwestern Medical Center, Dallas, TX Learning Objectives: To discuss the technical challenges of transjugular intrahepatic portosystemic shunt (TIPS) as well as to demonstrate alternative techniques and approaches in the management of varices. Background: The TIPS procedure involves creation of a shunt between the hepatic vein and portal vein to decompress the portal hypertension in the management of refractory variceal bleeding and refractory ascites or hydrothorax. Various technical challenges, especially due to unfavorable anatomy, are frequently encountered during the procedure. Additionally, TIPS may not always be the only or correct treatment procedure. Clinical Findings/Procedure Details: Technical challenges to perform TIPS and methods to overcome them. 1. Occluded internal jugular vein: Treatment options include femoral venous approach, “gun-shot” technique, and CT-guided DIPS (direct intrahepatic portocaval shunt). 2. Occluded hepatic vein (s): Treatment options include CT/intravascular ultrasound guided (IVUS) DIPS. 3. Occluded portal vein: Portal vein thrombolysis, recanalization and TIPS creation. 4. Acute hepatic vein angulation and small liver volumes: IVUS-guided TIPS, DIPS. Alternative techniques to treat varices (TIPS not necessary or appropriate). 1. BRTO/BATO (balloonoccluded retrograde or antegrade transvenous obliteration). 2. Percutaneous transhepatic portal access and obliteration of varices. 3. Percutaneous direct obliteration of stomal varices. 4. Splenic arterial embolization for splenic vein thrombosis and gastric varices. 5. Portal venous stenting for benign or malignant portal vein occlusion. Rescue methods to aid surgical portosystemic shunts. 1. Splenorenal/mesocaval shunt occlusion or stenosis can be treated with balloon angioplasty. Conclusions: TIPS is a fundamental procedure of interventional radiology to manage variceal bleeding. However, one should be familiar with the procedural limitations, challenges, and alternative techniques for the management of variceal bleeding.
Educational Exhibit
Abstract No. 637
Balloon-occluded retrograde transvenous obliteration for duodenal varices K. Yamada1, M. Yamamoto1, M. Horikawa2, H. Shinmoto1, T. Kaji1; 1National Defense Medical College, Tokorozawa, Saitama, Japan; 2Dotter Interventional Institute, Portland, OR
Posters and Exhibits
Learning Objectives: To understand the technique and potential anatomic variants in BRTO. To review the most common procedural complications and provide some tips to avoid them. To illustrate some unusual complications related to the technique. Background: BRTO has been used to treat bleeding gastric varices in Asia for over 20 years. The technique is gaining momentum in the West, however, several modifications to the technique are necessary in the US due to different embolization agents and procedural materials available in this country. Many of the procedural complications are related to the use of inadequate materials or poor understanding of the anatomy of the gastrorenal shunts. The purpose of this exhibit is to review the common and unusual procedural and post procedural complications after BRTO for the treatment of bleeding gastric varices. Clinical Findings/Procedure Details: Procedural complications: step by step review of the basic technique and potential complications. Post procedural complications: what to expect and what to worry about. Tips to prevent complications: lessons learned with BRTO in the last 5 years. Conclusions: BRTO is a very useful minimally invasive technique for the treatment of bleeding gastric varices. Most of the procedural complications can be avoided by adequate selection of the embolization agent, the occlusion balloon and with good understanding of the possible variations of the technique that are available in challenging cases.
Educational Exhibit
Abstract No. 635
Advanced techniques for gastric variceal obliteration: transhepatic and transsplecnic routes
Posters and Exhibits
A. Kumar1, M. Kolber2, P. Shukla2, T. Markowitz1; 1New York, NY; 2Mount Sinai Beth Israel, New York, NY Learning Objectives: This exhibit will review the use of advanced techniques for gastric variceal embolization. We will provide a case-based illustration of the use of transhepatic and transplenic access for balloon occluded transvenous obliteration of gastric varices, in particular in patients with partial splenic vein thrombosis and absent splenorenal shunt. Background: Hemorrhage from gastric varices can be a major cause of morbidity and mortality in patients with portal hypertension. Balloon occluded retrograde transvenous obliteration (BRTO) has been increasingly used in management of isolated gastric varices with favorable outcomes. Traditionally, this procedure is performed via a splenorenal shunt draining to the left renal vein. However, approximately 12% of patients with gastric varices require alternative routes of access. This is especially the case in patients with partial splenic vein thrombosis causing portal hypertension. Clinical Findings/Procedure Details: A case based illustration of transhepatic and transsplenic access for gastric variceal sclerosis will be provided. The exhibit will discuss preprocedure imaging, review variant anatomy, procedural details, tips to avoid common pitfalls, and potential post procedural complications. Conclusions: Modifications to the traditional BRTO technique are often required for gastric variceal sclerosis when variant anatomy is encountered. Careful evaluation of
’
JVIR
pre-procedural imaging and understanding of intraprocedural challenges are essential for successful treatment of gastric varices using transsplenic and transhepatic routes.
Educational Exhibit
Abstract No. 636
Above and beyond TIPS: procedural challenges and alternative techniques A. Patel1, M. Chamarthy2, A. Pillai2, P. Sutphin3, M. Reddick2, S. Kalva4; 1University of Texas Southwestern, Dallas, TX; 2Coppell, TX; 3Dallas, TX; 4 University of Texas Southwestern Medical Center, Dallas, TX Learning Objectives: To discuss the technical challenges of transjugular intrahepatic portosystemic shunt (TIPS) as well as to demonstrate alternative techniques and approaches in the management of varices. Background: The TIPS procedure involves creation of a shunt between the hepatic vein and portal vein to decompress the portal hypertension in the management of refractory variceal bleeding and refractory ascites or hydrothorax. Various technical challenges, especially due to unfavorable anatomy, are frequently encountered during the procedure. Additionally, TIPS may not always be the only or correct treatment procedure. Clinical Findings/Procedure Details: Technical challenges to perform TIPS and methods to overcome them. 1. Occluded internal jugular vein: Treatment options include femoral venous approach, “gun-shot” technique, and CT-guided DIPS (direct intrahepatic portocaval shunt). 2. Occluded hepatic vein (s): Treatment options include CT/intravascular ultrasound guided (IVUS) DIPS. 3. Occluded portal vein: Portal vein thrombolysis, recanalization and TIPS creation. 4. Acute hepatic vein angulation and small liver volumes: IVUS-guided TIPS, DIPS. Alternative techniques to treat varices (TIPS not necessary or appropriate). 1. BRTO/BATO (balloonoccluded retrograde or antegrade transvenous obliteration). 2. Percutaneous transhepatic portal access and obliteration of varices. 3. Percutaneous direct obliteration of stomal varices. 4. Splenic arterial embolization for splenic vein thrombosis and gastric varices. 5. Portal venous stenting for benign or malignant portal vein occlusion. Rescue methods to aid surgical portosystemic shunts. 1. Splenorenal/mesocaval shunt occlusion or stenosis can be treated with balloon angioplasty. Conclusions: TIPS is a fundamental procedure of interventional radiology to manage variceal bleeding. However, one should be familiar with the procedural limitations, challenges, and alternative techniques for the management of variceal bleeding.
Educational Exhibit
Abstract No. 637
Balloon-occluded retrograde transvenous obliteration for duodenal varices K. Yamada1, M. Yamamoto1, M. Horikawa2, H. Shinmoto1, T. Kaji1; 1National Defense Medical College, Tokorozawa, Saitama, Japan; 2Dotter Interventional Institute, Portland, OR