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Retrograde–Antegrade Accelerated Trap Obliteration: A Modified Approach to Transvenous Eradication of Gastric Varices
BRIEF REPORT
Retrograde–Antegrade Accelerated Trap Obliteration: A Modified Approach to Transvenous Eradication of Gastric Varices Ron C. Gaba, MD
ABSTRACT This series presents a hybrid technique for obliteration of gastric varices (GVs) termed retrograde–antegrade accelerated trap obliteration that employs sclerosant agent instillation under concurrent inflow and outflow vessel occlusion with coils or plugs. Six patients (mean age, 56 y) with GVs were treated in 2014 and 2015. Technical success rate was 100%. Five patients completed 30-day follow-up. There were no procedure-related complications, and clinical success rate was 100%, with no bleeding recurrence over a mean follow-up of 298 days ⫾ 178. GV obliteration rate was 100% (n ¼ 4) at a mean of 157 days ⫾ 158. This limited experience suggests that the described technique represents a viable approach to GV obliteration.
ABBREVIATIONS BATO = balloon-occluded antegrade transvenous obliteration, BRTO = balloon-occluded retrograde transvenous obliteration, CARTO = coil-assisted retrograde transvenous obliteration, GRS = gastrorenal shunt, GV = gastric varix, LGV = left gastric vein, PARTO = plug-assisted retrograde transvenous obliteration, PGV = posterior gastric vein, TIPS = transjugular intrahepatic portosystemic shunt
Recently, balloon-occluded transvenous obliteration has gained traction as a viable interventional approach for the management of gastric varices (GVs). The original forms of this procedure included balloon-occluded retrograde transvenous obliteration (BRTO) and balloonoccluded antegrade transvenous obliteration (BATO) (1,2), and more recent adaptations include coil-assisted retrograde transvenous obliteration (CARTO) (3) and plug-assisted retrograde transvenous obliteration (PARTO) (4,5). Although all are associated with high efficacy rates ranging from 90% to 100% (1–5), these procedures are subject to technical pitfalls, including the possibility of incomplete sclerosant agent filling into all afferent feeding vessels in the case of BRTO, risk for systemic spill of sclerosant agent in the setting of BATO, and From the Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital & Health Sciences System, 1740 W. Taylor St., MC 931, Chicago, IL 60612. Received May 13, 2016; final revision received October 2, 2016; accepted October 8, 2016. Address correspondence to R.C.G.; E-mail: [email protected] The author has not identified a conflict of interest. & SIR, 2016 J Vasc Interv Radiol 2017; 28:291–294 http://dx.doi.org/10.1016/j.jvir.2016.10.004
equipment compatibility issues, primarily pertaining to balloon-occlusion device and large coil or plug compatibility (6), with CARTO or PARTO. The present series aimed to assess the outcomes of a hybrid technical approach to GV obliteration—termed retrograde– antegrade accelerated trap obliteration—which was conceived to potentially overcome some challenges of BRTO, feature benefits of BATO, and showcase advantages of the accelerated, balloon-free obliteration of CARTO and PARTO.
CASE SERIES Patients Institutional review board approval is not required for retrospective case series at the author’s institution. The study cohort included six patients with liver cirrhosis and bleeding GVs who were treated by a single physician (with 8 y attending experience) between December 2014 and December 2015. The patient sample included two men (33%) and four women (67%) of mean age 56 years ⫾ 12 (range, 44–78 y). Causes of liver cirrhosis included alcohol (n ¼ 4; 67%), hepatitis C virus (n ¼ 1; 16%), and nonalcoholic steatohepatitis (n ¼ 1; 16%), and the mean Model for End-stage Liver Disease score was 14 ⫾ 3
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(range, 9–16). Varices included type 1 (n ¼ 5; 83%) and type 2 (n ¼ 1; 17%) isolated GVs (7,8), all diagnosed via esophagogastroduodenoscopy. Five patients (83%) had acute GV hemorrhage, and one (17%) had experienced a previous hemorrhage. All patients were in hemodynamically stable condition, and each patient underwent preprocedural contrast-enhanced computed tomography (CT) or magnetic resonance (MR) imaging for variceal anatomic delineation and procedure planning.
Procedure Technique Procedures were performed under general anesthesia with the use of retrograde and antegrade GV access. For retrograde access, the right internal jugular vein was punctured by using a 21-gauge needle (Micropuncture Introducer Set; Cook, Bloomington, Indiana). A 7-F, 45-cm-long sheath (Flexor Ansel Guiding Sheath; Cook) was placed and advanced into the gastrorenal shunt (GRS). For antegrade access, a 10-mm stent-graft transjugular intrahepatic portosystemic shunt (TIPS) was uneventfully created via a second jugular access by using standard technique (9) or percutaneous transhepatic or transsplenic access was attained by using ultrasoundguided puncture with a 21-gauge needle (Micropuncture Introducer Set; Cook) and exchanged for a 6-F (Brite tip; Cordis, Hialeah, Florida) or 4-F (Pinnacle; Terumo, Somerset, New Jersey) sheath, respectively. After splenoportography was performed, obliteration was pursued. First, GV complex inflow vessels were embolized via a 10-F, 40-cm-long TIPS sheath (RUPS100; Cook) or the transhepatic or transsplenic sheaths to consolidate inflow into the GV complex to a single dominant afferent vessel from which to inject sclerosant agent. Embolization involved catheter (MPA; AngioDynamics, Latham, New York) and coaxial microcatheter (Renegade STC; Boston Scientific, Marlborough, Massachusetts) selection of GV inflow vessels, generally the left gastric vein (LGV) and posterior gastric vein (PGV), followed by embolization with the use of metallic coils (MicroNester; Cook) or plugs (AMPLATZER Vascular Plug; St. Jude Medical, St. Paul, Minnesota). Venography was performed via the sole remaining inflow vessel to confirm single inflow and outflow vessels from the GV complex. The GV complex was then trapped and obliterated. For antegrade obliteration, metallic plugs (AMPLATZER Vascular Plug; St. Jude Medical) or coils were first deployed into the GRS for GV complex outflow occlusion to prevent systemic loss of sclerosant agent. The sole remaining inflow vessel into the GV complex—typically the short gastric vein (SGV)—was then catheterized with the use of a 5.5-F, 80-cm balloon-occlusion catheter (Fogarty; Edwards Lifesciences, Irvine, California) and coaxial microcatheter (Renegade STC; Boston Scientific). The inflow vessel balloon catheter was inflated, and a sclerosant mixture consisting of carbon dioxide, sodium
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tetradecyl sulfate, and Lipiodol (Guerbet, Villepinte, France) at a 3:2:1 ratio was injected. When the GV complex was filled with sclerosant agent, metallic coils (MicroNester; Cook) were immediately advanced via the microcatheter under persistent balloon occlusion for SGV closure, and the balloon was then deflated. For retrograde obliteration, the inflow vessel was first embolized with metallic coils, with subsequent retrograde sclerosant agent injection via a GRS occlusion balloon (Fogarty; Edwards Lifesciences) and microcatheter (Renegade STC; Boston Scientific) system followed by GRS coil embolization (MicroNester; Cook) and immediate balloon deflation. Fluoroscopy confirmed stasis of sclerosant agent within the GV complex. Final splenoportal venography was then performed. The jugular venous accesses were then removed, and hemostasis was achieved. Transhepatic and transsplenic accesses were removed, and embolization of the parenchymal tract was performed with microfibrillar collagen (Avitene; CR Bard, Murray Hill, New Jersey).
Clinical Outcomes and Statistical Analysis The outcome measures included procedure technical success, clinical success, and variceal obliteration rate. Technical success was defined as the successful administration of sclerosant agent into GVs with embolic occlusion of inflow and outflow vessels. Clinical success was defined by absence of recurrent bleeding. Variceal obliteration was delineated on follow-up contrastenhanced CT or MR imaging by complete absence of contrast medium–filled variceal channels identifiable within the gastric wall. Study population features and procedure clinical outcomes were assessed with descriptive statistical analysis performed with Excel (Microsoft, Redmond, Washington).
RESULTS The Table summarizes procedure technical details. In cases of antegrade TIPS access, shunts were created in the same procedure session as obliteration in three of four cases (75%) and 2 days earlier in the other (25%) as planned. Procedure technical success was achieved in all six cases (100%; Fig). No GV rupture was encountered. One patient was lost to follow-up at 8 days after the procedure and was excluded from clinical outcomes analysis. Among the remaining five cases, there were no complications within 30 days of obliteration procedures, although one patient required TIPS reduction 65 days after shunt creation as a result of hepatic encephalopathy. Clinical success rate was 100% (five of five), with no cases of recurrent bleeding over the course of 298 days ⫾ 178 (range, 124–515 d) of clinical follow-up. Four of five patients (80%) underwent follow-up crosssectional imaging (one patient was followed clinically but could not undergo cross-sectional imaging because of insurance restrictions). The GV obliteration rate was
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Table . Procedure Technical Details Occlusion Devices Pt. No.
IGV Type
Antegrade Access
Inflow Vessels
Inflow
Outflow
1
1
Trans-TIPS
LGV, SGV
Coils
16-mm plug
Sclerosant Injection Antegrade via LGV
2* 3
2 1
Transsplenic Trans-TIPS
SGV LGV, PGV, SGV
Coils Coils
Coils Coils, 18-mm plug
Retrograde via GRS† Antegrade via SGV
4‡
1
Transhepatic
LGV, SGV
Coils, 16-mm plug
Coils
Antegrade via SGV
5 6
1 1
Trans-TIPS Trans-TIPS
LGV, PGV, SGV LGV, PGV, SGV
Coils Coils
16-mm plug 20-mm plug
Antegrade via SGV Antegrade via SGV
Note–The outflow vessel was the gastrorenal shunt in all cases. GRS ¼ gastrorenal shunt; IGV ¼ isolated gastric varices; LGV ¼ left gastric vein; PGV ¼ posterior gastric vein; SGV ¼ short gastric vein; TIPS ¼ transjugular intrahepatic portosystemic shunt. * TIPS not created as a result of chronic portal vein occlusion. † Retrograde obliteration performed because of the presence of chronic portal vein occlusion and desire to minimize antegrade transsplenic percutaneous access size. ‡ TIPS not created as a result of hepatic encephalopathy.
Figure. Images of representative retrograde–antegrade accelerated trap obliteration in a 78-year-old woman with bleeding type 1 isolated GVs. Contrast-enhanced CT scan (a) demonstrates large fundal GV (arrowheads). Digital subtraction short gastric venogram (b) performed via trans-TIPS approach reveals large GV complex (black arrowheads) with outflow via large-caliber GRS (white arrowheads); LGV and PGV occluded by metallic coils are indicated by black and white arrows, respectively. Fluoroscopic spot image (c) taken during obliteration depicts sclerosant agent filling the GVs (white arrowheads); the metallic plug in the GRS is indicated by the white arrow, and the SGV occlusion balloon is indicated by the black arrow. (d) Fluoroscopic image after sclerosant agent administration shows immediate coil embolization (arrow) of the SGV. Fluoroscopic spot image after obliteration (e) shows radiopaque sclerosant agent securely trapped in the GV complex (arrowheads), and final digital subtraction splenoportogram (f) displays no further GV filling and splenoportal venous outflow via TIPS (arrowheads). Follow-up CT scan (g) demonstrates eradicated GVs (black arrowheads) and patent TIPS (black arrow); LGV coil pack is indicated by the white arrowhead.
100% (four of four) at a mean of 157 days ⫾ 158 (range, 28–387 d) after the procedure.
DISCUSSION The retrograde–antegrade accelerated trap obliteration technique described here represents another transvenous obliteration procedure iteration for treatment of GVs.
As in BATO, this approach provides anatomic delineation of afferent GV complex feeding vessels for embolization and obliteration, although inflow vessel anatomy may also be delineated on preprocedural crosssectional imaging. The antegrade approach, which may be used in the setting of a concurrently or previously created TIPS, also allows for LGV closure, which can theoretically minimize esophageal variceal aggravation
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risk after GV closure, although recanalization is common in the absence of a coexisting TIPS (10). The retrograde–antegrade accelerated trap obliteration method also provides embolic occlusion of afferent and efferent GV feeding vessels, trapping sclerosant agent in the GV complex and reducing the theoretical risk for variceal recanalization as well as nontarget systemic or portal venous spill. In addition, this strategy allows the use of smaller-diameter balloons for sclerosant agent instillation, as afferent feeding vessels are typically smaller in caliber than the efferent outflow vessels occluded and injected during BRTO. Antegrade balloon occlusion circumvents the device compatibility issues that arise in attempting to pass a large plug into a GRS under balloon occlusion during BRTO (maximal plug caliber restricted to 16 mm diameter with currently available balloon-occlusion sheaths) (6), as plug deployment occurs via a standard sheath and allows the use of largerdiameter plugs (as large as 20 mm in the present series). Similar to CARTO or PARTO, the technique described here does not involve prolonged balloon inflation, avoiding the need for a protracted obliteration period and distinguishing this method from conventionally reported combined retrograde–antegrade balloon-occluded approaches to GV obliteration (11). Theoretical downsides of the approach described here include injection of sclerosant agent into a closed system with brief GV complex pressurization after outflow occlusion. Although there were no cases of GV rupture in the present series, the metallic plug can be deployed during or after sclerosant agent instillation if desired based on practitioner preference. Another conceivable technical downside is the possible flow of sclerosant mixture across metallic plugs or coils, although, again, none was apparent in the reported cases. Limitations of the present report include its singlecenter, single-operator, and retrospective nature with a
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small sample size. Nonetheless, the retrograde–antegrade accelerated trap obliteration technique described here expands on the obliteration methods available to interventional radiologists. The limited clinical experience described here submits this approach to be useful for GV obliteration.
REFERENCES 1. Sabri SS, Swee W, Turba UC, et al. Bleeding gastric varices obliteration with balloon-occluded retrograde transvenous obliteration using sodium tetradecyl sulfate foam. J Vasc Interv Radiol 2011; 22:309–316; quiz 316. 2. Sabri SS, Abi-Jaoudeh N, Swee W, et al. Short-term rebleeding rates for isolated gastric varices managed by transjugular intrahepatic portosystemic shunt versus balloon-occluded retrograde transvenous obliteration. J Vasc Interv Radiol 2014; 25:355–361. 3. Lee EW, Saab S, Gomes AS, et al. Coil-assisted retrograde transvenous obliteration (CARTO) for the treatment of portal hypertensive variceal bleeding: preliminary results. Clin Transl Gastroenterol 2014; 5:e61. 4. Gwon DI, Kim YH, Ko GY, et al. Vascular plug-assisted retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy: a prospective multicenter study. J Vasc Interv Radiol 2015; 26:1589–1595. 5. Chang MY, Kim MD, Kim T, et al. Plug-assisted retrograde transvenous obliteration for the treatment of gastric variceal hemorrhage. Korean J Radiol 2016; 17:230–238. 6. Saad WE, Nicholson DB. Optimizing logistics for balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices by doing away with the indwelling balloon: concept and techniques. Tech Vasc Interv Radiol 2013; 16:152–157. 7. Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatol 1992; 16:1343–1349. 8. Sarin SK, Kumar A. Gastric varices: profile, classification, and management. Am J Gastroenterol 1989; 84:1244–1249. 9. Gaba RC. Transjugular intrahepatic portosystemic shunt creation with embolization or obliteration for variceal bleeding. Tech Vasc Interv Radiol 2016; 19:21–35. 10. Lunderquist A, Simert G, Tylen U, Vang J. Follow-up of patients with portal hypertension and esophageal varices treated with percutaneous obliteration of gastric coronary vein. Radiol 1977; 122:59–63. 11. Saad WE, Kitanosono T, Koizumi J. Balloon-occluded antegrade transvenous obliteration with or without balloon-occluded retrograde transvenous obliteration for the management of gastric varices: concept and technical applications. Tech Vasc Interv Radiol 2012; 15:203–225.
Retrograde–Antegrade Accelerated Trap Obliteration: A Modified Approach to Transvenous Eradication of Gastric Varices Ron C. Gaba, MD
ABSTRACT This series presents a hybrid technique for obliteration of gastric varices (GVs) termed retrograde–antegrade accelerated trap obliteration that employs sclerosant agent instillation under concurrent inflow and outflow vessel occlusion with coils or plugs. Six patients (mean age, 56 y) with GVs were treated in 2014 and 2015. Technical success rate was 100%. Five patients completed 30-day follow-up. There were no procedure-related complications, and clinical success rate was 100%, with no bleeding recurrence over a mean follow-up of 298 days ⫾ 178. GV obliteration rate was 100% (n ¼ 4) at a mean of 157 days ⫾ 158. This limited experience suggests that the described technique represents a viable approach to GV obliteration.
ABBREVIATIONS BATO = balloon-occluded antegrade transvenous obliteration, BRTO = balloon-occluded retrograde transvenous obliteration, CARTO = coil-assisted retrograde transvenous obliteration, GRS = gastrorenal shunt, GV = gastric varix, LGV = left gastric vein, PARTO = plug-assisted retrograde transvenous obliteration, PGV = posterior gastric vein, TIPS = transjugular intrahepatic portosystemic shunt
Recently, balloon-occluded transvenous obliteration has gained traction as a viable interventional approach for the management of gastric varices (GVs). The original forms of this procedure included balloon-occluded retrograde transvenous obliteration (BRTO) and balloonoccluded antegrade transvenous obliteration (BATO) (1,2), and more recent adaptations include coil-assisted retrograde transvenous obliteration (CARTO) (3) and plug-assisted retrograde transvenous obliteration (PARTO) (4,5). Although all are associated with high efficacy rates ranging from 90% to 100% (1–5), these procedures are subject to technical pitfalls, including the possibility of incomplete sclerosant agent filling into all afferent feeding vessels in the case of BRTO, risk for systemic spill of sclerosant agent in the setting of BATO, and From the Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital & Health Sciences System, 1740 W. Taylor St., MC 931, Chicago, IL 60612. Received May 13, 2016; final revision received October 2, 2016; accepted October 8, 2016. Address correspondence to R.C.G.; E-mail: [email protected] The author has not identified a conflict of interest. & SIR, 2016 J Vasc Interv Radiol 2017; 28:291–294 http://dx.doi.org/10.1016/j.jvir.2016.10.004
equipment compatibility issues, primarily pertaining to balloon-occlusion device and large coil or plug compatibility (6), with CARTO or PARTO. The present series aimed to assess the outcomes of a hybrid technical approach to GV obliteration—termed retrograde– antegrade accelerated trap obliteration—which was conceived to potentially overcome some challenges of BRTO, feature benefits of BATO, and showcase advantages of the accelerated, balloon-free obliteration of CARTO and PARTO.
CASE SERIES Patients Institutional review board approval is not required for retrospective case series at the author’s institution. The study cohort included six patients with liver cirrhosis and bleeding GVs who were treated by a single physician (with 8 y attending experience) between December 2014 and December 2015. The patient sample included two men (33%) and four women (67%) of mean age 56 years ⫾ 12 (range, 44–78 y). Causes of liver cirrhosis included alcohol (n ¼ 4; 67%), hepatitis C virus (n ¼ 1; 16%), and nonalcoholic steatohepatitis (n ¼ 1; 16%), and the mean Model for End-stage Liver Disease score was 14 ⫾ 3
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Retrograde–Antegrade Accelerated Trap Obliteration
(range, 9–16). Varices included type 1 (n ¼ 5; 83%) and type 2 (n ¼ 1; 17%) isolated GVs (7,8), all diagnosed via esophagogastroduodenoscopy. Five patients (83%) had acute GV hemorrhage, and one (17%) had experienced a previous hemorrhage. All patients were in hemodynamically stable condition, and each patient underwent preprocedural contrast-enhanced computed tomography (CT) or magnetic resonance (MR) imaging for variceal anatomic delineation and procedure planning.
Procedure Technique Procedures were performed under general anesthesia with the use of retrograde and antegrade GV access. For retrograde access, the right internal jugular vein was punctured by using a 21-gauge needle (Micropuncture Introducer Set; Cook, Bloomington, Indiana). A 7-F, 45-cm-long sheath (Flexor Ansel Guiding Sheath; Cook) was placed and advanced into the gastrorenal shunt (GRS). For antegrade access, a 10-mm stent-graft transjugular intrahepatic portosystemic shunt (TIPS) was uneventfully created via a second jugular access by using standard technique (9) or percutaneous transhepatic or transsplenic access was attained by using ultrasoundguided puncture with a 21-gauge needle (Micropuncture Introducer Set; Cook) and exchanged for a 6-F (Brite tip; Cordis, Hialeah, Florida) or 4-F (Pinnacle; Terumo, Somerset, New Jersey) sheath, respectively. After splenoportography was performed, obliteration was pursued. First, GV complex inflow vessels were embolized via a 10-F, 40-cm-long TIPS sheath (RUPS100; Cook) or the transhepatic or transsplenic sheaths to consolidate inflow into the GV complex to a single dominant afferent vessel from which to inject sclerosant agent. Embolization involved catheter (MPA; AngioDynamics, Latham, New York) and coaxial microcatheter (Renegade STC; Boston Scientific, Marlborough, Massachusetts) selection of GV inflow vessels, generally the left gastric vein (LGV) and posterior gastric vein (PGV), followed by embolization with the use of metallic coils (MicroNester; Cook) or plugs (AMPLATZER Vascular Plug; St. Jude Medical, St. Paul, Minnesota). Venography was performed via the sole remaining inflow vessel to confirm single inflow and outflow vessels from the GV complex. The GV complex was then trapped and obliterated. For antegrade obliteration, metallic plugs (AMPLATZER Vascular Plug; St. Jude Medical) or coils were first deployed into the GRS for GV complex outflow occlusion to prevent systemic loss of sclerosant agent. The sole remaining inflow vessel into the GV complex—typically the short gastric vein (SGV)—was then catheterized with the use of a 5.5-F, 80-cm balloon-occlusion catheter (Fogarty; Edwards Lifesciences, Irvine, California) and coaxial microcatheter (Renegade STC; Boston Scientific). The inflow vessel balloon catheter was inflated, and a sclerosant mixture consisting of carbon dioxide, sodium
Gaba
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JVIR
tetradecyl sulfate, and Lipiodol (Guerbet, Villepinte, France) at a 3:2:1 ratio was injected. When the GV complex was filled with sclerosant agent, metallic coils (MicroNester; Cook) were immediately advanced via the microcatheter under persistent balloon occlusion for SGV closure, and the balloon was then deflated. For retrograde obliteration, the inflow vessel was first embolized with metallic coils, with subsequent retrograde sclerosant agent injection via a GRS occlusion balloon (Fogarty; Edwards Lifesciences) and microcatheter (Renegade STC; Boston Scientific) system followed by GRS coil embolization (MicroNester; Cook) and immediate balloon deflation. Fluoroscopy confirmed stasis of sclerosant agent within the GV complex. Final splenoportal venography was then performed. The jugular venous accesses were then removed, and hemostasis was achieved. Transhepatic and transsplenic accesses were removed, and embolization of the parenchymal tract was performed with microfibrillar collagen (Avitene; CR Bard, Murray Hill, New Jersey).
Clinical Outcomes and Statistical Analysis The outcome measures included procedure technical success, clinical success, and variceal obliteration rate. Technical success was defined as the successful administration of sclerosant agent into GVs with embolic occlusion of inflow and outflow vessels. Clinical success was defined by absence of recurrent bleeding. Variceal obliteration was delineated on follow-up contrastenhanced CT or MR imaging by complete absence of contrast medium–filled variceal channels identifiable within the gastric wall. Study population features and procedure clinical outcomes were assessed with descriptive statistical analysis performed with Excel (Microsoft, Redmond, Washington).
RESULTS The Table summarizes procedure technical details. In cases of antegrade TIPS access, shunts were created in the same procedure session as obliteration in three of four cases (75%) and 2 days earlier in the other (25%) as planned. Procedure technical success was achieved in all six cases (100%; Fig). No GV rupture was encountered. One patient was lost to follow-up at 8 days after the procedure and was excluded from clinical outcomes analysis. Among the remaining five cases, there were no complications within 30 days of obliteration procedures, although one patient required TIPS reduction 65 days after shunt creation as a result of hepatic encephalopathy. Clinical success rate was 100% (five of five), with no cases of recurrent bleeding over the course of 298 days ⫾ 178 (range, 124–515 d) of clinical follow-up. Four of five patients (80%) underwent follow-up crosssectional imaging (one patient was followed clinically but could not undergo cross-sectional imaging because of insurance restrictions). The GV obliteration rate was
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Table . Procedure Technical Details Occlusion Devices Pt. No.
IGV Type
Antegrade Access
Inflow Vessels
Inflow
Outflow
1
1
Trans-TIPS
LGV, SGV
Coils
16-mm plug
Sclerosant Injection Antegrade via LGV
2* 3
2 1
Transsplenic Trans-TIPS
SGV LGV, PGV, SGV
Coils Coils
Coils Coils, 18-mm plug
Retrograde via GRS† Antegrade via SGV
4‡
1
Transhepatic
LGV, SGV
Coils, 16-mm plug
Coils
Antegrade via SGV
5 6
1 1
Trans-TIPS Trans-TIPS
LGV, PGV, SGV LGV, PGV, SGV
Coils Coils
16-mm plug 20-mm plug
Antegrade via SGV Antegrade via SGV
Note–The outflow vessel was the gastrorenal shunt in all cases. GRS ¼ gastrorenal shunt; IGV ¼ isolated gastric varices; LGV ¼ left gastric vein; PGV ¼ posterior gastric vein; SGV ¼ short gastric vein; TIPS ¼ transjugular intrahepatic portosystemic shunt. * TIPS not created as a result of chronic portal vein occlusion. † Retrograde obliteration performed because of the presence of chronic portal vein occlusion and desire to minimize antegrade transsplenic percutaneous access size. ‡ TIPS not created as a result of hepatic encephalopathy.
Figure. Images of representative retrograde–antegrade accelerated trap obliteration in a 78-year-old woman with bleeding type 1 isolated GVs. Contrast-enhanced CT scan (a) demonstrates large fundal GV (arrowheads). Digital subtraction short gastric venogram (b) performed via trans-TIPS approach reveals large GV complex (black arrowheads) with outflow via large-caliber GRS (white arrowheads); LGV and PGV occluded by metallic coils are indicated by black and white arrows, respectively. Fluoroscopic spot image (c) taken during obliteration depicts sclerosant agent filling the GVs (white arrowheads); the metallic plug in the GRS is indicated by the white arrow, and the SGV occlusion balloon is indicated by the black arrow. (d) Fluoroscopic image after sclerosant agent administration shows immediate coil embolization (arrow) of the SGV. Fluoroscopic spot image after obliteration (e) shows radiopaque sclerosant agent securely trapped in the GV complex (arrowheads), and final digital subtraction splenoportogram (f) displays no further GV filling and splenoportal venous outflow via TIPS (arrowheads). Follow-up CT scan (g) demonstrates eradicated GVs (black arrowheads) and patent TIPS (black arrow); LGV coil pack is indicated by the white arrowhead.
100% (four of four) at a mean of 157 days ⫾ 158 (range, 28–387 d) after the procedure.
DISCUSSION The retrograde–antegrade accelerated trap obliteration technique described here represents another transvenous obliteration procedure iteration for treatment of GVs.
As in BATO, this approach provides anatomic delineation of afferent GV complex feeding vessels for embolization and obliteration, although inflow vessel anatomy may also be delineated on preprocedural crosssectional imaging. The antegrade approach, which may be used in the setting of a concurrently or previously created TIPS, also allows for LGV closure, which can theoretically minimize esophageal variceal aggravation
294
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risk after GV closure, although recanalization is common in the absence of a coexisting TIPS (10). The retrograde–antegrade accelerated trap obliteration method also provides embolic occlusion of afferent and efferent GV feeding vessels, trapping sclerosant agent in the GV complex and reducing the theoretical risk for variceal recanalization as well as nontarget systemic or portal venous spill. In addition, this strategy allows the use of smaller-diameter balloons for sclerosant agent instillation, as afferent feeding vessels are typically smaller in caliber than the efferent outflow vessels occluded and injected during BRTO. Antegrade balloon occlusion circumvents the device compatibility issues that arise in attempting to pass a large plug into a GRS under balloon occlusion during BRTO (maximal plug caliber restricted to 16 mm diameter with currently available balloon-occlusion sheaths) (6), as plug deployment occurs via a standard sheath and allows the use of largerdiameter plugs (as large as 20 mm in the present series). Similar to CARTO or PARTO, the technique described here does not involve prolonged balloon inflation, avoiding the need for a protracted obliteration period and distinguishing this method from conventionally reported combined retrograde–antegrade balloon-occluded approaches to GV obliteration (11). Theoretical downsides of the approach described here include injection of sclerosant agent into a closed system with brief GV complex pressurization after outflow occlusion. Although there were no cases of GV rupture in the present series, the metallic plug can be deployed during or after sclerosant agent instillation if desired based on practitioner preference. Another conceivable technical downside is the possible flow of sclerosant mixture across metallic plugs or coils, although, again, none was apparent in the reported cases. Limitations of the present report include its singlecenter, single-operator, and retrospective nature with a
Gaba
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JVIR
small sample size. Nonetheless, the retrograde–antegrade accelerated trap obliteration technique described here expands on the obliteration methods available to interventional radiologists. The limited clinical experience described here submits this approach to be useful for GV obliteration.
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