Balloon-occluded retrograde transvenous obliteration for gastric varices: the relationship between the clinical outcome and gastrorenal shunt occlusion
© Katoh et al; licensee BioMed Central Ltd. 2010
Received: 16 January 2009
Accepted: 14 January 2010
Published: 14 January 2010
The rupture of gastric varices is associated with high mortality rate. Balloon-occluded retrograde transvenous obliteration (B-RTO), a minimally invasive procedure that was introduced in the mid-1990s, has been widely accepted in Japan. Several reports have indicated that B-RTO yields satisfactory results; however, few reports have discussed the recurrence of gastric varices after this therapy. The purpose of this study is to retrospectively evaluate the technical aspects of B-RTO and the recurrence of gastric varices after treatment with this procedure.
B-RTO was performed in 47 patients with gastric varices, who were at a risk of variceal ruptures and who may or may not have had a history of variceal bleeding. We injected a sclerosing agent into the gastric varices for 30-60 minutes. To evaluate the therapeutic efficacy of the technique, we obtained contrast-enhanced computed tomography (CT) scans 5 days after B-RTO. As a general rule, if the gastric varices did not appear thrombosed, we repeated the procedure 7 days after the first procedure.
B-RTO was a technical success in 37 patients. It was performed once in 26 patients, twice in 6 patients, thrice in 2 patients, and 4 times in 3 patients. Contrast-enhanced CT scans obtained after B-RTO showed thrombosed gastrorenal shunts in 29 patients and patent gastrorenal shunts in 8 patients. The gastric varices recurred in 2 patients who had patent gastrorenal shunts. The overall cumulative relapse-free rate of gastric varices was 90% at 5 years after B-RTO.
B-RTO is an effective treatment modality for gastric varices. Moreover, obliteration of the gastrorenal shunt as well as the gastric varices appears to be important for the treatment of gastric varices.
The rupture of gastric varices is associated with a mortality rate of 25-55% because it leads to extensive blood loss as compared to the blood loss because of the rupture of esophageal varices [1–4]. Because of poor liver function and rapid blood flow in patients with gastric varices, the development of effective treatment for this condition is a challenge. Gastric varices can be treated by endoscopic injection therapy with cyanoacrylate, but there is a risk of migration of this compound into systemic circulation through the inferior vena cava via the gastrorenal shunt . Balloon-occluded retrograde transvenous obliteration (B-RTO), a minimally invasive procedure that was introduced in the mid-1990s, has been widely accepted in Japan. In the standard technique, gastric varices are thrombosed using a sclerosing agent that is injected through a balloon catheter. Several reports have indicated that B-RTO yields satisfactory results [6–11]; however, few reports have discussed the recurrence of gastric varices after this therapy. The present study was conducted to evaluate the clinical outcomes of B-RTO performed for the treatment of gastric varices and to investigate the recurrence of these varices.
Main characteristics of the 47 patients
45 - 79 (61)
Cause of liver disease, no. (%)
Extra hepatic portal vein stenosis post surgery
Child-Pugh class, no. (%)
Previous gastic variceal bleeding, no. (%)
Follow-up CT and endoscopy were performed every 3-6 months. Depending on the patient's condition, the attending physician decided the follow-up interval. The recurrence of gastric varices was evaluated by performing follow-up endoscopy or contrast-enhanced CT. Follow-up evaluation of the esophageal varices was performed via endoscopy. When the follow-up endoscopy revealed newly developed esophageal varices, red spots on preexisting esophageal varices, or esophageal variceal bleeding, the esophageal varices were regarded as having worsened.
Definitions and Statistical Analysis
When the sclerosing agent was successfully injected and complete thrombosis of the varices, as observed on a contrast-enhanced CT scan after the first or subsequent B-RTO procedure, was achieved, B-RTO was considered successful. B-RTO failure was classified as either technical failure or thrombosis failure. Technical failure was defined as the inability of performing the B-RTO procedure. Thrombosis failure was defined as technically successful completion of the B-RTO procedure without thrombosis of gastric varices on the follow-up contrast-enhanced CT scan. The rates of patient survival and recurrence of the gastric and esophageal varices were calculated using the Kaplan-Meier method.
Outcome of B-RTO
In 37 of the 47 patients (79%), B-RTO was technically successful and complete thrombosis of the varices was observed on the contrast-enhanced CT scans. Of these 37 patients, B-RTO was performed once in 26 patients (70%), twice in 6 patients (16%), thrice in 2 patients (6%), and 4 times in 3 patients (8%). However, this technique was not successful in the other 10 patients. In 6 of these 10 patients, B-RTO could not be performed (technical failure) for the following reasons: (1) the gastrorenal shunt could not be occluded with the balloon catheter because the shunt was extremely large and because of rapid blood flow in the area (2 cases); (2) catheterization was difficult owing to the presence of fine and tortuous gastrocaval or gastrorenal shunts (2 cases); and (3) the gastric varices could not be visualized owing to the presence of many retroperitoneal veins (2 cases). Thrombosis failure was observed in 4 patients. In this group, B-RTO was performed once in 2 patients, thrice in 1 patient, and 4 times in 1 patient, but thrombosis of the varices could not be achieved. Among the 10 patients in whom this procedure failed, 3 underwent endoscopic injection therapy instead of B-RTO. The other patients did not provide their consent for further treatment.
Complications occurred during the procedures in the case of 4 patients. In 1 patient, iatrogenic injury to the gastrorenal shunt occurred during catheterization. The patient's vital signs remained normal, but no additional angiographic analyses or intervention was carried out at that time. After 2 months, B-RTO was attempted for the second time, and it was successful. In another patient, a microcoil (diameter, 3 mm) that was used for embolization of the inferior phrenic vein migrated to the distal region of the right pulmonary artery. Since the coil was small and since its potential adverse effects were considered to be minimal, we did not attempt to retrieve it. In the other 2 patients, the sclerosing agent entered systemic circulation within 5 minutes owing to dislodgement of the balloon catheter. One of these patients experienced chest discomfort, and his pulse oxygen saturation (SpO2) levels transiently decreased. Hence, no additional intervention was performed at that time, but B-RTO was repeated at a later date.
Recurrence of gastric varices and gastrorenal shunt patency
Progression of esophageal varices
The risk of bleeding from gastric varices is lower than that of bleeding from esophageal varices, but rupture of gastric varices is a serious condition associated with a mortality rate of 25-55% [1–4]. The risk factors for hemorrhage from gastric varices are large-sized varices, the presence of red spots on varices, and a severe Child's status . The available treatment options for gastric varices include shunt surgery, endoscopic injection sclerotherapy (EIS) with cyanoacrylate or ethanolamine oleate, and transjugular intrahepatic portosystemic shunting (TIPS). Gastric varices frequently develop from the short and posterior gastric veins; this is in contrast to esophageal varices, which are known to develop mainly from the coronary vein . In gastric varices with a large gastro-renal shunt, a sclerosing agent could even enter the renal shunt and from there, the inferior vena cava. Therefore, prophylactic EIS is not recommended for the treatment of gastric varices. B-RTO, which was introduced in the mid-1990s, has proven to be an effective method for this purpose. Since then, it has been used for the treatment of hemorrhagic gastric varices and for prophylactic treatment in Japan. Ninoi et al. reported that transcatheter sclerotherapy procedures such as B-RTO may be more effective than TIPS in controlling gastric variceal bleeding . In our study, the gastric varices recurred in only 2 patients, and no bleeding was observed. The overall cumulative relapse-free rate was 90% at 3 and 5 years after B-RTO. However, worsening of esophageal varices is one problem after B-RTO in long-term follow up as widely reported in some articles [8, 10, 11]. In our study, 44% of patients experienced worsening of their esophageal varices during median follow-up period of 656 days. Therefore, endoscopic examination is extremely important for discovering worsening of esophageal varices after B-RTO.
Although B-RTO is more efficient than other techniques and procedures and provides better long-term results, it may be difficult to achieve technical success in cases where the collateral vessels are numerous and large. Even in cases where the collateral vessels are occluded, multiple B-RTO procedures are frequently required to completely obliterate the gastric varices. Moreover, alternative procedures such as percutaneous transhepatic sclerotherapy may be necessary in some cases where B-RTO is unsuccessful .
Recently, a group of Korean investigators also reported the use of B-RTO for the treatment of gastric varices . They reported that B-RTO is an effective treatment for the obliteration of gastric varices. However, postprocedural liver failure resulted in the death or the discharge as hopeless within 2 months of 6 patients, and procedure-related death occurred in the case of 2 patients who were classified as C or late B (scores of 8 or 9) according to the Child-Pugh classification system. Therefore, they concluded that the use of this procedure in severely compromised patients should be considered carefully. In contrast to their results, we did not experience procedure-related liver failure; this was probably because the majority of our patients had early-stage liver disease. B-RTO is highly efficacious for the treatment of gastric varices; therefore, in Japan, it is often used as a prophylactic treatment technique before the rupture of gastric varices. Some authors have insisted that prophylactic treatment results in good survival rates . B-RTO is widely accepted in Japan, but not in other parts of the world. In particular, there is no mention of B-RTO in the AASLD (American Association for the Study of Liver Diseases) guidelines . For this therapy to be accepted universally, randomized controlled trials are required. In addition, further studies are required to evaluate the indications of this therapy in patients with poor liver function and the necessity of prophylactic treatment.
In summary, B-RTO is an effective method for the treatment of patients with gastric varices. Moreover, obliteration of the gastrorenal shunt as well as the varices appears to be particularly important for preventing the recurrence of gastric varices in this procedure.
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