Gastric varices and hepatic encephalopathy: treatment with vascular plug and gelatin sponge-assisted retrograde transvenous obliteration--a primary report.

PURPOSE 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). MATERIALS AND METHODS 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). RESULTS 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. CONCLUSION Vascular plug-assisted RTO is technically simple and safe and seems to be clinically effective for treatment of GV and HE.

[1]  W. Saad,et al.  Bleeding gastric varices obliteration with balloon-occluded retrograde transvenous obliteration using sodium tetradecyl sulfate foam. , 2011, Journal of vascular and interventional radiology : JVIR.

[2]  S. Bae,et al.  Transcatheter venous embolization of a massive hepatic arteriovenous shunt complicating hepatocellular carcinoma using an Amplatzer Vascular Plug , 2011, Japanese Journal of Radiology.

[3]  Sae-Jin Park,et al.  The prevalence, risk factors, and clinical outcome of balloon rupture in balloon-occluded retrograde transvenous obliteration of gastric varices. , 2010, Journal of vascular and interventional radiology : JVIR.

[4]  Kyung Ah Kim,et al.  Foam sclerotherapy using polidocanol for balloon-occluded retrograde transvenous obliteration (BRTO) , 2010, European Radiology.

[5]  K. Sung,et al.  Preoperative portal vein embolization using an amplatzer vascular plug , 2009, European Radiology.

[6]  Sung W. Shin,et al.  Balloon-occluded retrograde transvenous obliteration of gastric varices: outcomes and complications in 49 patients. , 2007, AJR. American journal of roentgenology.

[7]  S. Trerotola,et al.  Use of the Amplatzer Vascular Plug for embolization of a large retroperitoneal shunt during transjugular intrahepatic portosystemic shunt creation for gastric variceal bleeding. , 2006, Journal of vascular and interventional radiology : JVIR.

[8]  G. Stefanini,et al.  A New Device for Vascular Embolization: Report on Case of Two Pulmonary Arteriovenous Fistulas Embolization Using the Amplatzer Vascular Plug , 2006, CardioVascular and Interventional Radiology.

[9]  R. Yamada,et al.  Balloon-occluded retrograde transvenous obliteration of gastric varices with gastrorenal shunt: long-term follow-up in 78 patients. , 2005, AJR. American journal of roentgenology.

[10]  J. Cardella,et al.  Society of Interventional Radiology clinical practice guidelines. , 2003, Journal of vascular and interventional radiology : JVIR.

[11]  R. Franchis,et al.  Natural history of portal hypertension in patients with cirrhosis. , 2001, Clinics in liver disease.

[12]  F. Chikamori,et al.  Eight years of experience with transjugular retrograde obliteration for gastric varices with gastrorenal shunts. , 2001, Surgery.

[13]  T. Fukuda,et al.  Long-term results of balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy. , 2001, Journal of vascular and interventional radiology : JVIR.

[14]  M. Kono,et al.  Retrograde transvenous obliteration of gastric varices. , 1999, Radiology.

[15]  I. Hirata,et al.  Balloon-occluded retrograde transvenous obliteration of high risk gastric fundal varices , 1999, American Journal of Gastroenterology.

[16]  H. Sekihara,et al.  Use of balloon-occluded retrograde transvenous obliteration with ethanolamine oleate for the treatment of hepatic encephalopathy in a cirrhotic patient with a large spontaneous splenorenal shunt , 1998, Journal of Gastroenterology.

[17]  M. Kimura,et al.  Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Varices: A Feasibility Study , 1998, CardioVascular and Interventional Radiology.

[18]  T. Toyota,et al.  Changes in liver function parameters after occlusion of gastrorenal shunts with balloon-occluded retrograde transvenous obliteration. , 1997, The American journal of gastroenterology.

[19]  K. Koito,et al.  Balloon-occluded retrograde transvenous obliteration for gastric varices with gastrorenal or gastrocaval collaterals. , 1996, AJR. American journal of roentgenology.

[20]  T. Uchida,et al.  Treatment of gastric fundal varices by balloon‐occluded retrograde transvenous obliteration , 1996, Journal of gastroenterology and hepatology.

[21]  M. Hashizume,et al.  Portosystemic encephalopathy treated with balloon-occluded retrograde transvenous obliteration. , 1995, The American journal of gastroenterology.

[22]  S. Uh,et al.  A Case of Noncardiogenic Pulmonary Edema by Ethanolamine Oleate , 1994, The Korean journal of internal medicine.

[23]  S. Sarin,et al.  Prevalence, classification and natural history of gastric varices: A long‐term follow‐up study in 568 portal hypertension patients , 1992, Hepatology.

[24]  S. Bellary,et al.  Disseminated intravascular coagulation (DIC) after endoscopic injection sclerotherapy with ethanolamine oleate. , 1990, Endoscopy.

[25]  M. Hashizume,et al.  HAPTOGLOBIN TO PROTECT AGAINST RENAL DAMAGE FROM ETHANOLAMINE OLEATE SCLEROSANT , 1988, The Lancet.

[26]  M. Ohto,et al.  Portal hemodynamics in patients with gastric varices. A study in 230 patients with esophageal and/or gastric varices using portal vein catheterization. , 1988, Gastroenterology.

[27]  T. Prindiville,et al.  Endoscopic injection sclerosis in bleeding gastric varices. , 1986, Gastrointestinal endoscopy.

[28]  H. Schneider GLOMUS TUMOR OF THE STOMACH ; A CASE REPORT. , 1964, The American journal of roentgenology, radium therapy, and nuclear medicine.