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Interventional Case Record
Interventional Case Record
Contributed by : Saiprasad Shelke
Contributed by : Saiprasad Shelke
Plug assisted retrograde transvenous obliteration (PARTO) of varices in a patient with cirrhosis of the liver, portal hypertension and gastric varices.
Plug assisted retrograde transvenous obliteration (PARTO) of varices in a patient with cirrhosis of the liver, portal hypertension and gastric varices.
Introduction:
Introduction:
Upper gastrointestinal endoscopy is usually the first-line diagnostic and management tool for bleeding gastric varices (1). When endoscopy fails to control gastric variceal bleeding, a trans jugular intrahepatic portosystemic shunt (TIPS) is recommended to decompress the portal circulation (1, 2). However, TIPS may not be suitable for some patients with poor hepatic reserve, portal vein thrombosis, hepatic encephalopathy, or severe thrombocytopenia (1-3). Balloon-occluded retrograde transvenous obliteration (BRTO) is an endovascular technique that was refined in Japan as a therapeutic adjunct or alternative to TIPS for management of gastric varices (4). The BRTO technique has been described in many reports (4-7) and has shown considerable effectiveness with low rebleeding rates (4-10). Its advantages over TIPS include less invasiveness and greater performance ease in patients with poor hepatic reserve, encephalopathy, or refractory ascites (2,7,8). However, as BRTO requires an occlusion balloon catheter and sclerosing agents to occlude the portosystemic shunt, the indwelling catheter results in long procedural times and complications. Here we describe an alternative to balloon for retrograde shunt occlusion using a Vascular Plug.
Upper gastrointestinal endoscopy is usually the first-line diagnostic and management tool for bleeding gastric varices (1). When endoscopy fails to control gastric variceal bleeding, a trans jugular intrahepatic portosystemic shunt (TIPS) is recommended to decompress the portal circulation (1, 2). However, TIPS may not be suitable for some patients with poor hepatic reserve, portal vein thrombosis, hepatic encephalopathy, or severe thrombocytopenia (1-3). Balloon-occluded retrograde transvenous obliteration (BRTO) is an endovascular technique that was refined in Japan as a therapeutic adjunct or alternative to TIPS for management of gastric varices (4). The BRTO technique has been described in many reports (4-7) and has shown considerable effectiveness with low rebleeding rates (4-10). Its advantages over TIPS include less invasiveness and greater performance ease in patients with poor hepatic reserve, encephalopathy, or refractory ascites (2,7,8). However, as BRTO requires an occlusion balloon catheter and sclerosing agents to occlude the portosystemic shunt, the indwelling catheter results in long procedural times and complications. Here we describe an alternative to balloon for retrograde shunt occlusion using a Vascular Plug.
Case presentation:
Case presentation:
A 48-year old woman known to have hypothyroidism since 10 years, presented with complaints of two episodes of massive hematemesis. It was characterised by coffee ground vomitus, not preceded by retching, mixed with food particles and contained blood clots. Laboratory investigations showed a Hb 5.3 gm %, HBV, HCV and HIV negative. Ultrasound of abdomen showed hepatomegaly with altered echotexture, moderate splenomegaly with peri splenic and peripancreatic collaterals. UGI scopy showed Isolated Gastric Varices-1 (IGV-1) for which glue therapy was done. THe patient had persistent bleeding despite endoscopic management and was then referred to us for further intervention. CECT confirmed the ultrasound findings of liver cirrhosis and portal hypertension and showed a prominent gastrorenal shunt measuring 11 mm in calibre. [Figure 1)].
A 48-year old woman known to have hypothyroidism since 10 years, presented with complaints of two episodes of massive hematemesis. It was characterised by coffee ground vomitus, not preceded by retching, mixed with food particles and contained blood clots. Laboratory investigations showed a Hb 5.3 gm %, HBV, HCV and HIV negative. Ultrasound of abdomen showed hepatomegaly with altered echotexture, moderate splenomegaly with peri splenic and peripancreatic collaterals. UGI scopy showed Isolated Gastric Varices-1 (IGV-1) for which glue therapy was done. THe patient had persistent bleeding despite endoscopic management and was then referred to us for further intervention. CECT confirmed the ultrasound findings of liver cirrhosis and portal hypertension and showed a prominent gastrorenal shunt measuring 11 mm in calibre. [Figure 1)].
Fig 1 Preprocedural axial and coronal CT scan images show prominent fundal gastric varices.
Under local anesthesia, the right CFV was punctured and access obtained using 8F sheath. Using 4F SIM1 and Terumo guide wire gastrorenal shunt (GRS) was cannulated and documented (Figure 2).
Under local anesthesia, the right CFV was punctured and access obtained using 8F sheath. Using 4F SIM1 and Terumo guide wire gastrorenal shunt (GRS) was cannulated and documented (Figure 2).
Figure 2: Selective cannulation of gastrorenal shunt using 4F SIM1 catheter
Terumo guide wire was exchanged for AES stiff wire with help of Progreat microcatheter and Boston V18 wire. The 8F short sheath was exchanged for 10 F COOK 80 cm long sheath. A 2nd AES stiff was passed adjoining the 10F long sheath and 4F cobra catheter was secured within the gastrorenal shunt. An Amplatz Vascular Plug 16 mm was placed in the gastro renal shunt and shunt gram obtained. (Figure 3)
Terumo guide wire was exchanged for AES stiff wire with help of Progreat microcatheter and Boston V18 wire. The 8F short sheath was exchanged for 10 F COOK 80 cm long sheath. A 2nd AES stiff was passed adjoining the 10F long sheath and 4F cobra catheter was secured within the gastrorenal shunt. An Amplatz Vascular Plug 16 mm was placed in the gastro renal shunt and shunt gram obtained. (Figure 3)
Figure 3: Fluoroscopic image showing Amplatz Vascular Plug 16 mm at the narrowest region of the gastrorenal shunt through the 10 F vascular sheath and cobra catheter placed coaxially adjoining it.
Following this, the vascular plug was deployed halfway at the narrowest region of the gastrorenal shunt .Contrast injection showed stasis of injected contrast in the gastro renal shunt and gastric varices. Once stasis was confirmed gelfoam pledgets of uniform size were injected from the cobra catheter placed next to the long sheath within the GRS. Gelfoam sheets were cut with scissors and gelfoam and contrast agents were mixed into a slurry by sequential mixing through a 3-way stopcock connected to 2 syringes. The gelfoam slurry was injected through the Cobra catheter to achieve filling and stasis within the entire efferent shunt and varices. Post-embolization venography using the Cobra catheter was performed again, to confirm complete occlusion of the efferent shunt and complete stasis within the varices (Figure 3). On confirmed completion, the vascular plug was deployed completely and detached. The renal vein patency was documented (Figure 4).
Following this, the vascular plug was deployed halfway at the narrowest region of the gastrorenal shunt .Contrast injection showed stasis of injected contrast in the gastro renal shunt and gastric varices. Once stasis was confirmed gelfoam pledgets of uniform size were injected from the cobra catheter placed next to the long sheath within the GRS. Gelfoam sheets were cut with scissors and gelfoam and contrast agents were mixed into a slurry by sequential mixing through a 3-way stopcock connected to 2 syringes. The gelfoam slurry was injected through the Cobra catheter to achieve filling and stasis within the entire efferent shunt and varices. Post-embolization venography using the Cobra catheter was performed again, to confirm complete occlusion of the efferent shunt and complete stasis within the varices (Figure 3). On confirmed completion, the vascular plug was deployed completely and detached. The renal vein patency was documented (Figure 4).
Figure 4 :Left internal iliac angiogram showing prostatic artery(arrows) arising from the anterior division of the internal iliac artery. (C) Angiogram obtained at right anterior oblique view (30 degrees) showing the entire course of prostatic artery. (D) 3D Angiography of the internal iliac artery showing the common trunk arising from gluteal-pudendal trunk of IIA giving rise to superior vesicular artery(arrowhead) and prostatic artery(arrows).
A CT scan was done one week post procedure showed complete obliteration of gastric varices and gastrorenal shunt. (Figure 5)
A CT scan was done one week post procedure showed complete obliteration of gastric varices and gastrorenal shunt. (Figure 5)
Figure 5: CT images one week after PARTO show complete obliteration of the targeted varices.
Discussion:
Discussion:
BRTO is an established procedure, with considerable effectiveness in controlling gastric variceal bleeding with low rebleeding rates (4-9). However, BRTO requires prolonged indwelling of an occlusion balloon catheter, which makes this procedure difficult to tolerate in long-term bed-ridden patients. A permanent sclerosant can completely eradicate a gastric variceal complex, although this would increase portal hypertension (2, 12, 19). Therefore, it is important to determine whether vascular plug-assisted gelatin sponge embolization could eradicate gastric varices as effectively as a
BRTO is an established procedure, with considerable effectiveness in controlling gastric variceal bleeding with low rebleeding rates (4-9). However, BRTO requires prolonged indwelling of an occlusion balloon catheter, which makes this procedure difficult to tolerate in long-term bed-ridden patients. A permanent sclerosant can completely eradicate a gastric variceal complex, although this would increase portal hypertension (2, 12, 19). Therefore, it is important to determine whether vascular plug-assisted gelatin sponge embolization could eradicate gastric varices as effectively as a
Gwon et al. (13) reported that follow-up CT within 1 week after PARTO showed complete thrombosis of both gastric varices and gastrorenal shunts in all patients, and a 2-month follow up CT showed complete obliteration. Our case also demonstrated complete occlusion of the gastric varices and gastrorenal shunt in a week.
Gwon et al. (13) reported that follow-up CT within 1 week after PARTO showed complete thrombosis of both gastric varices and gastrorenal shunts in all patients, and a 2-month follow up CT showed complete obliteration. Our case also demonstrated complete occlusion of the gastric varices and gastrorenal shunt in a week.
Because PARTO does not require an indwelling balloon catheter or a sclerosing agent, it has significantly decreased procedure and fluoroscopy time. Despite the common purpose of PARTO and BRTO, PARTO seems to be technically easier, safer, and more convenient and comfortable for patients, with less radiation exposure.
Because PARTO does not require an indwelling balloon catheter or a sclerosing agent, it has significantly decreased procedure and fluoroscopy time. Despite the common purpose of PARTO and BRTO, PARTO seems to be technically easier, safer, and more convenient and comfortable for patients, with less radiation exposure.
Although conventional BRTO is reportedly effective in controlling gastric variceal hemorrhage (1, 12), PARTO has several advantages over conventional BRTO. First, there is no risk of balloon rupture and subsequent pulmonary embolism, which can be fatal. Second, dose limitation of sclerosants is not an obstacle for PARTO, because gelfoam slurry is used instead. All patients with whom we had technically success showed complete obliteration of GV by single session. Prior studies on conventional BRTO reported high technical and clinical successes, but in some studies, repeated BRTO procedures were necessary for complete obliteration of large varies (9, 16-18). Moreover, gelfoam is safer embolic material than ethanolamine oleate, which is recommended with 4000 units of haptoglobin to prevent renal failure (19). Gelfoam is also a more familiar embolic material to interventional radiologists because it is used in various procedures throughout the body. Third, PARTO does not require a long post-procedural bed-rest with the indwelling balloon catheter and full monitoring. Even though balloon dwelling time varies greatly from 30 minutes to 24 hours among studies, cases with short indwelling time tend to show low obliteration rate, so long indwelling time is preferred in cases with large varices for complete obliteration (12, 20).
Although conventional BRTO is reportedly effective in controlling gastric variceal hemorrhage (1, 12), PARTO has several advantages over conventional BRTO. First, there is no risk of balloon rupture and subsequent pulmonary embolism, which can be fatal. Second, dose limitation of sclerosants is not an obstacle for PARTO, because gelfoam slurry is used instead. All patients with whom we had technically success showed complete obliteration of GV by single session. Prior studies on conventional BRTO reported high technical and clinical successes, but in some studies, repeated BRTO procedures were necessary for complete obliteration of large varies (9, 16-18). Moreover, gelfoam is safer embolic material than ethanolamine oleate, which is recommended with 4000 units of haptoglobin to prevent renal failure (19). Gelfoam is also a more familiar embolic material to interventional radiologists because it is used in various procedures throughout the body. Third, PARTO does not require a long post-procedural bed-rest with the indwelling balloon catheter and full monitoring. Even though balloon dwelling time varies greatly from 30 minutes to 24 hours among studies, cases with short indwelling time tend to show low obliteration rate, so long indwelling time is preferred in cases with large varices for complete obliteration (12, 20).
During the injection of gelfoam slurry, all collateral veins were occluded spontaneously. Because of the risk of gelfoam embolization to pulmonary arteries though the collateral veins, we gradually injected gelfoam pledgets under fluoroscopic guidance. Contrast media was injected in between to confirm the occlusion of these collaterals. Small amount of gelfoam could be circulated via these systemic venous connections, however, none of the patients had symptoms or signs of pulmonary embolism or systemic arterial embolism. Minimal leakage of contrast solution to retroperitoneum may be reported in few patients probably due to the rupture of small collateral. The effectiveness of emergency BRTO for treating ruptured GV was reported previously, but repeated procedures were required in some of the patients (25, 26, 27). PARTO could also be an alternative method for preventing recurrent hemorrhage in patients with active gastric variceal bleeding.
During the injection of gelfoam slurry, all collateral veins were occluded spontaneously. Because of the risk of gelfoam embolization to pulmonary arteries though the collateral veins, we gradually injected gelfoam pledgets under fluoroscopic guidance. Contrast media was injected in between to confirm the occlusion of these collaterals. Small amount of gelfoam could be circulated via these systemic venous connections, however, none of the patients had symptoms or signs of pulmonary embolism or systemic arterial embolism. Minimal leakage of contrast solution to retroperitoneum may be reported in few patients probably due to the rupture of small collateral. The effectiveness of emergency BRTO for treating ruptured GV was reported previously, but repeated procedures were required in some of the patients (25, 26, 27). PARTO could also be an alternative method for preventing recurrent hemorrhage in patients with active gastric variceal bleeding.
Conclusion:
Conclusion:
PARTO can reduce procedural time and has a high technical success rate, as compared with BRTO. There were no procedure-related complications in any patients who underwent PARTO. Post-procedural hepatic function restoration was as effective as after BRTO. In conclusion, PARTO is a technically feasible, safe, and effective treatment for gastric variceal haemorrhage in patients with portal hypertension
PARTO can reduce procedural time and has a high technical success rate, as compared with BRTO. There were no procedure-related complications in any patients who underwent PARTO. Post-procedural hepatic function restoration was as effective as after BRTO. In conclusion, PARTO is a technically feasible, safe, and effective treatment for gastric variceal haemorrhage in patients with portal hypertension
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