Download PDF
CC BY-NC-ND 4.0 · Indian J Radiol Imaging 2017; 27(01): 100-104
DOI: 10.4103/0971-3026.202952
Interventional Radiology

Balloon occluded retrograde transvenous obliteration for bleeding gastric varices: Eyes see what the mind knows

Pushpinder S Khera
Department of Radiology, Seoul National University Hospital, Seoul, South Korea
,
Lee Myungsu
Department of Radiology, Seoul National University Hospital, Seoul, South Korea
,
Choi Joonsung
Department of Radiology, Seoul National University Hospital, Seoul, South Korea
› Author Affiliations Financial support and sponsorship Nil.
› Further Information
Also available at
  PDF Download Permissions and Reprints

Abstract

Approximately one in six patients with portal hypertension who develop varices at sites of portosystemic venous collaterals has gastric varices due to hepatofugal flow into the gastric veins. Bleeding from gastric varices, though less common, has a higher mortality and morbidity compared to bleeding esophageal varices, which are easier to manage endoscopically. The efferent channel for gastric varices is mostly the gastrorenal shunt (GRS) which opens into the left renal vein. Balloon-occluded transvenous obliteration (BRTO) involves accessing the GRS with an aim to temporarily occlude its outflow using a balloon catheter and at the same time injecting sclerosant mixture within the varix so as to cause its thrombosis and thereby obliteration. BRTO is one of the mainstays of minimally invasive treatment for bleeding gastric varices. In the minority of cases where the GRS is absent, conventional BRTO is technically not possible. However, accessing the small alternate shunt from the inferior phrenic vein may be possible if one is aware of its existence.

Keywords

Bleeding gastric varices - BRTO - gastrorenal shunt - inferior phrenic vein


Publication History

Article published online:
27 July 2021

© 2017. Indian Radiological Association. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Thieme Medical and Scientific Publishers Private Ltd.
A-12, Second Floor, Sector -2, NOIDA -201301, India

 

  • References

  • 1 Trudeau W, Prindiville T. Endoscopic injection sclerosis in bleeding gastric varices. Gastrointest Endosc 1986;32:264-8.
  • 2 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. Hepatology 1992;16:1343-9.
  • 3 Al-Osaimi AM, Caldwell SH. Medical and endoscopic management of gastric varices. Semin Interv Radiol 2011;28:273-82.
  • 4 Sarin SK. Long-term follow-up of gastric variceal sclerotherapy: An eleven-year experience. Gastrointest Endosc 1997;46:8-14.
  • 5 Roesch W, Rexroth G. Pulmonary, cerebral and coronary emboli during bucrylate injection of bleeding fundic varices. Endoscopy 1998;30:89-90.
  • 6 Hwang SS, Kim HH, Park SH, Kim SE, Jung JI, Ahn BY, et al. N-butyl-2-cyanoacrylate pulmonary embolism after endoscopic injection sclerotherapy for gastric variceal bleeding. J Comput Assist Tomogr 2001;25:16-22.
  • 7 Sanyal AJ, Freedman AM, Luketic VA, Purdum PP, Shiffman ML, DeMeo J, et al. The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts. Gastroenterology 1997;112:889-8.
  • 8 Somberg KA. TIPS: Safe, effective, better? Am J Gastroenterol 1997;92:1412-6.
  • 9 Somberg KA, Riegler JL, LaBerge JM, Doherty-Simor MM, Bachetti P, Roberts JP, et al. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunts: Incidence and risk factors. Am J Gastroenterol 1995;90:549-55.
  • 10 Riggio O, Nardelli S, Moscucci F, Pasquale C, Ridola L, Merli M. Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. Clin Liver Dis 2012;16:133-46.
  • 11 Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol 1996;11:51-8.
  • 12 Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori Y, Okino Y. Transcatheter obliteration of gastric varices: Part-1: Anatomic classification. Radiographics 2003;23:911-20.
  • 13 Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori Y, Okino Y. Transcatheter obliteration of gastric varices: Part-2: Strategy and techniques based on hemodynamic features. Radiographics 2003;23:921-37.
  • 14 Olson E, Yune HY, Klatte EC. Transrenal-vein reflux ethanol sclerosis of gastroesophageal varices. Am J Roentgenol 1984;143:627-8.
  • 15 Saad WEA, Sabri SS. Balloon-occluded transvenous obliteration [BRTO]: Technical results and outcomes. Management of Gastric Varices: Endoscopic, BRTO, & TIPS. Semin Interv Radiol 2011;28:333-8.
  • 16 Saad WEA, Al-Osaimi AMS, Caldwell SH. Pre– and post–balloon-occluded retrograde transvenous obliteration clinical evaluation, management, and imaging: Indications, management protocols, and follow-up. Tech Vasc Intervent Radiol 2012;15:165-202.
  • 17 Watanabe M, Shiozawa K, Ikehara T, Nakano S, Kougame M, Otsuka T, et al. Short- term effects and early complications of balloon-occluded retrograde transvenous obliteration for gastric varices. ISRN Gastroenterology 2012;2012:919371.
  • 18 Watanabe K, Kimura K, Matsutani S, Ohto M, Okuda K. Portal hemodynamics in patients with gastric varices: A study in 230 patients with esophageal and/or gastric varices using portal vein catheterization. Gastroenterology 1988;95:434-40.
  • 19 Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Correlation between endoscopic and angiographic findings in patients with esophageal and isolated gastric varices. Dig Surg 2001;18:176-81.
  • 20 Kimura K, Ohto M, Matsutani S, Furuse J, Hoshino K, Okuda K. Relative frequencies of portosystemic pathways and renal shunt formation through the “posterior” gastric vein: Portographic study in 460 patients. Hepatology 1990;12:725-8.
  • 21 Koito K, Namieno T, Nagakawa T, Morita K. Balloon-occluded retrograde transvenous obliteration for gastric varices with gastrorenal or gastrocaval collaterals. AJR Am J Roentgenol 1996;167:1317-20.
  • 22 Kameda N, Higuchi K, Shiba M, Kadouchi K, Machida H, Okazaki H, et al. Management of gastric fundal varices without gastro-renal shunt in 15 patients. World J Gastroenterol 2008;14:448-53.
  • 23 Maeda H, Hirota S, Yamamoto S, Kobayashi K, Arai K, Miyamoto Y, et al. Radiologic variations in gastrorenal shunts and collateral veins from gastric varices in images obtained before balloon-occluded retrograde transvenous obliteration. Cardiovasc Intervent Radiol 2007;30:410-4.
  • 24 Ibukuro K, Mori K, Tsukiyama T, Inoue Y, Iwamoto Y, Tagawa K. Balloon-occluded retrograde transvenous obliteration of gastric varix draining via the left inferior phrenic vein into the left hepatic vein. Cardiovasc Intervent Radiol 1999;22:415-7.
  • 25 Minamiguchi H, Kawai N, Sato M, Ikoma A, Sawa M, Sonomura T, et al. Balloon-occluded retrograde transvenous obliteration for gastric varices via the intercostal vein. World J Radiol 2012;28:121-5.
  • 26 Araki T, Hori M, Motosugi U, Sano K, Ishigame K, Nakajima H, et al. Can balloon-occluded retrograde transvenous obliteration be performed for gastric varices without gastrorenal shunts? J Vasc Interv Radiol 2010;21:663-70.
  • 27 Kageyama K, Nishida N, Matsui H, Yamamoto A, Nakamura K, Miki Y. Successful balloon-occluded retrograde transvenous obliteration for gastric varix mainly drainage into the pericardiophrenic vein. Cardiovasc Intervent Radiol 2012;35:180-3.
  • 28 Yoshimatsu R, Yamaguchi T, Tanaka O. Balloon-occluded retrograde transvenous obliteration of gastric varix via the pericardiophrenic vein. Cardiovasc Intervent Radiol 2011;34:S206-9.