We present a case of a patient with rapid deterioration of esophageal varices caused by portal hypertension accompanied by a large arterioportal shunt that developed after radiofrequency ablation of hepatocellular carcinoma. We used n-butyl cyanoacrylate (NBCA) as an embolic material to achieve pinpoint embolization of the shunt, because the microcatheter tip was 2 cm away from the shunt site. Under hepatic arterial flow control using a balloon catheter, the arterioportal shunt was successfully embolized with NBCA, which caused an improvement in the esophageal varices.
Aged ; Arteriovenous Fistula/etiology/radiography/*therapy ; Carcinoma, Hepatocellular/*surgery ; Catheter Ablation/*adverse effects ; Embolization, Therapeutic/*methods ; Enbucrilate/*therapeutic use ; Esophageal and Gastric Varices/etiology/*therapy ; Hepatic Artery/*abnormalities/radiography ; Humans ; Liver Neoplasms/*surgery ; Male ; Portal Vein/*abnormalities/radiography

OBJECTIVE: To evaluate the feasibility, safety, and clinical outcomes of plug-assisted retrograde transvenous obliteration (PARTO) to treat gastric variceal hemorrhage in patients with portal hypertension. MATERIALS AND METHODS: From May 2012 to June 2014, 19 patients (11 men and 8 women, median age; 61, with history of gastric variceal hemorrhage; 17, active bleeding; 2) who underwent PARTO using a vascular plug and a gelfoam pledget were retrospectively analyzed. Clinical and laboratory data were examined to evaluate primary (technical and clinical success, complications) and secondary (worsening of esophageal varix [EV], change in liver function) end points. Median follow-up duration was 11 months, from 6.5 to 18 months. The Wilcoxon signed-rank test was used to compare laboratory data before and after the procedure. RESULTS: Technical success (complete occlusion of the efferent shunt and complete filling of gastric varix [GV] with a gelfoam slurry) was achieved in 18 of 19 (94.7%) patients. The embolic materials could not reach the GV in 1 patient who had endoscopic glue injection before our procedure. The clinical success rate (no recurrence of gastric variceal bleeding) was the same because the technically failed patient showed recurrent bleeding later. Acute complications included fever (n = 2), fever and hypotension (n = 2; one diagnosed adrenal insufficiency), and transient microscopic hematuria (n = 3). Ten patients underwent follow-up endoscopy; all exhibited GV improvement, except 2 without endoscopic change. Five patients exhibited aggravated EV, and 2 of them had a bleeding event. Laboratory findings were significantly improved after PARTO. CONCLUSION: PARTO is technically feasible, safe, and effective for gastric variceal hemorrhage in patients with portal hypertension.
Aged ; Balloon Occlusion ; Embolization, Therapeutic ; Endoscopy, Digestive System ; Esophageal and Gastric Varices/complications/radiography/*therapy ; Female ; Gastrointestinal Hemorrhage/therapy ; Gelatin Sponge, Absorbable/chemistry ; Humans ; Hypertension, Portal/complications ; Male ; Middle Aged ; Retrospective Studies ; Tomography, X-Ray Computed

OBJECTIVE: This study was deigned to evaluate the technique and clinical efficacy of the use of percutaneous transportal sclerotherapy with N-butyl-2-cyanoacrylate (NBCA) for patients with gastric varices. MATERIALS AND METHODS: Seven patients were treated by transportal sclerotherapy with the use of NBCA. For transportal sclerotherapy, portal vein catheterization was performed with a 6-Fr sheath by the transhepatic approach. A 5-Fr catheter was introduced into the afferent gastric vein and a microcatheter was advanced through the 5-Fr catheter into the varices. NBCA was injected through the microcatheter in the varices by use of the continuous single-column injection technique. After the procedure, postcontrast computed tomography (CT) was performed on the next day and then every six months. Gastroendoscopy was performed at one week, three months, and then every six months after the procedure. RESULTS: The technical success rate of the procedure was 88%. In six patients, gastric varices were successfully obliterated with 1-8 mL (mean, 5.4 mL) of a NBCA-Lipiodol mixture injected via a microcatheter. No complications related to the procedure were encountered. As seen on the follow-up endoscopy and CT imaging performed after six months, the presence of gastric varcies was not seen in any of the patients after treatment with the NBCA-Lipiodol mixture and the use of microcoils. Recurrence of gastric varices was not observed during the follow-up period. Worsening of esophageal varices occurred in four patients after transportal sclerotherapy. The serum albumin level increased, the ammonia level decreased and the prothrombin time increased at six months after the procedure (p < 0.05). CONCLUSION: Percutaneous transportal sclerotherapy with NBCA is useful to obliterate gastric varices if it is not possible to perform balloon-occluded retrograde transvenous obliteration.
Aged ; Catheterization ; Contrast Media/administration & dosage ; Enbucrilate/*administration & dosage ; Esophageal and Gastric Varices/radiography/*therapy ; Female ; Fluoroscopy ; Humans ; Iodized Oil/administration & dosage ; Male ; Middle Aged ; Portal Vein ; Sclerotherapy/*methods ; Tissue Adhesives/*administration & dosage ; Tomography, X-Ray Computed ; Ultrasonography, Interventional

OBJECTIVE: To evaluate the efficacy and safety of balloon-occluded retrograde transvenous obliteration (BRTO) with sodium tetradecyl sulfate (STS) liquid sclerotherapy of gastric varices. MATERIALS AND METHODS: Between February 2012 and August 2014, STS liquid sclerotherapy was performed in 17 consecutive patients (male:female = 8:9; mean age 58.6 years, range 44-86 years) with gastric varices. Retrograde venography was performed after occlusion of the gastrorenal shunt using a balloon catheter and embolization of collateral draining veins using coils or gelfoam pledgets, to evaluate the anatomy of the gastric varices. We prepared 2% liquid STS by mixing 3% STS and contrast media in a ratio of 2:1. A 2% STS solution was injected into the gastric varices until minimal filling of the afferent portal vein branch was observed (mean 19.9 mL, range 6-33 mL). Patients were followed up using computed tomography (CT) or endoscopy. RESULTS: Technical success was achieved in 16 of 17 patients (94.1%). The procedure failed in one patient because the shunt could not be occluded due to the large diameter of gastrorenal shunt. Complete obliteration of gastric varices was observed in 15 of 16 patients (93.8%) with follow-up CT or endoscopy. There was no rebleeding after the procedure. There was no procedure-related mortality. CONCLUSION: BRTO using STS liquid can be a safe and useful treatment option in patients with gastric varices.
Adult ; Aged ; Aged, 80 and over ; Balloon Occlusion ; Contrast Media/*chemistry ; Demography ; Embolization, Therapeutic ; Endoscopy, Digestive System ; Esophageal and Gastric Varices/*therapy ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Portal Vein/radiography ; Sclerotherapy ; Sodium Tetradecyl Sulfate/*chemistry ; Tomography, X-Ray Computed

OBJECTIVE: To evaluate the feasibility of percutaneous access via the recanalized paraumbilical vein for varix embolization. MATERIALS AND METHODS: Between July 2008 and Jan 2014, percutaneous access via the recanalized paraumbilical vein for varix embolization was attempted in seven patients with variceal bleeding. Paraumbilical vein puncture was performed under ultrasonographic guidance, followed by introduction of a 5-Fr sheath. We retrospectively evaluated the technical feasibility, procedure-related complications, and clinical outcomes of each patient. RESULTS: Recanalized paraumbilical vein catheterization was performed successfully in all patients. Gastroesophageal varix embolization was performed in six patients, and umbilical varix embolization was performed in one patient. Embolic materials used are N-butyl cyanoacrylate (n = 6) and coil with N-butyl cyanoacrylate (n = 1). There were no procedure-related complications. One patient underwent repeated variceal embolization 6 hours after initial procedure via recanalized paraumbilical vein, due to rebleeding from gastric varix. CONCLUSION: Percutaneous access via the paraumbilical vein for varix embolization is a simple alternative in patients with portal hypertension.
Adult ; Child ; Embolization, Therapeutic ; Enbucrilate/therapeutic use ; Esophageal and Gastric Varices/radiography/*therapy ; Female ; Humans ; Intracranial Hemorrhages/etiology ; Male ; Middle Aged ; Retrospective Studies ; Tomography, X-Ray Computed ; Treatment Outcome ; Umbilical Veins/surgery/ultrasonography

Intravariceal injection of N-butyl-2-cyanoacrylate is widely used for the hemostasis of bleeding gastric varices, but not routinely for esophageal variceal hemorrhage because of various complications such as pyrexia, bacteremia, deep ulceration, and pulmonary embolization. We report a rare case of esophageal sinus formation after cyanoacrylate obliteration therapy for uncontrolled bleeding from post-endoscopic variceal ligation (EVL) ulcer. A 50-year-old man with alcoholic liver cirrhosis presented with hematemesis. Emergent esophagogastroscopy revealed bleeding from large esophageal varices with ruptured erosion, and bleeding was initially controlled by EVL, but rebleeding from the post-EVL ulcer occurred at 17th day later. Although we tried again EVL and the injections of 5% ethanolamine oleate at paraesophageal varices, bleeding was not controlled. Therefore, we administered 1 mL cyanoacrylate diluted with lipiodol and bleeding was controlled. Three months after the endoscopic therapy, follow-up endoscopy showed medium to large-sized esophageal varices and sinus at lower esophagus. Barium esophagography revealed an outpouching in esophageal wall and endoscopic ultrasonography demonstrated an ostium with sinus. It is noteworthy that esophageal sinus can be developed as a rare late complication of endoscopic cyanoacrylate obliteration therapy.
Cyanoacrylates/administration & dosage/*adverse effects ; *Embolization, Therapeutic ; Endoscopy, Digestive System ; Esophageal and Gastric Varices/complications/*diagnosis/therapy ; Esophagus/radiography/ultrasonography ; Ethiodized Oil/therapeutic use ; Gastrointestinal Hemorrhage/surgery/*therapy ; Humans ; Ligation ; Liver Cirrhosis, Alcoholic/*complications/diagnosis ; Male ; Middle Aged ; Tissue Adhesives/administration & dosage/*adverse effects ; Ulcer/*complications

OBJECTIVE: To retrospectively evaluate the frequency and risk factors for developing thrombus in a systemic vein such as the infrarenal inferior vena cava or the iliac vein, in which a balloon-occluded retrograde transvenous obliteration (B-RTO) catheter was indwelled. MATERIALS AND METHODS: Forty-nine patients who underwent B-RTO for gastric varices were included in this study. The B-RTO procedure was performed from the right femoral vein, and the B-RTO catheter was retained overnight in all patients. Pre- and post-procedural CT scans were retrospectively compared in order to evaluate the development of thrombus in the systemic vein in which the catheter was indwelled. Additionally, several variables were analyzed to assess risk factors for thrombus in a systemic vein. RESULTS: In all 49 patients (100%), B-RTO was technically successful, and in 46 patients (94%), complete thrombosis of the gastric varices was achieved. In 6 patients (12%), thrombus developed in the infrarenal inferior vena cava or the right common-external iliac vein. All thrombi lay longitudinally on the right side of the inferior vena cava or the right iliac vein. One of the aforementioned 6 patients required anticoagulation therapy. No symptoms suggestive of pulmonary embolism were observed. Prothrombin time-international normalized ratio and the addition of 5% ethanolamine oleate iopamidol, on the second day, were related to the development of thrombus. CONCLUSION: Development of a thrombus in a systemic vein such as the inferior vena cava or iliac vein, caused by indwelling of the B-RTO catheter, is relatively frequent. Physicians should be aware of the possibility of pulmonary embolism due to iliocaval thrombosis.
Adult ; Aged ; Aged, 80 and over ; Balloon Occlusion/*methods ; Catheters, Indwelling/*adverse effects ; Esophageal and Gastric Varices/etiology/*therapy ; Female ; Femoral Vein ; Humans ; International Normalized Ratio ; Iopamidol/administration & dosage ; Male ; Middle Aged ; Oleic Acids/administration & dosage ; Prothrombin Time ; Retrospective Studies ; Risk Factors ; Statistics, Nonparametric ; Tomography, X-Ray Computed ; Treatment Outcome ; Venous Thrombosis/drug therapy/*etiology/*radiography

OBJECTIVE: To determine the safety and usefulness of a two-tiered approach to balloon-occluded retrograde transvenous obliteration (B-RTO) as a treatment for large gastric varices after portal hypertension. MATERIALS AND METHODS: 50 patients were studied who underwent B-RTO for gastric varices between October 2004 and October 2011 in our institution. The B-RTO procedure was performed from the right femoral vein and the B-RTO catheter was retained until the following morning. Distribution of sclerotic agents in the gastric varices on fluoroscopy was evaluated in all patients on days 1 and 2. When distribution of sclerotic agents in the gastric varices on day 1 had been none or very scanty even though the volume of the sclerotic agent infused was above the acceptable level, a second infusion was administered on day 2. When distribution was satisfactory, the B-RTO catheter was removed. RESULTS: In 8 (16%) patients, little or no sclerotic agent infused on day 1 was distributed in the gastric varices. However, on day 2, sclerotic agents were distributed in all gastric varices. Mean volume of ethanolamine oleate-iopamidol infused on day 1 was 24.6 mL and was 19.4 mL on day 2. Gastric varices were well obliterated with no recurrence. Complications caused by the sclerotic agent such as pulmonary edema or renal insufficiencies were not seen. CONCLUSION: When gastric varices are very large, a strategy involving thrombosis of only the drainage vein on the first day followed by infusing the sclerotic agent on the following day might be effective and feasible.
Adult ; Aged ; Aged, 80 and over ; Balloon Occlusion/*methods ; Catheters, Indwelling ; Collateral Circulation ; Drug Administration Schedule ; Esophageal and Gastric Varices/etiology/radiography/*therapy ; Female ; Femoral Vein ; Gastrointestinal Hemorrhage/etiology/*therapy ; Humans ; Hypertension, Portal/*complications ; Iopamidol/*administration & dosage/adverse effects ; Male ; Middle Aged ; Oleic Acids/*administration & dosage/adverse effects ; Recurrence ; Retrospective Studies ; Sclerosing Solutions/*administration & dosage/adverse effects ; Tomography, X-Ray Computed

OBJECTIVE: We wanted to evaluate the short-term effects of balloon-occluded retrograde transvenous obliteration (BRTO) for treating gastric variceal bleeding, in terms of the portal hypertensive changes, by comparing CT scans. MATERIALS AND METHODS: We enrolled 27 patients who underwent BRTO for gastric variceal bleeding and they had CT scans performed just before and after BRTO. The pre- and post-procedural CT scans were retrospectively compared by two radiologists working in consensus to evaluate the short-term effects of BRTO on the subsequent portal hypertensive changes, including ascites, splenomegaly, portosystemic collaterals (other than gastrorenal shunt), the gall bladder (GB) edema and the intestinal wall edema. Statistical differences were analyzed using the Wilcoxon signed rank test and the paired t-test. RESULTS: Following BRTO, ascites developed or was aggravated in 22 (82%) of 27 patients and it was improved in two patients; the median spleen volumes increased from 438.2 cm3 to 580.8 cm3, and based on a 15% volume change cut-off value, splenic enlargement occurred in 15 (56%) of the 27 patients. The development of new collaterals or worsening of existing collaterals was not observed in any patient. GB wall edema developed or was aggravated in four of 23 patients and this disappeared or improved in five; intestinal wall edema developed or was aggravated in nine of 27 patients, and this disappeared or improved in five. Statistically, we found significant differences for ascites and the splenic volumes before and after BRTO (p = 0.001 and p < 0.001, respectively) CONCLUSION: Some portal hypertensive changes, including ascites and splenomegaly, can be aggravated shortly after BRTO.
Adult ; Aged ; Aged, 80 and over ; Ascites/diagnosis/etiology ; Balloon Occlusion/adverse effects/*methods ; Cholecystography ; Contrast Media/administration & dosage ; Edema/diagnosis/etiology ; Esophageal and Gastric Varices/complications/*therapy ; Female ; Follow-Up Studies ; Gastrointestinal Hemorrhage/etiology/*therapy ; Humans ; Hypertension, Portal/*diagnosis/etiology ; Intestines/radiography ; Iohexol/analogs & derivatives/diagnostic use ; Liver Cirrhosis/complications ; Male ; Middle Aged ; Observer Variation ; Organ Size ; Retrospective Studies ; Spleen/radiography ; Splenomegaly/diagnosis/etiology ; Time Factors ; Tomography, X-Ray Computed/*methods ; Treatment Outcome