Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Variceal Hemorrhage

Abstract

ObjectiveTo 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 MethodsFrom 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.ResultsTechnical 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.ConclusionPARTO is technically feasible, safe, and effective for gastric variceal hemorrhage in patients with portal hypertension.

Evolution of Retrograde Transvenous Obliteration Techniques

“…For BRTO, PARTO, and CARTO, this ranges from 79 to 100%, 94.7 to 100%, and 100%, respectively. 2,4,5,[27][28][29]31,38,39 In a recent retrospective study comparing BRTO and PARTO, Kim et al reported similar technical success rates of BRTO with EO (93.9%) or STS (92%), and PARTO with Gelfoam (100%). 31 Notably, the success rate of BRTO increases from 84-98% to 98-100% when used in conjunction with balloon-occluded antegrade transvenous obliteration (BATO), although combination therapies are beyond the scope of this article.…”

“…AVPII sizes range from 3 to 22 mm, and a plug 20 to 30% larger than the narrowest point of the varix near the left renal vein is selected to avoid migration. 4,[27][28][29] If subsequent contrast injection through the upstream catheter demonstrates inadequate occlusion, with continued portosystemic flow into the left renal vein, small volume Gelfoam embolization, or waiting for 5 to 10 minutes, will achieve stasis. 28 With contrast stasis in the shunt, Gelfoam embolization is performed through the catheter, upstream to the plug, with same end point as BRTO.…”

“…30 Additionally, EO is associated with pulmonary edema, disseminated intravascular coagulation, and cardiogenic shock. 28,31 Limiting the total volume of 5 to 10% EO to 20 to 30 cc (or <0.4 mL/kg), or dividing treatment into multiple sessions may mitigate these risks. 2,30,32 Polidocanol, a relatively new sclerosing agent in the United States, is used in foam form for varicose vein sclerotherapy and BRTO.…”

“…29,35,37 Substituting traditional sclerosants for Gelfoam introduces an embolization agent with no dose limitations, along with greater safety profiles and familiarity among interventionalists. 28,33 However, higher rates of gastric variceal recurrence are reported after PARTO with Gelfoam versus BRTO with EO or STS. Although this recurrence was not directly attributed to Gelfoam, periprocedural shunt thrombosis followed by recurrence may relate to recanalization before complete variceal obliteration.…”

“…31 Reports of minimal systemic leakage of Gelfoam resulted in no clinically evident pulmonary or arterial embolization. 28 Importantly, Gelfoam eliminates the need to embolize small draining collateral veins, a requirement in BRTO to avoid systemic leak of sclerosant.…”