Simultaneous combined balloon‐occluded retrograde transvenous obliteration and partial splenic embolization for gastric fundal varices

Abstract

Background: We previously reported the techniques and usefulness of simultaneous combined balloon-occluded retrograde transvenous obliteration (B-RTO) and partial splenic embolization (PSE), based on the hypothesis that concomitant PSE can diminish the increase in portal venous pressure after B-RTO. Objective: After experiencing more cases and performing longer-term follow-up, we re-evaluated the efficacy of simultaneous combined B-RTO and PSE for gastric fundal varices (GVs). Methods: We performed B-RTO in 36 consecutive patients treated for GVs from 2005 to 2013. Twenty-three patients underwent simultaneous combined B-RTO and PSE (Group 1) and 13 underwent B-RTO monotherapy (Group 2). The outcomes were retrospectively evaluated. Results: There were no significant differences in baseline characteristics between the two groups except that the splenic volumes were larger in Group 1 than 2. B-RTO was technically successful in 21 of 23 patients (91.3%) in Group 1 and in 12 of 13 patients (92.3%) in Group 2. In all patients with ruptured GVs (six in Group 1 and five in Group 2), complete hemostasis was obtained by B-RTO. Exacerbation of esophageal varices was significantly less frequent in Group 1 than 2 (p ¼ 0.0017). Conclusion: Concomitant PSE with B-RTO may contribute to prevention of the exacerbation of esophageal varices after B-RTO.

Balloon-occluded retrograde transvenous obliteration for treatment of gastric varices

“…We use BRTO for both emergency and elective treatment of ruptured GVs as well as prophylactic treatment according to the criteria described below[ 15 , 16 ]. Indications for prophylactic treatment of GVs include nodular form and red color spot lesions[ 17 ], increasing size over time, and hepatic encephalopathy.…”

“…Indications for prophylactic treatment of GVs include nodular form and red color spot lesions[ 17 ], increasing size over time, and hepatic encephalopathy. However, we do not treat patients with severe hepatic dysfunction (total bilirubin ≥ 4.0 mg/dL, Child-Pugh score ≥ 13), renal dysfunction (eGFR < 30 mL/min/1.73 m 2 ), or other serious diseases with poor prognosis as well as those without a portosystemic shunt amenable to a retrograde approach[ 15 ]. We consider the presence of contrast agent flowing freely from the GRS into the portal vein on balloon-occluded retrograde venography (BRTV) a relative contraindication[ 16 ].…”

“…BRTO is highly effective to eradicate GVs[ 6 - 8 , 15 , 34 ] and can be effective for prophylactic[ 7 - 9 , 34 ] as well as emergency bleeding treatment[ 15 , 35 , 36 ]. Several studies have shown that BRTO is superior to endoscopic interventions in terms of bleeding control and prognosis in patients with GVs[ 35 , 37 , 38 ].…”

“…Our conventional BRTO method is described as follows[ 15 , 49 ]: GRS is diagnosed by computed tomography (CT). An 8 Fr long shepherd hook-shaped (Asato; Medikit, Tokyo, Japan) or cobra-shaped (S-one sheath; Terumo Clinical Supply Co., Gifu, Japan) sheath introducer is advanced into the left renal vein via the right femoral or internal jugular vein, respectively.…”

The first case of balloon-occluded retrograde transvenous obliteration and partial splenic embolization for gastric varices in situs inversus abdominus

“…A retrospective study of BRTO showed that the clinical success rate of BRTO-that is, no recurrence of GVs with no rebleeding-was 97.3%, confirming the efficacy of BRTO [7]. The combination of BRTO with PSE can decrease the portal venous pressure and prevent the exacerbation of EVs [8][9][10][11][12], and can significantly reduce the amount of the sclerosing agent required, including 5% EOI for BRTO [8]. However, exacerbation of EVs has been observed in 33.3% of patients treated with BRTO without PSE [7].…”