The combination of balloon-assisted antegrade transvenous obliteration and transjugular intrahepatic portosystemic shunt for the management of cardiofundal varices hemorrhage

Abstract

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CC-BY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.Objectives: In this study, we propose a modified balloon-occluded retrograde transvenous obliteration (BRTO) strategy -balloon-assisted antegrade transvenous obliteration (BAATO), and explore the feasibility, efficacy and safety of BAATO combined with transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of cardiofundal varices (GOV2 or IGV1) hemorrhage. Materials and methods: In this retrospective cohort study, 15 patients with cardiofundal varices hemorrhage who received BAATO combined with TIPS procedures, from August 2017 to September 2019 in our center, were enrolled. They consisted of seven patients with GOV2 and eight patients with IGV1. The clinical efficacy and safety of BAATO + TIPS procedures were assessed by comparing the clinical symptoms, laboratory and imaging examinations before and after treatment. Results: The technical success rate of BAATO + TIPS procedure was 100%. After the procedure, clinical symptoms were improved and complete regression of gastric varices (GVs) was observed in all patients, besides, the control efficiency of ascites and PVT which were 77.8 and 87.5%, respectively. No patient died or had a rebleeding during the follow up, but grade II hepatic encephalopathy (HE) occurred in two patients (13.3%) and shunt dysfunction was discovered in one patient (6.7%). Conclusion:For the treatment of GVs, the new technique BAATO is feasible, safe and effective, and it may be a more convenient and economical method than conventional BRTO. In addition, the combination of BAATO and TIPS may play a positive role in achieving hemostasis and improving the complications of portal hypertension such as ascites and PVT. Eur J

North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension

“…[57][58][59][60][61][62][63][64] Nevertheless, balloon-retrograde transvenous obliteration requires the presence of a spontaneous portosystemic shunt (eg, gastro Q31 or splenorenal shunt) and may be associated with increased ascites and bleeding from esophageal varices. TIPS combined with variceal obliteration appears to be associated with a potential decrease in rebleeding rates (0%-15%), [65][66][67] particularly when the pretreatment PSG is less than 12 mm Hg. In addition to the earlierdescribed considerations, the most appropriate management for bleeding from GV will depend on the vascular anatomy of the portal venous system in addition to center and surgeon expertise.…”

“…The presence of a patent TIPS in patients undergoing LT is unlikely to negatively impact surgical outcomes, although it may increase surgical complexity. [65][66][67][68] During LT, the presence of TIPS may cause hyperdynamic circulation and increased portal flow, 67,69 but does not impact blood transfusion requirements, surgical time, or hospital length of stay. [65][66][67][68] Surgical factors are more favorable with TIPS compared with pretransplant surgical shunts.…”

“…[65][66][67][68] During LT, the presence of TIPS may cause hyperdynamic circulation and increased portal flow, 67,69 but does not impact blood transfusion requirements, surgical time, or hospital length of stay. [65][66][67][68] Surgical factors are more favorable with TIPS compared with pretransplant surgical shunts. 66 TIPS malposition may affect up to 20% of transplants, 66,68 therefore, care should be taken to ensure that the TIPS device does not extend into the right atrium and leaves a segment of the portal vein for transplant anastomoses.…”

Management of Refractory Variceal Bleed in Cirrhosis

“…40 Balloon-assisted antegrade transvenous obliteration (BAATO) combined with TIPS has also been shown to be safe and effective in management of gastric varices in a recent study. 41…”

Balloon-occluded retrograde transvenous obliteration for treatment of gastric varices

“…Saad et al [ 67 ] therefore proposed use of BATO via the TIPS route, combined TIPS and BRTO, or combined BATO and BRTO, depending on the clinical situation. A recent study[ 68 ] has proposed a modified method, balloon-assisted antegrade transvenous obliteration (BAATO), in which balloon occlusion of the GRS is performed in retrograde fashion followed by antegrade trans-TIPS catheter injection of CA rather than sclerosant. The distribution of CA in GVs can be controlled by modifying blood flow velocity via balloon size adjustment.…”