Transcatheter Obliteration of Gastric Varices

Abstract

Balloon-occluded retrograde transvenous obliteration (BRTO) has become the treatment of choice for gastric varices at many institutions in Japan. However, in some cases that involve complex types of afferent or draining veins, the use of standard BRTO for the treatment of gastric varices may be associated with several difficulties that can lead to unfavorable results. In such cases, additional techniques are required for successful treatment. These techniques include stepwise injection of the sclerosing agent, selective injection of the agent via a microcatheter, coil embolization of the afferent gastric veins, double-balloon catheterization, and BRTO performed with percutaneous transhepatic portal venous access or transileocolic venous access. The majority of gastric varices can be treated successfully with a combination of these techniques. However, accurate assessment of the variceal hemodynamic pattern is the most important factor in ensuring successful treatment.

The History and Evolution of Balloon-occluded Retrograde Transvenous Obliteration (BRTO): From the United States to Japan and Back

“…[1][2][3]39 Most authors refer to Kanagawa et al (1991Kanagawa et al ( -1993 as the originator of the BRTO procedure 1 However, the first published document of an attempt at balloon-occluded sclerotherapy of the gastrorenal shunt for the management of gastric varices was authored by Olson et al in 1984. 39 This is clearly 5 and 7 years prior to the practice and publications, respectively, of Kanagawa et al (1991Kanagawa et al ( -1993, respectively).…”

“…Risks of this agent endovascularly include hemolysis, hemoglobinuria, and potentially hemoglobin-induced renal tubular dysfunction. 2,3 The antidote of free hemoglobin is haptoglobin, which conjugates with it. Haptoglobin is available in Japan and is not available for human and commercial use in the United States.…”

“…The hemolysis problem with ethanolamine oleate limits the usable sclerosant volume to 40 mL. 2,3 This led Japanese operators to resort to one of two strategies. The first strategy was to adopt a staged multisession treatment where the gastric varices and gastrorenal shunt would be ''lavaged'' with 5% ethanolamine oleate with a volume limit of 20-30 mL.…”

The Frequency and Significance of Portopulmonary Venous Anastomosis (PPVA): A Case Report and Literature Review

“…The increased pressure in the portal system leads to the development of portosystemic collateral vessels. Many pathways of collateral communication between the portal and systemic circulation have been described [1,2]. Some cirrhotic patients with portal hypertension develop collateral communication between the portal system and the pulmonary veins [3,4].…”

Balloon-occluded retrograde transvenous obliteration for gastric varicesviathe intercostal vein

“…Gastric varices most commonly have a spontaneous gastro-renal (G-R) shunt with the left adrenal vein targeted as the main draining vessel by balloon inflation. However, gastric varices which are not associated with a G-R shunt have been observed [3,4] . The outflow vessels of gastric varices without a G-R shunt such as the inferior phrenic vein, cardiophrenic vein, pericardial vein, retroperitoneal vein and intercostal vein are anatomically listed [5] .…”