MDCT angiography to evaluate the therapeutic effect of PTVE for esophageal varices

Abstract

Aim: To evaluate the role of multi-detector row computed tomography (MDCT) angiography for assessing the therapeutic effects of percutaneous transhepatic variceal embolization (PTVE) for esophageal varices (EVs).

Methods: The subjects of this prospective study were 156 patients who underwent PTVE with cyanoacrylate for EVs. Patients were divided into three groups according to the filling range of cyanoacrylate in EVs and their feeding vessels: (1) group A, complete obliteration, with at least 3 cm of the lower EVs and peri-/EVs, as well as the adventitial plexus of the gastric cardia and fundus filled with cyanoacrylate; (2) group B, partial obliteration of varices surrounding the gastric cardia and fundus, with their feeding vessels being obliterated with cyanoacrylate, but without reaching lower EVs; and (3) group C, trunk obliteration, with the main branch of the left gastric vein being filled with cyanoacrylate, but without reaching varices surrounding the gastric cardia or fundus. We performed chart reviews and a prospective follow-up using MDCT images, angiography, and gastrointestinal endoscopy.

Results: The median follow-up period was 34 mo. The rate of eradication of varices for all patients was 56.4% (88/156) and the rate of relapse was 31.3% (41/131). The rates of variceal eradication at 1, 3, and 5 years after PTVE were 90.2%, 84.1% and 81.7%, respectively, for the complete group; 61.2%, 49% and 42.9%, respectively, for the partial group; with no varices disappearing in the trunk group. The relapse-free rates at 1, 3 and 5 years after PTVE were 91.5%, 86.6% and 81.7%, respectively, for the complete group; 71.1%, 55.6% and 51.1%, respectively, for the partial group; and all EVs recurred in the trunk group. Kaplan-Meier analysis showed P values of 0.000 and 0.000, and odds ratios of 3.824 and 3.603 for the rates of variceal eradication and relapse free rates, respectively. Cyanoacrylate in EVs disappeared with time, but those in the EVs and other feeding vessels remained permanently in the vessels without a decrease with time, which is important for the continued obliteration of the feeding vessels and prevention of EV relapse.

Conclusion: MDCT provides excellent visualization of cyanoacrylate obliteration in EV and their feeding veins after PTVE. It confirms that PTVE is effective for treating EVs.

Keywords: Cyanoacrylate; Esophageal varices; Multi-detector row computed tomography; Percutaneous transhepatic variceal embolization; Therapeutic effect.

Figure 1

Study flow chart. PTVE: Percutaneous transhepatic variceal embolization; MDCT: Multi-detector row computed tomography; GI: Gastrointestinal.

Figure 2

Volume rendering of the multi-detector row computed tomography angiography data set during the portal venous phase demonstrated the esophageal-gastric varices and their afferent vessels before and after percutaneous transhepatic variceal embolization. A-C: Volume rendering of multi-detector row computed tomography angiography data set during the portal venous phase demonstrates the esophageal-gastric varices and their afferent vessels (left gastric vein (LGV) only for A, LGV and short gastric vein (SGV) for B, LGV, posterior gastric vein and SGV for C); D-F: All varices and their feeding vessels are completely filled with cyanoacrylate (arrows) after percutaneous transhepatic variceal embolization; no flow signals were revealed in any of the cases.

Figure 3

Coronal thin-slab maximum intensity projection of multi-detector row computed tomography angiography during the portal venous phase demonstrates the three different obliteration types of cyanoacrylate. A: Complete obliteration: with the lower esophageal varices (EVs) and peri-/para-EVs, as well as the adventitial plexus of the gastric cardia and fundus, filled with cyanoacrylate; B: Partial obliteration: along with the left gastric vein (LGV) and its main branches being obliterated with cyanoacrylate, the varices surrounding the gastric cardia and fundus are also obliterated, but without reaching the lower EVs; C: Trunk obliteration: cyanoacrylate mainly obliterates the LGV and its main branches outside of the gastric wall.

Figure 4

Computed tomography image follow-up revealed the different outcome of cyanoacrylate in the different veins: cyanoacrylate in submucosal varices (within the wall of the fundus, large arrow) disappeared with time, but those in the para- and peri-gastric varices (outside the wall of the fundus, small arrow) remained permanently in the vessels without a time-dependent decrease. A: The cyanoacrylate in both the gastric varices and peri-and para-gastric varices stayed full at 3 mo after percutaneous transhepatic variceal embolization (PTVE); B: The cyanoacrylate in the gastric varices was reduced at 6 mo after PTVE; C: The cyanoacrylate in the gastric varices nearly disappeared at 12 mo after PTVE, but the cyanoacrylate in the peri- and para-gastric vessels retained the same as before.

Figure 5

Kaplan-Meier analysis of the disappearance rate (A) and non-relapse rate (B) of varices shown at gastroscopy during the follow-up. Group A: Complete obliteration; Group B: Partial obliteration; Group C: Trunk obliteration.

Figure 6

Kaplan-Meier analysis of non-rebleeding (A) and survival rates (B) among the different obliteration types after modified percutaneous transhepatic variceal embolization. Group A: Complete obliteration; Group B: Partial obliteration; Group C: trunk obliteration.