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

Abstract

Objective: To 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 methods: From 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.

Results: Technical 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.

Conclusion: PARTO is technically feasible, safe, and effective for gastric variceal hemorrhage in patients with portal hypertension.

Keywords: BRTO; Variceal bleeding; Vascular Plug.

Fig. 1. 72-year-old female with GV and GRS.

A. 9 Fr TIPS sheath is placed in left renal vein and tip is in orifice to GRS. Contrast injection reveals GRS with waist (black arrow). Small inferior phrenic collateral vein (black arrowhead) is also seen. B. Vascular plug (arrow) is placed at waist of GRS. With gelfoam slurry injection, inferior phrenic collateral vein is spontaneously occluded and GV is completely filled with gelfoam mixture. C. Pre-procedural CT scan shows GV (asterisk). D. Complete thrombosis (asterisk) of GV is reported on post-procedural CT scan 4 days after PARTO. CT = computed tomography, GRS = gastrorenal shunt, GV = gastric varix, PARTO = plug-assisted retrograde transvenous obliteration, TIPS = transjugular intrahepatic portosystemic shunt

Fig. 2. 58-year-old male with previous endoscopic histoacryl injection.

A. Injected glue (asterisk) is demonstrated in upper portion of GV. B. Gelfoam embolization is performed sufficiently until left gastric vein (white arrow) is visualized. C. GV (asterisk) is delineated on pre-procedural CT scan, which is performed 1 week before endoscopic glue injection and 8 weeks before PARTO procedure. Concomitant HCC (white arrow) is observed in left lateral lobe of liver, although it was not clearly visualized on this hepatic venous phase image. Post-ablation area (black arrow) is seen in right lobe of liver. D. Post-procedural CT scan reveals residual GV (black arrows) and previously injected endoscopic glue (black asterisk). Amount of ascites is increased after procedure. CT = computed tomography, GV = gastric varix, HCC = hepatocellular carcinoma, PARTO = plug-assisted retrograde transvenous obliteration