Vascular Plug Assisted Retrograde Transvenous Obliteration (PARTO) for Gastric Varix Bleeding Patients in the Emergent Clinical Setting

Abstract

Purpose: To evaluate the technical feasibility and safety of vascular plug assisted retrograde transvenous obliteration (PARTO) for bleeding gastric varix performed in the emergent clinical setting and describe the mid-term clinical results.

Materials and methods: From April 2012 to January 2015, emergent PARTO was tried in total 9 patients presented with active gastric varix bleeding. After initial insufficient or failure of endoscopic approach, they underwent PARTO in the emergent clinical setting. Gelatin sponge embolization of both gastrorenal (GR) shunt and gastric varix was performed after retrograde transvenous placement of a vascular plug in GR shunt. Coil assisted RTO (CARTO) was performed in one patient who had challenging GR shunt anatomy for vascular plug placement. Additional embolic materials, such as microcoils and NBCA glue-lipiodol mixture, were required in three patients to enhance complete occlusion of GR shunt or obliteration of competitive collateral vessels. Clinical success was defined as no variceal rebleeding and disappearance of gastric varix.

Results: All technical and clinical success-i.e., complete GR shunt occlusion and offending gastric varix embolization with immediate bleeding control-was achieved in all 9 patients. There was no procedure-related complication. All cases showed successful clinical outcome during mean follow up of 17 months (12-32 months), evidenced by imaging studies, endoscopy and clinical data. In 4 patients, mild worsening of esophageal varices or transient ascites was noted as portal hypertensive related change.

Conclusion: Emergent PARTO is technically feasible and safe, with acceptable mid-term clinical results, in treating active gastric varix bleeding.

Keywords: BRTO; Liver cirrhosis; PARTO; gastric varix; portal hypertension.

Fig. 1. An illustration of vascular plug-assisted retrograde transvenous obliteration (PARTO) procedure. This illustration demonstrates complete obliteration/thrombosis of GV and GR shunt (in gray color). GV gelatin sponge embolization was done via 4 Fr catheter in retrograde fashion. To achieve proper location of vascular plug, guiding sheath advance is most important technical process. GV, gastric varix; GR shunt, gastrorenal shunt.

Fig. 2. Fundal GV in a 46-year-old man with massive hematemesis. (A) Contrast-enhanced axial CT images obtained before and after PARTO show completely disappeared fundal GV. (B) Fluoroscopic images of PARTO: minimal contrast leakage after gelatin sponge embolization to massive GR shunt, probably from intra-shunt pressure increase, was controlled by additional embolization. (C) Endoscopic images of the GV also show successful treatment result. Before procedure, massive hemorrhage was noted in the gastric lumen. GV, gastric fundal varix; PARTO, plug assisted retrograde transvenous obliteration; GR, gastrorenal.

Fig. 3. Fundal GV in a 52-year-old man with massive hematemesis. Coil-assisted RTO (CARTO) was performed after failed guiding sheath advance for vascular plug deployment. Technically successful CARTO demonstrating complete stasis and opacification of GR shunt and GV. GV, gastric fundal varix; RTO, retrograde transvenous obliteration; GR, gastrorenal.