Comparison of Transjugular Intrahepatic Portosystemic Shunt with Covered Stent and Balloon-Occluded Retrograde Transvenous Obliteration in Managing Isolated Gastric Varices

Abstract

Objective: Although a transjugular intrahepatic portosystemic shunt (TIPS) is commonly placed to manage isolated gastric varices, balloon-occluded retrograde transvenous obliteration (BRTO) has also been used. We compare the long-term outcomes from these procedures based on our institutional experience.

Materials and methods: We conducted a retrospective review of patients with isolated gastric varices who underwent either TIPS with a covered stent or BRTO between January 2000 and July 2013. We identified 52 consecutive patients, 27 who had received TIPS with a covered stent and 25 who had received BRTO. We compared procedural complications, re-bleeding rates, and clinical outcomes between the two groups.

Results: There were no significant differences in procedural complications between patients who underwent TIPS (7%) and those who underwent BRTO (12%) (p = 0.57). There were also no statistically significant differences in re-bleeding rates from gastric varices between the two groups (TIPS, 7% [2/27]; BRTO, 8% [2/25]; p = 0.94) or in developing new ascites following either procedure (TIPS, 4%; BRTO, 4%; p = 0.96); significantly more patients who underwent TIPS developed hepatic encephalopathy (22%) than did those who underwent BRTO (0%, p = 0.01). There was no statistically significant difference in mean survival between the two groups (TIPS, 30 months; BRTO, 24 months; p = 0.16); median survival for the patients who received TIPS was 16.6 months, and for those who underwent BRTO, it was 26.6 months.

Conclusion: BRTO is an effective method of treating isolated gastric varices with similar outcomes and complication rates to those of TIPS with a covered stent but with a lower rate of hepatic encephalopathy.

Keywords: Balloon-occluded retrograde transvenous obliteration; Gastric varices; Portal hypertension; Transjugular intrahepatic portosystemic shunt.

Fig. 1. 68-year-old woman with nonalcoholic steatohepatitis cirrhosis and recurrent gastric variceal bleeding.

A. Balloon-occluded venogram of gastro-renal shunt shows contrast filling of gastric varices (arrows) along with draining inferior phrenic collateral vein (open arrow). B. Inferior phrenic vein was embolized with microcoils (open arrow). This was followed by injection of sodium tetradecyl sulfate (Sotradecol; AngioDynamics) mixed with Lipiodol into gastric varices (arrows). C. It was not possible to leave occlusion balloon and sheath due to common femoral artery injury while obtaining femoral venous access. Therefore, gastrorenal shunt was embolized with multiple coils (open arrow) to retain sclerosant (arrows) in gastric varices before balloon was deflated and sheath was removed. D. Patient presented with hematemesis two days following procedure. TIPS was performed due to presumed gastric variceal bleeding. Venogram after TIPS placement showed no gastric varix filling from afferent veins and dense Lipiodol uptake (arrows) in gastric varices. Portosystemic gradient decreased from 15 mm Hg to 5 mm Hg. TIPS = transjugular intrahepatic portosystemic shunts

Fig. 2. Flowchart summarizing re-bleeding after TIPS or BRTO in 52 patients.

BRTO = balloon-occluded retrograde transvenous obliteration, GV = gastric varices, TIPS = transjugular intrahepatic portosystemic shunts

Fig. 3. 47-year-old man with alcoholic liver cirrhosis with acute gastric variceal bleeding.

A. TIPS procedure was performed using 10 × 50 mm Viatorr stent (arrows) and 10 × 68 mm Wallstent (open arrows) extending to hepaticocaval junction. Portosystemic gradient decreased from 20 mm Hg to 8 mm Hg. Patient presented with recurrent gastric variceal bleeding two years later. B. TIPS venogram showed tight stenosis (arrows) at TIPS stent near hepaticocaval junction. C. Balloon angioplasty was performed at tight stenosis (arrows) near hepaticocaval junction. D. TIPS venogram after balloon angioplasty showed interval improvement of stenosis (arrows). Portosystemic gradient decreased from 15 mm Hg to 5 mm Hg. TIPS = transjugular intrahepatic portosystemic shunts