Isolated Gastric Varices Refractory to Balloon-occluded Retrograde Transvenous Obliteration (BRTO) Successfully Treated by Shunt-occluded Endoscopic Injection Sclerotherapy (SO-EIS): A Case Report and Review of the Literature

Abstract

Balloon-occluded retrograde transvenous obliteration (BRTO) is widely used to treat isolated gastric varices (IGVs) in Japan. However, BRTO is difficult to perform for IGVs with many small collateral veins, and no secondary treatment has been established. We herein report a rare case of IGVs refractory to BRTO successfully treated by shunt-occluded endoscopic injection sclerotherapy (SO-EIS), which is a combination therapy of major shunt occlusion by a balloon catheter and endoscopic injection sclerotherapy. Since SO-EIS can be performed regardless of the IGVs' anatomical configuration, it may be a promising alternative treatment for IGVs refractory to BRTO.

Keywords: balloon-occluded retrograde transvenous obliteration (BRTO); isolated gastric varices; shunt-occluded endoscopic injection sclerotherapy (SO-EIS).

Figure 1.

(a) Esophagogastroduodenoscopy (EGD) showed that the isolated gastric varices (IGVs) were white, large, and located in the cardia and fundus. (b, c) Dynamic computed tomography (CT) also showed that IGVs were in the cardia and fundus, suggesting that the left renal vein was the efferent vein.

Figure 2.

The portal phase of superior mesenteric angiography showed that portal flow was hepatopetal, and the IGVs were not visualized (a). CT of splenic arterial portography showed that the efferent veins were the pericardiacophrenic vein (red arrow) (b), inferior phrenic vein (red triangle), para-esophageal vein (blue arrow) (c), and left renal vein (yellow arrow), which was the main drainage route afferent vein (d). CT also showed that the short gastric vein (green arrow) was the afferent vein (e).

Figure 3.

Balloon-occluded retrograde transvenous varicerography (BRTV) showed that the IGVs were not opacified because the inferior phrenic veins (red arrow) worked as collateral veins. (a) Frontal view, (b) lateral view.

Figure 4.

We punctured the right internal jugular vein and introduced an 8-Fr balloon catheter with a 20-mm diameter. We advanced it to the left renal vein and occluded the end of the efferent vein (a). We then tried to cannulate the inferior phrenic vein from the inferior vena cava (IVC). We injected contrast medium via the balloon catheter and performed CT to determine where the end of the inferior phrenic vein was located (b, c). Although we used various types of catheter, such as Cobra, Multipurpose, and Michaelson types, we were unable to cannulate due to indentation.

Figure 5.

Shunt-occluded endoscopic injection sclerotherapy (SO-EIS) procedure. (a, b) First puncture. (c, d) Second puncture. (e) Just after the treatment.

Figure 6.

One week after shunt-occluded endoscopic injection sclerotherapy (SO-EIS), esophagogastroduodenoscopy (EGD) and enhanced computed tomography (CT) showed complete thrombosis of the isolated gastric varices (IGVs) and afferent vein (a-c). Three months after SO-EIS, EGD showed that the IGVs had shrunk (d).