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. 2019 Apr 3:2019:2674758.
doi: 10.1155/2019/2674758. eCollection 2019.

Balloon-Assisted Percutaneous Transhepatic Antegrade Embolization with 2-Octyl Cyanoacrylate for the Treatment of Isolated Gastric Varices with Large Gastrorenal Shunts

Guangchuan Wang  1 , Dongxiao Meng  1 , Guangjun Huang  1 , Qingshan Pei  1 , Lianhui Zhao  1 , Yongjun Shi  1 , Mingyan Zhang  1 , Hua Feng  1 , Junyong Zhang  1 , Chunqing Zhang  1
Affiliations

Balloon-Assisted Percutaneous Transhepatic Antegrade Embolization with 2-Octyl Cyanoacrylate for the Treatment of Isolated Gastric Varices with Large Gastrorenal Shunts

Guangchuan Wang et al. Biomed Res Int. .

Abstract

Aims: To evaluate the safety and effectiveness of percutaneous transhepatic antegrade embolization (PTAE) with 2-octyl cyanoacrylate assisted with balloon occlusion of the left renal vein or gastrorenal shunts (GRSs) for the treatment of isolated gastric varices (IGVs) with large GRSs.

Methods: Thirty patients with IGVs associated with large GRSs who had underwent PTAE assisted with a balloon to block the opening of the GRS in the left renal vein were retrospectively evaluated and followed up. Clinical and laboratory data were collected to evaluate the technical success of the procedure, complications, changes in the liver function using Child-Pugh scores, worsening of the esophageal varices, the rebleeding rate, and survival. Laboratory data obtained before and after PTAE were compared (paired-sample t-test).

Results: PTAE was technically successful in all 30 patients. No serious complications were observed except for one nonsymptomatic pulmonary embolism. During a mean follow-up of 30 months, rebleeding was observed in 4/30 (13.3%) patients, worsening of esophageal varices was observed in 4/30 (13.3%) patients, and newly developed or aggravated ascites were observed on CT in 3/30 (10%) patients. Significant improvement was observed in Child-Pugh scores (p=0.009) and the international normalized ratio (INR) (p=0.004) at 3 months after PTAE. The cumulative survival rates at 1, 2, 3, and 5 years were 96.3%, 96.3%, 79.9%, and 79.9%, respectively.

Conclusion: Balloon-assisted PTAE with 2-octyl cyanoacrylate is technically feasible, safe, and effective for the treatment of IGV associated with a large GRS.

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Figures

Figure 1
Figure 1
A 56-year-old woman suffering from recurrent upper gastrointestinal bleeding from gastric varices. (a) Direct portography showed gastric varices (white asterisk) from the short gastric vein (white arrow). (b) Angiography of the short gastric vein (white arrow) showed gastric varices (white asterisk) and GRS (black arrow) that drained into left renal vein. (c) A balloon catheter was inserted into the left renal vein (short black arrow) to decrease the blood flow of the GRS (black arrow), and cyanoacrylate was then injected into the varices through the catheter into the feeding vein (white arrow). (d) Direct portography performed immediately after embolotherapy showing the varices (black asterisk) and the feeding vessels (white arrow) were filled with cyanoacrylate. PV, portal vein; SV, splenic vein; LRV, left renal vein; IVC, inferior vena cava.
Figure 2
Figure 2
A 65-year-old man suffering from gastric variceal bleeding and encephalopathy. (a) Direct portography showed gastric varices (white asterisk) from the short gastric vein (white arrow) with drainage into the left renal vein through a large GRS (black arrow). (b) A balloon catheter (short white arrow) was introduced into the GRS (black arrow) through the femoral vein, and cyanoacrylate was directly infused into the gastric varices (white asterisk) from the catheter (white arrow) into the posterior gastric vein. (c) Before removal, the balloon catheter (short white arrow) was inflated in place for 1 min until the gastric varices (white asterisk) and the feeding vessels (white arrow) were completely obliterated by the cyanoacrylate. (d) Direct portography performed immediately after the embolotherapy showed the gastric varices (black asterisk) and the feeding vessels (white arrow) were filled with cyanoacrylate. PV, portal vein; SV, splenic vein; LRV, left renal vein.
Figure 3
Figure 3
Endoscopic follow-up of the patient shown in Figure 2. (a) Endoscopic image obtained before percutaneous transhepatic antegrade variceal embolization showing large gastric varices. (b) Endoscopic image obtained 1 month after the procedure showing congestion and edema in the mucosa. (c) At 3 months after the procedure, the varices were markedly smaller. (d) One year after the procedure, the gastric varices had mostly disappeared.
Figure 4
Figure 4
Kaplan-Meier analysis of variceal rebleeding, and aggravation of the esophageal varices. (a) The cumulative rebleeding rate. (b) The cumulative rate of aggravation of esophageal varices.
Figure 5
Figure 5
CT follow-up of the patient shown in Figure 2. (a) CT portal venography image obtained before percutaneous transhepatic antegrade variceal embolization showing large gastric varices with drainage by a large GRS. (b) CT portal venography image obtained 3 months after percutaneous transhepatic variceal embolization showing that the gastric varices (asterisk) and their feeding veins (white arrow) were filled with cyanoacrylate. (c) CT portal venography image obtained 1 year after percutaneous transhepatic variceal embolization showing that the cyanoacrylate in the submucosa varices had almost disappeared (asterisk), while the perifundus varices and the feeding veins (white arrow) were still filled with cyanoacrylate, similar to result observed before follow-up. Moreover, the gastrorenal shunt was reserved (black arrow). GRS, gastrorenal shunt; GV, gastric varices; SGV, short gastric vein; PV, portal vein; LRV, left renal vein; SMV, superior mesenteric vein; SV, splenic vein.
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