Utility of low-dose gelatin sponge particles and 5% ethanolamine oleate iopamidol mixture in retrograde transvenous obliteration (GERTO) for gastric varices

Abstract

Objective: To determine the utility of low-dose gelatin sponge particles and 5% ethanolamine oleate iopamidol (EOI) mixture in retrograde transvenous obliteration (GERTO) for gastric varices (GV).

Methods: 57 consecutive patients who underwent balloon-occluded retrograde transvenous obliteration (B-RTO) for GV were divided into three groups with Hirota's grade by balloon-occluded retrograde transvenous venography. Hirota's Grade 1 patients were assigned to G1 group and underwent treatment with 5% EOI. Grade ≥ 2 patients prior to August 2015 were G ≥ 2 group treated with 5% EOI, and those treated thereafter were GERTO group. The amount of EOI used per unit GV volume (EOI/GV ratio), the times to embolization and recurrence rate of GV were evaluated.

Results: The EOI/GV ratio was 0.66 ± 0.19 in G1, 1.5 ± 0.8 in G ≥ 2, and 0.58 ± 0.23 in GERTO (G ≥ 2 vs GERTO, p < 0.0001). The times to embolization were 26.5 ± 10.5 min for G1, 39.2 ± 26.8 for G ≥ 2, and 21.4 ± 9.4 for GERTO (G ≥ 2 vs GERTO, p = 0.005). The recurrence rate was not significantly different in any of the groups.

Conclusion: GERTO was performed in lower amount of sclerosants and in less time compared to conventional B-RTO in Hirota's grade ≥2.

Advances in knowledge: Feasibility of low-dose gelatin sponge particles and 5% EOI mixture as sclerosants for GV.

Figure 1.

Volumetry of gastric varices. Synapse Vincent was used for volumetric analysis. Areas in green represent traces of the gastric varices. MDCT scans are (a) axial, (b) sagittal, (c) coronal, and (d) a three-dimensional representation of the traces. The variceal volume of this patient is 26.9 ml. MDCT, multidetector row computed tomography.

Figure 2.

CECT, DSA and fluoroscopic images of Hirota’s Grade 4 case (a) Pre-procedural CECT coronal MIP image. The arrow indicates the areas identified as varices. (b) Green traces of varices analyzed with Synapse Vincent volumetry. The variceal volume of this patient is 12.9 ml. (c) This patient was classified as Hirota’s Grade 4 because variceal extraction was not possible despite the presence of many narrow draining veins in B-RTV from the GR shunt. (d) This unenhanced X-ray taken after the injection of 9 ml of 5% EOI with gelatin sponge particles shows satisfactory retention of the sclerosant in the varices (arrow head). B-RTV, balloon occluded retrograde transvenous venography; CECT, contrast-enhanced CT; DSA, digital subtraction angiography; EOI, ethanolamine oleateiopamidol; GR, gastrorenal; MIP, maximum intensity projection.

Figure 3.

Expected recurrence rate of GV after B-RTO by Kaplan–Meier method (a) 6 month, 1-, and 2 year overall recurrence rates of gastric varices were 2.0, 2.0, and 2.0%. (b) 6 month, 1-, and 2 year recurrence rates of gastric varices were 0, 0, and 0% in G1 group, 7.7, 7.7, and 7.7% in G ≥ 2 group with EO, 0, 0, and 0% in GERTO group. Significant difference was not found in any of the patient groups. B-RTO, balloon-occluded retrograde transvenous obliteration; GERTO, retrograde transvenous obliteration; GV, gastric varices.

Figure 4.

Schema about injection of sclerosant from gastrorenal shunt under balloon occlusion in Hirota’s high grade case (a) 5% EOI is washed out from fine collateral veins in conventional B-RTO and sclerosant loss arises. As a result varices is difficult to be visualized. Further stepwise injection of EO to embolize narrow draining veins takes time. (b) In 5% EOI containing GS particles (orange square grains), GS particles produce downgrading to embolize collateral veins. So much less amount of sclerosant is required. Good stagnation of EO is obtained and makes robust damage of vascular endothelium. Stepwise injection is unneeded, so embolization takes less time. B-RTO, balloon-occluded retrograde transvenous obliteration; EOI, ethanolamine oleateiopamidol; GS, gelatin sponge.