Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices with Gastrorenal Shunt: Long-Term Follow-Up in 78 Patients

Ninoi, Teruhisa; Nishida, Norifumi; Kaminou, Toshio; Sakai, Yukimasa; Kitayama, Toyoki; Hamuro, Masao; Yamada, Ryusaku; Nakamura, Kenji; Arakawa, Tetsuo; Inoue, Yuichi

doi:10.2214/ajr.184.4.01841340

Cited by 227 publications

(308 citation statements)

References 30 publications

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“…GV have a lower bleeding rate than esophageal varices, 3,4 but once ruptured, GV tend to bleed profusely as they have greater blood flow compared with esophageal varices. The cumulative risk for bleeding from gastric fundal varices is 16%, 36%, and 44% at 1, 3, and 5 years, respectively.…”

Section: Discussionmentioning

confidence: 99%

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Balloon-Occluded Retrograde Transvenous Obliteration (BRTO): A Novel Method of Control of Bleeding from Post-Glue Ulcer over Gastric Varices. Report of Two Cases and Review of Literature

Prajapati

Ranjan

Gupta

et al. 2016

Journal of Clinical and Experimental Hepatology

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Bleeding gastric varices (GV) are managed by cyanoacrylate glue injection with transjugular intrahepatic portosystemic shunt (TIPSS) as modality for treatment failure. Ulcer can form at the site of glue injection over GV and it can cause bleeding. Treatment approach for such bleed is not well described. Balloon-occluded retrograde transvenous obliteration (BRTO), TIPSS, and devascularization remain the treatment options in this scenario. BRTO is an endovascular procedure where a balloon catheter is inserted into a draining vein of GV, and the sclerosant can be injected into the varices through the catheter during balloon occlusion. BRTO has the benefit of increasing portal hepatic blood flow and can also be useful in patients who may not tolerate TIPSS. We report two cases where BRTO was done for control of bleeding from ulcers formed over previously injected GV. 1 Treatment modalities for bleeding GV are cyanoacrylate glue injection and transjugular intrahepatic portosystemic shunt (TIPSS). Balloon-occluded retrograde transvenous obliteration (BRTO) has been used as a primary treatment for acute bleeding GV. Ulcer can form at the site of glue injection over GV and it can cause bleeding. The exact prevalence of such bleeding and treatment options is not well established. BRTO has been proposed as a possible treatment option in such situation. TIPSS and devascularization remain other therapeutic options in this scenario.BRTO is an endovascular procedure where a balloon catheter is inserted into a draining vein of GV, and the sclerosant can be injected into the varices through the catheter during balloon occlusion. BRTO has been used for active GV hemorrhage, which was transiently treated by either endoscopic sclerotherapy or Sengstaken-Blakemore tubes, recent bleeding, and preventive GV obliteration in patients who had never bled.2 Reports of refractory variceal bleed treated with BRTO are rare. 2 We report two cases where BRTO was done for control of bleeding from ulcers formed over previously injected GV. CASE 1A 44-year-old male with Child-Pugh class B cirrhosis presented with UGI bleed. He had past history of glue injection for gastric variceal bleeding one month ago. At admission, the patient had tachycardia (pulse 116/min) and hypotension (BP 86/50 mmHg) pallor. He was resuscitated with crystalloid infusion and blood transfusion and terlipressin infusion was started. After hemodynamic stabilization, he underwent emergent UGI endoscopy which showed small esophageal varices with no stigmata of bleed with large deep white based ulcer over GV at the site of previous glue injection (Figure 1). There was no unsolidified area in the varices for further glue injection. There was ongoing bleeding as indicated by persistent tachycardia and requirement of blood transfusion. Options of TIPSS or BRTO were considered and CT angiography abdomen was done to assess patency of portal vein, hepatic veins, splenic vein, and presence of gastrorenal shunt. CT showed patent portal and splenic veins and a large gastrorenal shunt d...

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Section: Discussionmentioning

confidence: 99%

“…16 Worsening of esophageal varices was seen in 27% of patients at 1 year and 58% at 3 years. 4 Therefore, esophageal varices should be followed every 6 months after BRTO. Worsening of ascites and hydrothorax has been seen post-BRTO.…”

mentioning

confidence: 99%

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO): A Novel Method of Control of Bleeding from Post-Glue Ulcer over Gastric Varices. Report of Two Cases and Review of Literature

Prajapati

Ranjan

Gupta

et al. 2016

Journal of Clinical and Experimental Hepatology

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“…9,10,19,22,24 The second strategy was to use an adjunct sclerosant such as 50% glucose solution or absolute alcohol to keep the 5% ethanolamine oleate dose/volume to less than 40 mL. 4,8,17,19 Subsequently, American interventionalists introduced a new sclerosant: 3% Sotradecol, to perform the . This has caused some Japanese institutions to reconsider use of their ethanolamine oleate concoctions by mixing them with air to create a frothy consistency to the sclerosant with its desired sclerosant dose reduction (relative to volume) and the frothy percolative effect of the sclerosant.…”

Section: Conception and Evolution Of The Brto Proceduresmentioning

confidence: 99%

The History and Evolution of Balloon-occluded Retrograde Transvenous Obliteration (BRTO): From the United States to Japan and Back

Saad

2011

Semin intervent Radiol

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The concept of obliterating varices that complicate portal hypertension dates back to the 1970s, but its minimally invasive clinical utilization was probably lost with the advent of the transjugular intrahepatic portosystemic shunt (TIPS). The conception of retrograde obliteration of a gastrorenal shunt via the left renal vein was reported by Olson et al from the University of Indiana. However, the definition, development, technical perfection, and clinical implementation of the balloon-occluded retrograde transvenous obliteration (BRTO) occurred in Japan (by Kanagawa et al and others). The BRTO-procedure is currently undergoing a renaissance in the United States particularly for patients who are not TIPS candidates.

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“…Although endoscopic variceal ligation therapy (EVL) has shown its benefit for esophageal varices, it cannot achieve a similar success in the management of gastric varices [6] . It was reported that balloon retrograde transvenous obliteration (B-RTO) is a useful treatment for gastric fundal varices, but it requires a gastrorenal shunt as the draining vein [7] . We report two cases of marked gastric varices with no gastrorenal shunt, who were successfully treated with endoscopic therapy with combined adhesives and sclerosants.…”

Section: Introductionmentioning

confidence: 99%

Successful endoscopic sclerotherapy for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol

Shi¹,

Wu²,

Zhu³

et al. 2008

WJG

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Two patients with liver cirrhosis and portal hypertension related to hepatitis infection were admitted to Shanghai Ruijin Hospital due to recurrent melena and hematemesis. Isolated gastric varices were observed in the gastric fundus during the retroflexion of gastroscope. We carried out endoscopic sclerotherapy successfully for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol, which disappeared dramatically several months after two courses of sclerotherapy for each patient. No complication and clinical signs of gastrointestinal re-bleeding were observed during the 6-mo endoscopic follow-up. CT portal angiography (CTPA) has been widely used in the assessment of variceal treatment and improves the results of endoscopic injection therapy.

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Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices with Gastrorenal Shunt: Long-Term Follow-Up in 78 Patients

Cited by 227 publications

References 30 publications

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO): A Novel Method of Control of Bleeding from Post-Glue Ulcer over Gastric Varices. Report of Two Cases and Review of Literature

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO): A Novel Method of Control of Bleeding from Post-Glue Ulcer over Gastric Varices. Report of Two Cases and Review of Literature

The History and Evolution of Balloon-occluded Retrograde Transvenous Obliteration (BRTO): From the United States to Japan and Back

Successful endoscopic sclerotherapy for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol

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