Coil-assisted retrograde transvenous obliteration for the treatment of duodenal varix

Abstract

Duodenal variceal bleeding is a rare complication of portal hypertension; although it only occurs in 0.4% of cases, it is often catastrophic because of the difficulties in diagnosis and treatment (1). Endoscopic therapy is usually the initial treatment option for bleeding duodenal varices, but it is not always feasible or successful (2). In such circumstances, endovascular treatment could be considered as an alternative option for duodenal variceal bleeding (2). Several studies reported successful results with transjugular intrahepatic portosystemic shunts (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), and percutaneous transhepatic obliteration (PTO) in treatment of duodenal varices (2-4). To the best of our knowledge, only one case of coil-assisted retrograde transvenous obliteration (CARTO), which is a modified version of BRTO using coils and gelfoam, has been reported for duodenal varix treatment without documentation of collateral pathway (5). Herein we report a case of duodenal varices originating from the inferior pancreaticoduodenal vein and draining into the right ovarian vein that was successfully embolized with coils and gelfoam using double microcatheters. TechniqueA 79-year-old female with a history of right hepatic lobectomy for intrahepatic cholangiocarcinoma presented with hematochezia. An emergency endoscopy showed tortuous blue varices with a cherry red spot in the third portion of the duodenum, suggesting a recent bleeding episode. The varices were not amenable to band ligation or endoscopic injection sclerotherapy due to their location and extent. Contrast-enhanced computed tomography (CT) revealed duodenal varices with markedly dilated veins at the third portion of the duodenum (Fig. 1a). The inferior pancreaticoduodenal vein (one of tributary of superior mesenteric vein) was the feeder of the duodenal varices, and the right ovarian vein was detected as an efferent vein (Fig. 1b).After obtaining informed consent, we initially planned retrograde venous approach via right ovarian vein to perform BRTO. Procedure was performed in the angiography suite under intravenous sedation and local anesthesia. After obtaining right internal jugular access with micropuncture access set (Cook Medical), 9 F Flexor RTPS guiding sheath (Cook Medical) was advanced to the inferior vena cava. After selection of the right ovarian vein with 5 F Torcon NB (C2) catheter (Cook Medical), we tried to advance occlusion balloon catheter into draining vein deep enough to avoid injecting sclerosing agent into a non-target vessel. However, 5 F catheter and 0.035-inch guidewire (Radiofocus, Terumo) could not be advanced into the distal efferent vein because of severe vascular tortuosity. Therefore, we ABSTRACTDuodenal variceal bleeding is a rare but potentially life-threatening complication of portal hypertension. Endoscopic therapy is usually the initial treatment option for bleeding duodenal varices, but it is not always feasible or successful. We present a technique of coil-assisted retrograde transven...

Severe Stenosis of Mitral Bioprosthetic Valve Thrombosis in a Patient with HCV-Related Cirrhosis and Duodenal Variceal Bleeding: The Deadly Triad

“…A balloon-assisted retrograde transvenous obliteration (BRTO), or plug-assisted retrograde transvenous obliteration (PARTO), or coil-assisted retrograde transvenous obliteration (CARTO) could be performed (if specific expertise is present) as an alternative to TIPS depending upon the patient’s clinical status [ 18 , 19 , 20 , 21 ].…”

Coil-Assisted Retrograde Transvenous Obliteration (CARTO) for the Treatment of Gastric Variceal Bleeding in a Patient with a Gastrorenal Shunt: A Case Report

“…When endoscopic banding is ineffective and TIPS placement is contra-indicated due to risk of post-TIPS encephalopathy, coil-assisted retrograde transvenous obliteration (CARTO), which has shown great success in some studies, can be an effective treatment. 5,8,9,10 This case demonstrates successful use of CARTO to treat GVB in a patient with a gastrorenal shunt (GRS) who presented with pHTN.…”

Successful Treatment of Duodenal Variceal Bleeding with Coil-Assisted Retrograde Transvenous Obliteration: A Case Report

“…이러한 경우 Lee 등( 6 )은 역행성 경정맥 폐색술 시 코일의 사용(coil assisted retrograde transvenous obliteration; 이하 CARTO)을 대안으로 제시하였으며 위정맥류 출혈 환자에 서 효과를 입증하였다. 아직까지 CARTO를 시행하여 십이지장 정맥류 출혈을 지혈한 경우는 매우 드물게 보고되어 있으며( 7 ), 이에 저자들은 TIPS 및 BRTO를 시행할 수 없는 환자에서 CARTO를 통하여 성공적으로 십이지장 정맥류를 치료한 1예를 보고하고자 한다.…”

“…크기가 크고 혈류가 빠른 션트를 막기 위해 새롭게 CARTO가 제시되었으며 30 mm 크기의 션트를 가진 정맥류 출혈의 경우에도 효과적으로 지혈할 수 있다( 6 9 ). 또한 션트의 크기가 작고 구불구불한 경우에도 효과적으로 지혈을 한 경우가 보고된 바 있다( 7 ). 본 증례에서도 MELD 점수가 22점으로 측정되어 TIPS를 시행할 경우 합병증이 발생할 확률이 높을 것으로 예상되었고, 경화제로 인한 합병증과 시술 시간을 줄이기 위해 BRTO 대신 PARTO를 시행하려고 하였으며, 혈관이 작고 구불구불하여 7F 도관이 들어갈 수 없었다.…”