Gastric varices bleed at lower portosystemic pressure gradients than esophageal varices

Morrison, Joseph D.; Mendoza-Elias, Nasya; Lipnik, Andrew J.; Lokken, R. Peter; Bui, Jenny; Ray, Charles E.; Gaba, Ron C.

doi:10.1016/j.jvir.2016.12.1007

Cited by 7 publications

(8 citation statements)

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“…( 33 ) Similarly, a recent study revealed that pre‐TIPS PSG was highest among EVs (23 mm Hg), with lower PSGs identified for GOV (20 mm Hg) and IGV (16 mm Hg). ( 34 ) Whether adding β‐blockers to repeated cyanoacrylate injection can reduce rebleeding from GVs remains open for study. ( 18,35 ) Nonetheless, we could not dispute that β‐blockers may reduce the risk of worsening of EVs, ascites, or other portal‐hypertension–related complications.…”

Section: Discussionmentioning

confidence: 99%

Endoscopic Cyanoacrylate Injection Versus Balloon‐Occluded Retrograde Transvenous Obliteration for Prevention of Gastric Variceal Bleeding: A Randomized Controlled Trial

Luo

Xiang

et al. 2021

Hepatology

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Background and Aims The optimal treatment for gastric varices (GVs) is a topic that remains open for study. This study compared the efficacy and safety of endoscopic cyanoacrylate injection and balloon‐occluded retrograde transvenous obliteration (BRTO) to prevent rebleeding in patients with cirrhosis and GVs after primary hemostasis. Approach and Results Patients with cirrhosis and history of bleeding from gastroesophageal varices type 2 or isolated gastric varices type 1 were randomized to cyanoacrylate injection (n = 32) or BRTO treatment (n = 32). Primary outcomes were gastric variceal rebleeding or all‐cause rebleeding. Patient characteristics were well balanced between two groups. Mean follow‐up time was 27.1 ± 12.0 months in a cyanoacrylate injection group and 27.6 ± 14.3 months in a BRTO group. Probability of gastric variceal rebleeding was higher in the cyanoacrylate injection group than in the BRTO group (P = 0.024). Probability of remaining free of all‐cause rebleeding at 1 and 2 years for cyanoacrylate injection versus BRTO was 77% versus 96.3% and 65.2% versus 92.6% (P = 0.004). Survival rates, frequency of complications, and worsening of esophageal varices were similar in both groups. BRTO resulted in fewer hospitalizations, inpatient stays, and lower medical costs. Conclusions BRTO is more effective than cyanoacrylate injection in preventing rebleeding from GVs, with similar frequencies of complications and mortalities.

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Section: Discussionmentioning

confidence: 99%

Endoscopic Cyanoacrylate Injection Versus Balloon‐Occluded Retrograde Transvenous Obliteration for Prevention of Gastric Variceal Bleeding: A Randomized Controlled Trial

Luo

Xiang

et al. 2021

Hepatology

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“…e GRS allow for partial decompression of the portal venous system while carrying large amounts of venous blood within it. Consequently, GV exist as "low pressure, high volume" channels and can bleed at lower pressures than esophageal varices (15-20 mm Hg vs 21-23 mm Hg, respectively) [66,67]. More importantly, between 10% and 16% of gastric varices can bleed at portosystemic gradient (PSG) <12 mm Hg [64].…”

Section: Gastric Variceal Bleeding Gastric Varices (Gv) Arementioning

confidence: 99%

“…It allows clear delineation of the complex GV inflow anatomy, GV inflow and outflow control, and avoidance of the need for prolonged balloon inflation, as in traditional B-RTO. Performing BRTO followed by TIPS improves technical success in cases where the portal vein is severely attenuated due to the siphoning of blood away from the liver by the large GRS [65,66]. ese diminutive portal veins can be difficult to target during TIPS and may require additional techniques for achieving the desired results.…”

Section: Gastric Variceal Bleeding Gastric Varices (Gv) Arementioning

confidence: 99%

Friend or Foe? Spontaneous Portosystemic Shunts in Cirrhosis—Current Understanding and Future Prospects

Rajesh

Philips

Ahamed

et al. 2021

Canadian Journal of Gastroenterology and Hepatology

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Portal hypertension (PHT) in cirrhosis results from increased resistance to splanchnic blood flow secondary to parenchymal and vascular changes within the liver. In an attempt to counteract the increased portal pressure, two mechanisms simultaneously occur: splanchnic vasodilatation and formation of spontaneous portosystemic shunts (SPSS). Long considered to be a compensatory mechanism to decompress the portal venous system, it is now well established that SPSS are not only inefficient in decreasing the portal pressure but also contribute to reduced hepatocyte perfusion and increased splanchnic blood flow and resistance, associated with worsening PHT. Recent studies have described a high prevalence of SPSS in cirrhosis patients, increasing with liver dysfunction, and observed an association between the presence of SPSS and worse clinical outcomes. In cirrhosis patients with preserved liver functions, the presence of SPSS independently increases the risk of hepatic encephalopathy, variceal bleeding, and ascites, and reduces transplant-free survival. Moreover, the presence of SPSS in patients undergoing transjugular intrahepatic portosystemic shunting and liver transplant has been shown to variably affect the postprocedural outcome. This article provides an overview of the current understanding of the role of SPSS in the natural history of liver cirrhosis and their status as a therapeutic target and an imaging biomarker to identify patients at higher risk of developing complications of PHT.

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“…A PSG of less than 12 mm Hg after TIPS creation has been accepted as the threshold to reduce the risk of esophageal variceal rebleeding (36). However, studies have shown that GVs may form and bleed at portosystemic gradients below 12 mm Hg, suggesting that TIPS alone may be an insufficient treatment for the prevention of GV bleeding (6,37,38). This may be related to a preferential flow through a gastrorenal or other portosystemic shunt that supplies the varices, allowing the GVs to maintain patency even after TIPS creation (38).…”

Section: Discussionmentioning

confidence: 99%

“…Therefore, it has been hypothesized that TIPS with or without afferent vessel embolization is a suboptimal therapy for the management of GVs (5). Furthermore, the creation of an additional portosystemic shunt can worsen hepatic encephalopathy (HE) and liver failure (6).…”

mentioning

confidence: 99%

Combined Transjugular Intrahepatic Portosystemic Shunt Plus Variceal Obliteration versus Transjugular Intrahepatic Portosystemic Shunt Alone for the Management of Gastric Varices: Comparative Single-Center Clinical Outcomes

Shah

Ren

Simpson

et al. 2021

Journal of Vascular and Interventional Radiology

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Purpose: To compare the safety and clinical outcomes of combined transjugular intrahepatic portosystemic shunt (TIPS) plus variceal obliteration to those of TIPS alone for the treatment of gastric varices (GVs). Materials and Methods:A single-center, retrospective study of 40 patients with bleeding or high-risk GVs between 2008 and 2019 was performed. The patients were treated with combined therapy (n ¼ 18) or TIPS alone (n ¼ 22). There were no significant differences in age, sex, model for end-stage liver disease score, or GV type between the groups. The primary outcomes were the rates of GV eradication and rebleeding. The secondary outcomes included portal hypertensive complications and hepatic encephalopathy. Results:The mean follow-up period was 15.4 months for the combined therapy group and 22.9 months for the TIPS group (P ¼ .32). After combined therapy, there was a higher rate of GV eradication (92% vs 47%, P ¼ .01) and a trend toward a lower rate of GV rebleeding (0% vs 23%, P ¼ .056). The estimated rebleeding rates were 0% versus 5% at 3 months, 0% versus 11% at 6 months, 0% versus 18% at 1 year, and 0% versus 38% at 2 years after combined therapy and TIPS, respectively (P ¼ .077). There was no difference in ascites (13% vs 11%, P ¼ .63), hepatic encephalopathy (47% vs 55%, P ¼ .44), or esophageal variceal bleeding (0% vs 0%, P > .999) after the procedure between the groups. Conclusions:The GV eradication rate is significantly higher after combined therapy, with no associated increase in portal hypertensive complications. This translates to a clinically meaningful trend toward a reduction in GV rebleeding. The value of a combined treatment strategy should be prospectively studied in a larger cohort to determine the optimal management of GVs. ABBREVIATIONSBATO ¼ balloon-occluded antegrade transvenous obliteration, BRTO ¼ balloon-occluded retrograde transvenous obliteration, EV ¼ esophageal varice, GV ¼ gastric varice, HE ¼ hepatic encephalopathy, PSG ¼ portosystemic pressure gradient, TIPS ¼ transjugular intrahepatic portosystemic shunt From the Department of Radiology (K.

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Gastric varices bleed at lower portosystemic pressure gradients than esophageal varices

Cited by 7 publications

References 0 publications

Endoscopic Cyanoacrylate Injection Versus Balloon‐Occluded Retrograde Transvenous Obliteration for Prevention of Gastric Variceal Bleeding: A Randomized Controlled Trial

Endoscopic Cyanoacrylate Injection Versus Balloon‐Occluded Retrograde Transvenous Obliteration for Prevention of Gastric Variceal Bleeding: A Randomized Controlled Trial

Friend or Foe? Spontaneous Portosystemic Shunts in Cirrhosis—Current Understanding and Future Prospects

Combined Transjugular Intrahepatic Portosystemic Shunt Plus Variceal Obliteration versus Transjugular Intrahepatic Portosystemic Shunt Alone for the Management of Gastric Varices: Comparative Single-Center Clinical Outcomes

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