Usefulness of intra-procedural cone-beam computed tomography in modified balloon-occluded retrograde transvenous obliteration of gastric varices

Abstract

AIM:To evaluate whether intra-procedural conebeam computed tomography (CBCT) performed during modified balloon-occluded retrograde transvenous obliteration (mBRTO) can accurately determine technical success of complete variceal obliteration. METHODS:From June 2012 to December 2014, 15 patients who received CBCT during mBRTO for treatment of portal hypertensive gastric variceal bleeding were retrospectively evaluated. Three-dimensional (3D) CBCT images were performed and evaluated prior to the end of the procedure, and these were further analyzed and compared to the pre-procedure contrast-enhanced computed tomography to determine the technical success of mBRTO including: Complete occlusion/obliteration of: (1) gastrorenal shunt (GRS); (2) gastric varices; and (3) Core tip: This is a retrospective study to evaluate the feasibility, usefulness and efficacy of cone-beam computed tomography (CBCT) in modified balloonoccluded retrograde transvenous obliteration (mBRTO) procedures including coil-assisted retrograde transvenous obliteration and plug-assisted retrograde transvenous oblitearation. With an intra-procedural three-dimensional CBCT, the technical success of mBRTO was determined prior to the completion of the procedure in 100% of cases. With CBCT, a complete anatomy of gastric varices including gastrorenal shunt, gastric varices, collaterals, afferent and efferent vessels were identified easily. The CBCT may improve the technical and clinical success of mBRTO procedures and potentially reduce additional procedure time and cost.Lee EW, So N, Chapman R, McWilliams JP, Loh CT, Busuttil RW, Kee ST. Usefulness of intra-procedural cone-beam computed tomography in modified balloon-occluded retrograde transvenous obliteration of gastric varices.

Evolution of Retrograde Transvenous Obliteration Techniques

“…For BRTO, PARTO, and CARTO, clinical success ranges from 91 to 100%, 90.6 to 100%, and 100%, respectively. 2,4,24,[27][28][29]31,38,39 Kim et al detected similar clinical success rates (defined as lack of variceal enhancement on postprocedural CT and cessation of bleeding on endoscopy) between BRTO with EO (93.9%) or STS (92%) and PARTO with Gelfoam (100%). 31 Acutely bleeding gastric varices carry a high mortality with limited treatment options.…”

“…11 The use of cone beam CT can aid in evaluating this embolization end point. 24 The balloon remains inflated for 4 to 24 hours while the patient is immobilized in the ICU, followed by return to the angiography suite for balloon deflation. 11,20,23 An accelerated BRTO technique can be used in small gastrorenal shunts (<15 mm), in which traditional BRTO is followed by terminal Gelfoam plug or coil deployment, through the occlusion balloon, eliminating the need for prolonged balloon inflation.…”

Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Varices: The Role of Intra-Procedural Cone-Beam Computed Tomography

“…The mean fluoroscopic time was 27 minutes and ranged from 13 minutes to 47 minutes. The reported technical success rates of BRTO and modified BRTO ranged from 79.6% to 100% ( 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 24 26 ). We believe this technical success can be further improved using an intra-procedural CBCT.…”

“…We believe this technical success can be further improved using an intra-procedural CBCT. The utility of the CBCT in conventional and modified BRTO has been described in several studies ( 20 21 22 23 24 ). In these studies, investigators concluded that CBCT can provide enough information to either terminate or continue the procedure.…”

“…In recent years, the availability of intra-procedural cone-beam computed tomography (CBCT) has revolutionized problem solving during a variety of procedures including transcatheter arterial chemoembolization, BRTO, modified BRTO, and others ( 20 21 22 23 24 ). CBCT generates substantially more information than fluoroscopy because the image delineates the exact location of the embolized veins and varices and its relationship to surrounding soft-tissue structures.…”