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Transcatheter Obliteration of Gastric Varices

Part 1. Anatomic Classification¹

¹ From the Department of Radiology, Oita Medical University, 1-1 Hasama, Oita 879-55, Japan. Presented as an education exhibit at the 2001 RSNA scientific assembly. Received March 4, 2002; revision requested May 29 and received August 7; accepted September 26. Address correspondence to H.K. (e-mail: hkiyosue@oita-med.ac.jp).

View larger version (76K): [in a new window]   Figure 1a.  (a) Drawing illustrates the afferent gastric veins, any of which has the potential to form a gastric varix. GEV = gastroepiploic vein, LGV = left gastric vein, PGV = posterior gastric vein, SGV = short gastric vein. (b) Splenic venogram shows cardiac gastric varices from the left gastric vein. Note the drainage into the esophageal veins. (c) Splenic venogram demonstrates fundal gastric varices from the posterior gastric vein. (d) Superior mesenteric venogram shows large gastric varices that developed after left gastric vein-inferior vena cava shunt placement. The varices are supplied by the gastroepiploic vein.

View larger version (144K): [in a new window]   Figure 1b.  (a) Drawing illustrates the afferent gastric veins, any of which has the potential to form a gastric varix. GEV = gastroepiploic vein, LGV = left gastric vein, PGV = posterior gastric vein, SGV = short gastric vein. (b) Splenic venogram shows cardiac gastric varices from the left gastric vein. Note the drainage into the esophageal veins. (c) Splenic venogram demonstrates fundal gastric varices from the posterior gastric vein. (d) Superior mesenteric venogram shows large gastric varices that developed after left gastric vein-inferior vena cava shunt placement. The varices are supplied by the gastroepiploic vein.

View larger version (108K): [in a new window]   Figure 1c.  (a) Drawing illustrates the afferent gastric veins, any of which has the potential to form a gastric varix. GEV = gastroepiploic vein, LGV = left gastric vein, PGV = posterior gastric vein, SGV = short gastric vein. (b) Splenic venogram shows cardiac gastric varices from the left gastric vein. Note the drainage into the esophageal veins. (c) Splenic venogram demonstrates fundal gastric varices from the posterior gastric vein. (d) Superior mesenteric venogram shows large gastric varices that developed after left gastric vein-inferior vena cava shunt placement. The varices are supplied by the gastroepiploic vein.

View larger version (134K): [in a new window]   Figure 1d.  (a) Drawing illustrates the afferent gastric veins, any of which has the potential to form a gastric varix. GEV = gastroepiploic vein, LGV = left gastric vein, PGV = posterior gastric vein, SGV = short gastric vein. (b) Splenic venogram shows cardiac gastric varices from the left gastric vein. Note the drainage into the esophageal veins. (c) Splenic venogram demonstrates fundal gastric varices from the posterior gastric vein. (d) Superior mesenteric venogram shows large gastric varices that developed after left gastric vein-inferior vena cava shunt placement. The varices are supplied by the gastroepiploic vein.

View larger version (75K): [in a new window]   Figure 2a.  (a) Drawing illustrates potential draining veins. AZV = azygos vein, ICV = intercostal vein, IPV = inferior phrenic vein, LRV = left renal vein, PEV = paraesophageal vein, PPhV = pericardiophrenic vein, VPlx = vertebral venous plexus. (b) Magnetic resonance angiogram shows fundal gastric varices (GV) draining through the gastrorenal (arrowheads) and gastrocaval (single arrows) shunts into the inferior vena cava (double arrows). LGV = left gastric vein, RV = renal vein. (c) Balloon-occluded venogram shows that the inferior phrenic vein (gastrorenal shunt) communicates with the pericardiophrenic vein (PPhV), an intercostal vein (ICV), and small mediastinal veins. (d) Balloon-occluded venogram shows that the inferior phrenic vein (gastrorenal shunt) is contiguous with the paravertebral plexus (arrows) and azygos vein (AZV).

View larger version (128K): [in a new window]   Figure 2b.  (a) Drawing illustrates potential draining veins. AZV = azygos vein, ICV = intercostal vein, IPV = inferior phrenic vein, LRV = left renal vein, PEV = paraesophageal vein, PPhV = pericardiophrenic vein, VPlx = vertebral venous plexus. (b) Magnetic resonance angiogram shows fundal gastric varices (GV) draining through the gastrorenal (arrowheads) and gastrocaval (single arrows) shunts into the inferior vena cava (double arrows). LGV = left gastric vein, RV = renal vein. (c) Balloon-occluded venogram shows that the inferior phrenic vein (gastrorenal shunt) communicates with the pericardiophrenic vein (PPhV), an intercostal vein (ICV), and small mediastinal veins. (d) Balloon-occluded venogram shows that the inferior phrenic vein (gastrorenal shunt) is contiguous with the paravertebral plexus (arrows) and azygos vein (AZV).

View larger version (185K): [in a new window]   Figure 2c.  (a) Drawing illustrates potential draining veins. AZV = azygos vein, ICV = intercostal vein, IPV = inferior phrenic vein, LRV = left renal vein, PEV = paraesophageal vein, PPhV = pericardiophrenic vein, VPlx = vertebral venous plexus. (b) Magnetic resonance angiogram shows fundal gastric varices (GV) draining through the gastrorenal (arrowheads) and gastrocaval (single arrows) shunts into the inferior vena cava (double arrows). LGV = left gastric vein, RV = renal vein. (c) Balloon-occluded venogram shows that the inferior phrenic vein (gastrorenal shunt) communicates with the pericardiophrenic vein (PPhV), an intercostal vein (ICV), and small mediastinal veins. (d) Balloon-occluded venogram shows that the inferior phrenic vein (gastrorenal shunt) is contiguous with the paravertebral plexus (arrows) and azygos vein (AZV).

View larger version (186K): [in a new window]   Figure 2d.  (a) Drawing illustrates potential draining veins. AZV = azygos vein, ICV = intercostal vein, IPV = inferior phrenic vein, LRV = left renal vein, PEV = paraesophageal vein, PPhV = pericardiophrenic vein, VPlx = vertebral venous plexus. (b) Magnetic resonance angiogram shows fundal gastric varices (GV) draining through the gastrorenal (arrowheads) and gastrocaval (single arrows) shunts into the inferior vena cava (double arrows). LGV = left gastric vein, RV = renal vein. (c) Balloon-occluded venogram shows that the inferior phrenic vein (gastrorenal shunt) communicates with the pericardiophrenic vein (PPhV), an intercostal vein (ICV), and small mediastinal veins. (d) Balloon-occluded venogram shows that the inferior phrenic vein (gastrorenal shunt) is contiguous with the paravertebral plexus (arrows) and azygos vein (AZV).

View larger version (47K): [in a new window]   Figure 3.  Drawings illustrate the standard BRTO method for gastric varices that drain through the gastrorenal shunt. Right femoral access is used to insert a balloon catheter into the outlet of the gastrorenal (GR) or gastrocaval shunt. Balloon-occluded venography is performed, and 5% EOI is injected via the balloon catheter until the gastric varices (GV) are completely filled with EOI. The EOI is then allowed to stagnate for 30-45 minutes. AdV = adrenal vein.

View larger version (37K): [in a new window]   Figure 4.  Drawings illustrate the classification of gastric varices according to the patterns of their afferent gastric veins. Type 1 gastric varices are supplied by a single afferent gastric vein, type 2 are supplied by multiple afferent gastric veins, and type 3 are supplied by single or multiple gastric veins with coexistent gastric veins that are directly contiguous with the shunt (arrow) but do not contribute to the varices.

View larger version (42K): [in a new window]   Figure 5a.  (a) Drawing illustrates type 1 gastric varices (GV), which are supplied by a single afferent gastric vein. (b) Drawing illustrates the standard BRTO method for type 1 gastric varices, whereby EOI injected via a balloon catheter results in good filling of the varices.

View larger version (41K): [in a new window]   Figure 5b.  (a) Drawing illustrates type 1 gastric varices (GV), which are supplied by a single afferent gastric vein. (b) Drawing illustrates the standard BRTO method for type 1 gastric varices, whereby EOI injected via a balloon catheter results in good filling of the varices.

View larger version (51K): [in a new window]   Figure 6a.  (a) Drawing illustrates type 2 gastric varices from gastric veins with different pressures. (b) Drawing illustrates the standard BRTO method in this situation. EOI injected via a balloon catheter into the draining vein tends to flow into a low-pressure gastric vein (red arrows), thereby increasing the risk of inflow into the portal vein (PV) (black arrow) or of insufficient obliteration of the varices.

View larger version (45K): [in a new window]   Figure 6b.  (a) Drawing illustrates type 2 gastric varices from gastric veins with different pressures. (b) Drawing illustrates the standard BRTO method in this situation. EOI injected via a balloon catheter into the draining vein tends to flow into a low-pressure gastric vein (red arrows), thereby increasing the risk of inflow into the portal vein (PV) (black arrow) or of insufficient obliteration of the varices.

View larger version (174K): [in a new window]   Figure 7a.  Fluoroscopic images obtained immediately (a) and 40 minutes (b) after injection of EOI during balloon occlusion show that the EOI has entered an afferent vein—in this case, the posterior gastric vein (arrows in b).

View larger version (179K): [in a new window]   Figure 7b.  Fluoroscopic images obtained immediately (a) and 40 minutes (b) after injection of EOI during balloon occlusion show that the EOI has entered an afferent vein—in this case, the posterior gastric vein (arrows in b).

View larger version (155K): [in a new window]   Figure 8a.  (a) Contrast material-enhanced computed tomographic (CT) scan shows large varices with multiple afferent veins surrounding the stomach. (b) Contrast-enhanced CT scan obtained 1 month after BRTO shows marked reduction of the varices but incomplete obliteration. These residual varices were completely obliterated with repeat BRTO.

View larger version (149K): [in a new window]   Figure 8b.  (a) Contrast material-enhanced computed tomographic (CT) scan shows large varices with multiple afferent veins surrounding the stomach. (b) Contrast-enhanced CT scan obtained 1 month after BRTO shows marked reduction of the varices but incomplete obliteration. These residual varices were completely obliterated with repeat BRTO.

View larger version (47K): [in a new window]   Figure 9a.  (a) Drawing illustrates type 3 gastric varices that are supplied by multiple gastric veins with coexistent gastric veins that are directly contiguous with the shunt but do not contribute to the varices. Arrow indicates direct shunting vein. (b) Drawing illustrates the standard BRTO method for type 3 gastric varices. EOI injected via a balloon catheter tends to flow into the direct shunting vein (arrows).

View larger version (43K): [in a new window]   Figure 9b.  (a) Drawing illustrates type 3 gastric varices that are supplied by multiple gastric veins with coexistent gastric veins that are directly contiguous with the shunt but do not contribute to the varices. Arrow indicates direct shunting vein. (b) Drawing illustrates the standard BRTO method for type 3 gastric varices. EOI injected via a balloon catheter tends to flow into the direct shunting vein (arrows).

View larger version (71K): [in a new window]   Figure 10.  Drawings illustrate the classification of gastric varices according to the pattern of their draining veins. Type A gastric varices are contiguous with a single shunt alone, type B are contiguous with a single shunt and collateral veins, type C are contiguous with both the gastrorenal and gastrocaval shunts, and type D are not contiguous with a catheterizable shunt.

View larger version (36K): [in a new window]   Figure 11.  Drawings illustrate the three subtypes of type B gastric varices: B-1 is characterized by small and low-flow collateral draining veins; B-2, by medium-sized, low-flow collateral draining veins; and B-3, by high-flow collateral draining veins. Arrows indicate direction of flow through the collateral veins.

View larger version (165K): [in a new window]   Figure 12.  Balloon-occluded venogram shows type B-1 gastric varices with the gastrorenal shunt, which is contiguous with small collateral veins (arrows).

View larger version (161K): [in a new window]   Figure 13a.  (a) Balloon-occluded venogram of the gastrocaval shunt shows multiple collateral veins, a finding that is typical of type B-3 gastric varices, although no gastric varices are seen. A pacemaker catheter (arrows) is positioned in the right ventricle. Arrowheads indicate the balloon catheter. (b) Venogram obtained after embolization of these collateral veins with coils (arrows) reveals that EOI injected via a microcatheter navigated close to the gastric varices through the balloon catheter has filled the varices well.

View larger version (187K): [in a new window]   Figure 13b.  (a) Balloon-occluded venogram of the gastrocaval shunt shows multiple collateral veins, a finding that is typical of type B-3 gastric varices, although no gastric varices are seen. A pacemaker catheter (arrows) is positioned in the right ventricle. Arrowheads indicate the balloon catheter. (b) Venogram obtained after embolization of these collateral veins with coils (arrows) reveals that EOI injected via a microcatheter navigated close to the gastric varices through the balloon catheter has filled the varices well.

View larger version (117K): [in a new window]   Figure 14.  On a balloon-occluded venogram of the gastrorenal shunt, the inferior phrenic vein is contiguous with the inferior vena cava. Arrows indicate the gastrocaval shunt. Type C gastric varices are contiguous with both shunts, as in this case.

View larger version (149K): [in a new window]   Figure 15.  Portogram obtained with transileocolic catheterization shows type D gastric varices with drainage into the paraesophageal vein alone (arrows).