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Transcatheter Obliteration of Gastric Varices

Part 2. Strategy and Techniques Based on Hemodynamic Features¹

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 (49K): [in a new window]   Figure 1a.  Drawings illustrate additional techniques for treatment of type 2 gastric varices. (a) Subselective injection of EOI via a microcatheter. The microcatheter is navigated through a balloon catheter into the nonopacified portion of the varices. EOI injected via the microcatheter will fill the entire variceal complex. (b) Coil embolization of afferent gastric veins, which prevents insufficient variceal filling and unexpected flow of EOI into the portal vein. The coil is placed in the gastric vein via a catheter that is introduced by means of portal venous access (PTO) or transileocolic venous access (TIO) at minilaparotomy.

View larger version (49K): [in a new window]   Figure 1b.  Drawings illustrate additional techniques for treatment of type 2 gastric varices. (a) Subselective injection of EOI via a microcatheter. The microcatheter is navigated through a balloon catheter into the nonopacified portion of the varices. EOI injected via the microcatheter will fill the entire variceal complex. (b) Coil embolization of afferent gastric veins, which prevents insufficient variceal filling and unexpected flow of EOI into the portal vein. The coil is placed in the gastric vein via a catheter that is introduced by means of portal venous access (PTO) or transileocolic venous access (TIO) at minilaparotomy.

View larger version (174K): [in a new window]   Figure 2a.  Successful treatment of type 2 gastric varices with a combination of BRTO and coil embolization of afferent veins by means of transileocolic venous access. (a) Contrast material-enhanced computed tomographic (CT) scan shows gastric varices at the fundus that are supplied by multiple afferent veins (arrowheads). (b) Fluoroscopic image obtained during BRTO performed with injection of EOI after transileocolic embolization of the afferent gastric veins shows sufficient variceal opacification. Arrows indicate coils. (c) CT scan obtained 1 month later shows complete obliteration of the varices. Arrow indicates a coil.

View larger version (106K): [in a new window]   Figure 2b.  Successful treatment of type 2 gastric varices with a combination of BRTO and coil embolization of afferent veins by means of transileocolic venous access. (a) Contrast material-enhanced computed tomographic (CT) scan shows gastric varices at the fundus that are supplied by multiple afferent veins (arrowheads). (b) Fluoroscopic image obtained during BRTO performed with injection of EOI after transileocolic embolization of the afferent gastric veins shows sufficient variceal opacification. Arrows indicate coils. (c) CT scan obtained 1 month later shows complete obliteration of the varices. Arrow indicates a coil.

View larger version (167K): [in a new window]   Figure 2c.  Successful treatment of type 2 gastric varices with a combination of BRTO and coil embolization of afferent veins by means of transileocolic venous access. (a) Contrast material-enhanced computed tomographic (CT) scan shows gastric varices at the fundus that are supplied by multiple afferent veins (arrowheads). (b) Fluoroscopic image obtained during BRTO performed with injection of EOI after transileocolic embolization of the afferent gastric veins shows sufficient variceal opacification. Arrows indicate coils. (c) CT scan obtained 1 month later shows complete obliteration of the varices. Arrow indicates a coil.

View larger version (43K): [in a new window]   Figure 3a.  Drawings illustrate additional techniques for treatment of type 3 gastric varices. (a) Subselective injection of EOI via a microcatheter. EOI is injected via the microcatheter, which has been navigated through a balloon catheter into the varices, and fills the varices. (b) Coil embolization of afferent gastric veins, which prevents the flow of EOI into the direct shunting vein and the portal vein. The coil is placed in the direct shunting vein via a catheter that is introduced by means of percutaneous transhepatic portal venous access or transileocolic venous access at minilaparotomy.

View larger version (43K): [in a new window]   Figure 3b.  Drawings illustrate additional techniques for treatment of type 3 gastric varices. (a) Subselective injection of EOI via a microcatheter. EOI is injected via the microcatheter, which has been navigated through a balloon catheter into the varices, and fills the varices. (b) Coil embolization of afferent gastric veins, which prevents the flow of EOI into the direct shunting vein and the portal vein. The coil is placed in the direct shunting vein via a catheter that is introduced by means of percutaneous transhepatic portal venous access or transileocolic venous access at minilaparotomy.

View larger version (113K): [in a new window]   Figure 4a.  Treatment of a type 3 gastric varix with a combination of BRTO and coil embolization of a direct shunting vein. (a, b) Contrast-enhanced CT scans show small gastric varices (arrow in a) and multiple enlarged gastric veins (arrowheads in b). (c) Splenic venogram (transileocolic venous access) shows the small gastric varices (arrows) to be contiguous with a large gastrorenal shunt. (d) Posterior gastric venogram shows direct communication between the posterior gastric vein and the gastrorenal shunt. (e) Fluoroscopic image obtained during BRTO performed after coil embolization of the direct shunting vein and afferent gastric veins shows sufficient variceal opacification (arrows). Arrowheads indicate coils in the left gastric and posterior gastric veins.

View larger version (132K): [in a new window]   Figure 4b.  Treatment of a type 3 gastric varix with a combination of BRTO and coil embolization of a direct shunting vein. (a, b) Contrast-enhanced CT scans show small gastric varices (arrow in a) and multiple enlarged gastric veins (arrowheads in b). (c) Splenic venogram (transileocolic venous access) shows the small gastric varices (arrows) to be contiguous with a large gastrorenal shunt. (d) Posterior gastric venogram shows direct communication between the posterior gastric vein and the gastrorenal shunt. (e) Fluoroscopic image obtained during BRTO performed after coil embolization of the direct shunting vein and afferent gastric veins shows sufficient variceal opacification (arrows). Arrowheads indicate coils in the left gastric and posterior gastric veins.

View larger version (112K): [in a new window]   Figure 4c.  Treatment of a type 3 gastric varix with a combination of BRTO and coil embolization of a direct shunting vein. (a, b) Contrast-enhanced CT scans show small gastric varices (arrow in a) and multiple enlarged gastric veins (arrowheads in b). (c) Splenic venogram (transileocolic venous access) shows the small gastric varices (arrows) to be contiguous with a large gastrorenal shunt. (d) Posterior gastric venogram shows direct communication between the posterior gastric vein and the gastrorenal shunt. (e) Fluoroscopic image obtained during BRTO performed after coil embolization of the direct shunting vein and afferent gastric veins shows sufficient variceal opacification (arrows). Arrowheads indicate coils in the left gastric and posterior gastric veins.

View larger version (117K): [in a new window]   Figure 4d.  Treatment of a type 3 gastric varix with a combination of BRTO and coil embolization of a direct shunting vein. (a, b) Contrast-enhanced CT scans show small gastric varices (arrow in a) and multiple enlarged gastric veins (arrowheads in b). (c) Splenic venogram (transileocolic venous access) shows the small gastric varices (arrows) to be contiguous with a large gastrorenal shunt. (d) Posterior gastric venogram shows direct communication between the posterior gastric vein and the gastrorenal shunt. (e) Fluoroscopic image obtained during BRTO performed after coil embolization of the direct shunting vein and afferent gastric veins shows sufficient variceal opacification (arrows). Arrowheads indicate coils in the left gastric and posterior gastric veins.

View larger version (158K): [in a new window]   Figure 4e.  Treatment of a type 3 gastric varix with a combination of BRTO and coil embolization of a direct shunting vein. (a, b) Contrast-enhanced CT scans show small gastric varices (arrow in a) and multiple enlarged gastric veins (arrowheads in b). (c) Splenic venogram (transileocolic venous access) shows the small gastric varices (arrows) to be contiguous with a large gastrorenal shunt. (d) Posterior gastric venogram shows direct communication between the posterior gastric vein and the gastrorenal shunt. (e) Fluoroscopic image obtained during BRTO performed after coil embolization of the direct shunting vein and afferent gastric veins shows sufficient variceal opacification (arrows). Arrowheads indicate coils in the left gastric and posterior gastric veins.

View larger version (68K): [in a new window]   Figure 5a.  Drawings illustrate BRTO techniques for reducing the dosage of EOI in cases involving a large shunt. (a) Further advancement of a balloon catheter. EOI is injected via the catheter, which has been advanced into the more proximal portion of the draining vein. (b) Selective injection via a microcatheter. EOI is injected via the microcatheter, which has been advanced through the balloon catheter into the varices.

View larger version (67K): [in a new window]   Figure 5b.  Drawings illustrate BRTO techniques for reducing the dosage of EOI in cases involving a large shunt. (a) Further advancement of a balloon catheter. EOI is injected via the catheter, which has been advanced into the more proximal portion of the draining vein. (b) Selective injection via a microcatheter. EOI is injected via the microcatheter, which has been advanced through the balloon catheter into the varices.

View larger version (67K): [in a new window]   Figure 6a.  BRTO technique for type B-1 gastric varices. (a) Drawing illustrates gastric varices treated with BRTO. Small collateral veins are occluded with stepwise injection of EOI. (b) Balloon-occluded venogram shows the small collateral veins (arrows). (c) Fluoroscopic image obtained during BRTO performed after obliteration of the small collateral veins with stepwise injection of EOI shows sufficient variceal filling.

View larger version (193K): [in a new window]   Figure 6b.  BRTO technique for type B-1 gastric varices. (a) Drawing illustrates gastric varices treated with BRTO. Small collateral veins are occluded with stepwise injection of EOI. (b) Balloon-occluded venogram shows the small collateral veins (arrows). (c) Fluoroscopic image obtained during BRTO performed after obliteration of the small collateral veins with stepwise injection of EOI shows sufficient variceal filling.

View larger version (188K): [in a new window]   Figure 6c.  BRTO technique for type B-1 gastric varices. (a) Drawing illustrates gastric varices treated with BRTO. Small collateral veins are occluded with stepwise injection of EOI. (b) Balloon-occluded venogram shows the small collateral veins (arrows). (c) Fluoroscopic image obtained during BRTO performed after obliteration of the small collateral veins with stepwise injection of EOI shows sufficient variceal filling.

View larger version (59K): [in a new window]   Figure 7a.  Selective injection via a microcatheter for type B-2 gastric varices. (a) Drawing illustrates selective injection via a microcatheter. (b) On a balloon-occluded venogram, the gastrorenal shunt is seen to communicate with the pericardiophrenic vein (arrowheads) and small collateral veins. (c) Fluoroscopic image shows a microcatheter that has been navigated through the shunt to the gastric varices. Arrow indicates the tip of the microcatheter. (d) Fluoroscopic image obtained during BRTO performed with selective injection of EOI via a microcatheter shows sufficient opacification of the varices.

View larger version (130K): [in a new window]   Figure 7b.  Selective injection via a microcatheter for type B-2 gastric varices. (a) Drawing illustrates selective injection via a microcatheter. (b) On a balloon-occluded venogram, the gastrorenal shunt is seen to communicate with the pericardiophrenic vein (arrowheads) and small collateral veins. (c) Fluoroscopic image shows a microcatheter that has been navigated through the shunt to the gastric varices. Arrow indicates the tip of the microcatheter. (d) Fluoroscopic image obtained during BRTO performed with selective injection of EOI via a microcatheter shows sufficient opacification of the varices.

View larger version (126K): [in a new window]   Figure 7c.  Selective injection via a microcatheter for type B-2 gastric varices. (a) Drawing illustrates selective injection via a microcatheter. (b) On a balloon-occluded venogram, the gastrorenal shunt is seen to communicate with the pericardiophrenic vein (arrowheads) and small collateral veins. (c) Fluoroscopic image shows a microcatheter that has been navigated through the shunt to the gastric varices. Arrow indicates the tip of the microcatheter. (d) Fluoroscopic image obtained during BRTO performed with selective injection of EOI via a microcatheter shows sufficient opacification of the varices.

View larger version (137K): [in a new window]   Figure 7d.  Selective injection via a microcatheter for type B-2 gastric varices. (a) Drawing illustrates selective injection via a microcatheter. (b) On a balloon-occluded venogram, the gastrorenal shunt is seen to communicate with the pericardiophrenic vein (arrowheads) and small collateral veins. (c) Fluoroscopic image shows a microcatheter that has been navigated through the shunt to the gastric varices. Arrow indicates the tip of the microcatheter. (d) Fluoroscopic image obtained during BRTO performed with selective injection of EOI via a microcatheter shows sufficient opacification of the varices.

View larger version (63K): [in a new window]   Figure 8a.  Drawings illustrate embolization of high-flow collateral veins in a type B-3 gastric varix. (a) EOI injected via a balloon catheter. The EOI flows into the collateral veins (arrows). (b) Coil embolization of the collateral draining veins with a microcatheter. (c) Selective injection of EOI after coil embolization of the collateral draining veins.

View larger version (66K): [in a new window]   Figure 8b.  Drawings illustrate embolization of high-flow collateral veins in a type B-3 gastric varix. (a) EOI injected via a balloon catheter. The EOI flows into the collateral veins (arrows). (b) Coil embolization of the collateral draining veins with a microcatheter. (c) Selective injection of EOI after coil embolization of the collateral draining veins.

View larger version (68K): [in a new window]   Figure 8c.  Drawings illustrate embolization of high-flow collateral veins in a type B-3 gastric varix. (a) EOI injected via a balloon catheter. The EOI flows into the collateral veins (arrows). (b) Coil embolization of the collateral draining veins with a microcatheter. (c) Selective injection of EOI after coil embolization of the collateral draining veins.

View larger version (145K): [in a new window]   Figure 9a.  Type B-3 gastric varices. (a) Contrast-enhanced CT scan shows gastric varices. (b) Balloon-occluded venogram of the gastrorenal shunt shows only the collateral draining veins. (c) Fluoroscopic image obtained after coil embolization of these collateral vessels (arrows indicate coils) demonstrates the drainage route of the varices. The image shows that EOI injected via the microcatheter fills the varices well. (d) Contrast-enhanced CT scan obtained 2 weeks later shows complete thrombosis of the varices.

View larger version (176K): [in a new window]   Figure 9b.  Type B-3 gastric varices. (a) Contrast-enhanced CT scan shows gastric varices. (b) Balloon-occluded venogram of the gastrorenal shunt shows only the collateral draining veins. (c) Fluoroscopic image obtained after coil embolization of these collateral vessels (arrows indicate coils) demonstrates the drainage route of the varices. The image shows that EOI injected via the microcatheter fills the varices well. (d) Contrast-enhanced CT scan obtained 2 weeks later shows complete thrombosis of the varices.

View larger version (172K): [in a new window]   Figure 9c.  Type B-3 gastric varices. (a) Contrast-enhanced CT scan shows gastric varices. (b) Balloon-occluded venogram of the gastrorenal shunt shows only the collateral draining veins. (c) Fluoroscopic image obtained after coil embolization of these collateral vessels (arrows indicate coils) demonstrates the drainage route of the varices. The image shows that EOI injected via the microcatheter fills the varices well. (d) Contrast-enhanced CT scan obtained 2 weeks later shows complete thrombosis of the varices.

View larger version (149K): [in a new window]   Figure 9d.  Type B-3 gastric varices. (a) Contrast-enhanced CT scan shows gastric varices. (b) Balloon-occluded venogram of the gastrorenal shunt shows only the collateral draining veins. (c) Fluoroscopic image obtained after coil embolization of these collateral vessels (arrows indicate coils) demonstrates the drainage route of the varices. The image shows that EOI injected via the microcatheter fills the varices well. (d) Contrast-enhanced CT scan obtained 2 weeks later shows complete thrombosis of the varices.

View larger version (74K): [in a new window]   Figure 10a.  Drawings illustrate selective retrograde obliteration with a mixture of NBCA and lipiodol. (a) EOI injected via a balloon catheter flows into the collateral veins that cannot be catheterized. Arrows indicate direction of flow through the collateral veins. (b) Two catheters are introduced into the shunt—one from each femoral vein. A microcatheter is advanced into the varices through one of the catheters. (c) The draining shunt is occluded with coils placed via the other catheter. (d) An NBCA-lipiodol mixture (1:3) is injected via the microcatheter until the entire variceal complex is opacified.

View larger version (72K): [in a new window]   Figure 10b.  Drawings illustrate selective retrograde obliteration with a mixture of NBCA and lipiodol. (a) EOI injected via a balloon catheter flows into the collateral veins that cannot be catheterized. Arrows indicate direction of flow through the collateral veins. (b) Two catheters are introduced into the shunt—one from each femoral vein. A microcatheter is advanced into the varices through one of the catheters. (c) The draining shunt is occluded with coils placed via the other catheter. (d) An NBCA-lipiodol mixture (1:3) is injected via the microcatheter until the entire variceal complex is opacified.

View larger version (76K): [in a new window]   Figure 10c.  Drawings illustrate selective retrograde obliteration with a mixture of NBCA and lipiodol. (a) EOI injected via a balloon catheter flows into the collateral veins that cannot be catheterized. Arrows indicate direction of flow through the collateral veins. (b) Two catheters are introduced into the shunt—one from each femoral vein. A microcatheter is advanced into the varices through one of the catheters. (c) The draining shunt is occluded with coils placed via the other catheter. (d) An NBCA-lipiodol mixture (1:3) is injected via the microcatheter until the entire variceal complex is opacified.

View larger version (73K): [in a new window]   Figure 10d.  Drawings illustrate selective retrograde obliteration with a mixture of NBCA and lipiodol. (a) EOI injected via a balloon catheter flows into the collateral veins that cannot be catheterized. Arrows indicate direction of flow through the collateral veins. (b) Two catheters are introduced into the shunt—one from each femoral vein. A microcatheter is advanced into the varices through one of the catheters. (c) The draining shunt is occluded with coils placed via the other catheter. (d) An NBCA-lipiodol mixture (1:3) is injected via the microcatheter until the entire variceal complex is opacified.

View larger version (138K): [in a new window]   Figure 11a.  Treatment of a type B-3 gastric varix with retrograde injection of an NBCA-lipiodol mixture. (a) Contrast-enhanced CT scan shows fundal gastric varices. (b) Splenic venogram shows that the varices drain through the gastrocaval shunt (arrows). (c) Balloon-occluded venogram obtained after coil embolization of collateral vessels demonstrates residual high-flow collateral vessels. The microcatheter was advanced farther into the varices, and 4 mL of NBCA-lipiodol mixture was injected via the microcatheter. (d) Fluoroscopic image obtained immediately after injection shows that the NBCA-lipiodol mixture fills the varices well. (e) CT scan obtained 2 weeks later shows NBCA-lipiodol mixture in the varices.

View larger version (154K): [in a new window]   Figure 11b.  Treatment of a type B-3 gastric varix with retrograde injection of an NBCA-lipiodol mixture. (a) Contrast-enhanced CT scan shows fundal gastric varices. (b) Splenic venogram shows that the varices drain through the gastrocaval shunt (arrows). (c) Balloon-occluded venogram obtained after coil embolization of collateral vessels demonstrates residual high-flow collateral vessels. The microcatheter was advanced farther into the varices, and 4 mL of NBCA-lipiodol mixture was injected via the microcatheter. (d) Fluoroscopic image obtained immediately after injection shows that the NBCA-lipiodol mixture fills the varices well. (e) CT scan obtained 2 weeks later shows NBCA-lipiodol mixture in the varices.

View larger version (193K): [in a new window]   Figure 11c.  Treatment of a type B-3 gastric varix with retrograde injection of an NBCA-lipiodol mixture. (a) Contrast-enhanced CT scan shows fundal gastric varices. (b) Splenic venogram shows that the varices drain through the gastrocaval shunt (arrows). (c) Balloon-occluded venogram obtained after coil embolization of collateral vessels demonstrates residual high-flow collateral vessels. The microcatheter was advanced farther into the varices, and 4 mL of NBCA-lipiodol mixture was injected via the microcatheter. (d) Fluoroscopic image obtained immediately after injection shows that the NBCA-lipiodol mixture fills the varices well. (e) CT scan obtained 2 weeks later shows NBCA-lipiodol mixture in the varices.

View larger version (163K): [in a new window]   Figure 11d.  Treatment of a type B-3 gastric varix with retrograde injection of an NBCA-lipiodol mixture. (a) Contrast-enhanced CT scan shows fundal gastric varices. (b) Splenic venogram shows that the varices drain through the gastrocaval shunt (arrows). (c) Balloon-occluded venogram obtained after coil embolization of collateral vessels demonstrates residual high-flow collateral vessels. The microcatheter was advanced farther into the varices, and 4 mL of NBCA-lipiodol mixture was injected via the microcatheter. (d) Fluoroscopic image obtained immediately after injection shows that the NBCA-lipiodol mixture fills the varices well. (e) CT scan obtained 2 weeks later shows NBCA-lipiodol mixture in the varices.

View larger version (163K): [in a new window]   Figure 11e.  Treatment of a type B-3 gastric varix with retrograde injection of an NBCA-lipiodol mixture. (a) Contrast-enhanced CT scan shows fundal gastric varices. (b) Splenic venogram shows that the varices drain through the gastrocaval shunt (arrows). (c) Balloon-occluded venogram obtained after coil embolization of collateral vessels demonstrates residual high-flow collateral vessels. The microcatheter was advanced farther into the varices, and 4 mL of NBCA-lipiodol mixture was injected via the microcatheter. (d) Fluoroscopic image obtained immediately after injection shows that the NBCA-lipiodol mixture fills the varices well. (e) CT scan obtained 2 weeks later shows NBCA-lipiodol mixture in the varices.

View larger version (61K): [in a new window]   Figure 12a.  Coil embolization of the gastrocaval shunt in type C gastric varices. (a) Drawing illustrates BRTO with concurrent coil embolization of the gastrocaval shunt and selective EOI injection. (b) Balloon-occluded venogram reveals that the gastrorenal shunt is contiguous with a small gastrocaval shunt (arrowheads) and other collateral draining veins. (c) On a fluoroscopic image obtained after coil embolization of the gastrocaval shunt and collateral vessels, EOI that was injected via a microcatheter is seen to fill the variceal complex well. Arrows indicate coils.

View larger version (129K): [in a new window]   Figure 12b.  Coil embolization of the gastrocaval shunt in type C gastric varices. (a) Drawing illustrates BRTO with concurrent coil embolization of the gastrocaval shunt and selective EOI injection. (b) Balloon-occluded venogram reveals that the gastrorenal shunt is contiguous with a small gastrocaval shunt (arrowheads) and other collateral draining veins. (c) On a fluoroscopic image obtained after coil embolization of the gastrocaval shunt and collateral vessels, EOI that was injected via a microcatheter is seen to fill the variceal complex well. Arrows indicate coils.

View larger version (185K): [in a new window]   Figure 12c.  Coil embolization of the gastrocaval shunt in type C gastric varices. (a) Drawing illustrates BRTO with concurrent coil embolization of the gastrocaval shunt and selective EOI injection. (b) Balloon-occluded venogram reveals that the gastrorenal shunt is contiguous with a small gastrocaval shunt (arrowheads) and other collateral draining veins. (c) On a fluoroscopic image obtained after coil embolization of the gastrocaval shunt and collateral vessels, EOI that was injected via a microcatheter is seen to fill the variceal complex well. Arrows indicate coils.

View larger version (59K): [in a new window]   Figure 13a.  Double-balloon catheterization for the treatment of type C gastric varices. (a) Drawing illustrates the double-balloon technique. (b) Balloon-occluded venogram shows that the gastrocaval shunt is contiguous with the gastrorenal shunt and other draining veins. (c) Fluoroscopic image obtained after the injection of EOI with balloon occlusion of both shunts shows sufficient opacification of the varices.

View larger version (103K): [in a new window]   Figure 13b.  Double-balloon catheterization for the treatment of type C gastric varices. (a) Drawing illustrates the double-balloon technique. (b) Balloon-occluded venogram shows that the gastrocaval shunt is contiguous with the gastrorenal shunt and other draining veins. (c) Fluoroscopic image obtained after the injection of EOI with balloon occlusion of both shunts shows sufficient opacification of the varices.

View larger version (171K): [in a new window]   Figure 13c.  Double-balloon catheterization for the treatment of type C gastric varices. (a) Drawing illustrates the double-balloon technique. (b) Balloon-occluded venogram shows that the gastrocaval shunt is contiguous with the gastrorenal shunt and other draining veins. (c) Fluoroscopic image obtained after the injection of EOI with balloon occlusion of both shunts shows sufficient opacification of the varices.

View larger version (72K): [in a new window]   Figure 14a.  Drawings illustrate selective antegrade obliteration with an NBCA-lipiodol mixture. (a) A 4-F catheter is introduced into the major afferent vein by means of percutaneous transhepatic or transileocolic venous access. Two or three Gianturco coils are placed in the major afferent vein to reduce flow. (b) A microcatheter is advanced through the 4-F catheter and into the varices. An NBCA-lipiodol mixture is injected via the microcatheter until the entire variceal complex is opacified.

View larger version (72K): [in a new window]   Figure 14b.  Drawings illustrate selective antegrade obliteration with an NBCA-lipiodol mixture. (a) A 4-F catheter is introduced into the major afferent vein by means of percutaneous transhepatic or transileocolic venous access. Two or three Gianturco coils are placed in the major afferent vein to reduce flow. (b) A microcatheter is advanced through the 4-F catheter and into the varices. An NBCA-lipiodol mixture is injected via the microcatheter until the entire variceal complex is opacified.

View larger version (174K): [in a new window]   Figure 15a.  Selective antegrade obliteration of a type D varix with an NBCA-lipiodol mixture. (a) Contrast-enhanced CT scan shows a gastric varix at the fundus. (b) Posterior gastric venogram (percutaneous transhepatic approach) shows that the gastric varix drains through the inferior phrenic vein into small draining veins. An NBCA-lipiodol mixture was injected via a microcatheter after the placement of coils to reduce flow. (c) Fluoroscopic image obtained after injection shows that the mixture fills the varix well. Arrows indicate coils. (d) CT scan obtained 1 month later shows retention of NBCA in the varix.

View larger version (131K): [in a new window]   Figure 15b.  Selective antegrade obliteration of a type D varix with an NBCA-lipiodol mixture. (a) Contrast-enhanced CT scan shows a gastric varix at the fundus. (b) Posterior gastric venogram (percutaneous transhepatic approach) shows that the gastric varix drains through the inferior phrenic vein into small draining veins. An NBCA-lipiodol mixture was injected via a microcatheter after the placement of coils to reduce flow. (c) Fluoroscopic image obtained after injection shows that the mixture fills the varix well. Arrows indicate coils. (d) CT scan obtained 1 month later shows retention of NBCA in the varix.

View larger version (165K): [in a new window]   Figure 15c.  Selective antegrade obliteration of a type D varix with an NBCA-lipiodol mixture. (a) Contrast-enhanced CT scan shows a gastric varix at the fundus. (b) Posterior gastric venogram (percutaneous transhepatic approach) shows that the gastric varix drains through the inferior phrenic vein into small draining veins. An NBCA-lipiodol mixture was injected via a microcatheter after the placement of coils to reduce flow. (c) Fluoroscopic image obtained after injection shows that the mixture fills the varix well. Arrows indicate coils. (d) CT scan obtained 1 month later shows retention of NBCA in the varix.

View larger version (169K): [in a new window]   Figure 15d.  Selective antegrade obliteration of a type D varix with an NBCA-lipiodol mixture. (a) Contrast-enhanced CT scan shows a gastric varix at the fundus. (b) Posterior gastric venogram (percutaneous transhepatic approach) shows that the gastric varix drains through the inferior phrenic vein into small draining veins. An NBCA-lipiodol mixture was injected via a microcatheter after the placement of coils to reduce flow. (c) Fluoroscopic image obtained after injection shows that the mixture fills the varix well. Arrows indicate coils. (d) CT scan obtained 1 month later shows retention of NBCA in the varix.