DOI: 10.1148/rg.234025135
(Radiographics. 2003;23:921-937.)
© RSNA, 2003
Transcatheter Obliteration of Gastric Varices
Part 2. Strategy and Techniques Based on Hemodynamic Features1
Hiro Kiyosue, MD,
Hiromu Mori, MD,
Shunro Matsumoto, MD,
Yasunari Yamada, MD,
Yuzo Hori, MD and
Yuriko Okino, MD
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).
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Abstract
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Balloon-occluded retrograde transvenous obliteration (BRTO) has become the treatment of choice for gastric varices at many institutions in Japan. However, in some cases that involve complex types of afferent or draining veins, the use of standard BRTO for the treatment of gastric varices may be associated with several difficulties that can lead to unfavorable results. In such cases, additional techniques are required for successful treatment. These techniques include stepwise injection of the sclerosing agent, selective injection of the agent via a microcatheter, coil embolization of the afferent gastric veins, double-balloon catheterization, and BRTO performed with percutaneous transhepatic portal venous access or transileocolic venous access. The majority of gastric varices can be treated successfully with a combination of these techniques. However, accurate assessment of the variceal hemodynamic pattern is the most important factor in ensuring successful treatment.
© RSNA, 2003
Index Terms: Catheters and catheterization • Stomach, interventional procedures • Stomach, varices, 72.1269, 72.75 • Veins, gastric, 72.75 • Venography, 95.124
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Introduction
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Standard endoscopic injection sclerotherapy with ethanolamine oleate or polidocanol has become accepted as the most useful treatment for esophageal varices (1–3). However, this technique is less effective and even risky in the treatment of gastric varices, especially fundal varices (4,5). Endoscopic injection of n-butyl-2-cyanoacrylate (NBCA), a tissue adhesive agent, is the only endoscopic treatment that has been shown to be effective for gastric varices (6–9). Several investigators have demonstrated the efficacy of this treatment in achieving initial hemostasis of gastric variceal bleeding (83%–100% of cases) (6,8,9). However, relatively high rates of rebleeding (20%–25% of cases) were also observed (6,9,10). Furthermore, this method carries a potential risk of migration of NBCA from the varices to the systemic venous circulation, especially in patients with fundal varices associated with a large gastrosystemic venous shunt. This migration of NBCA may result in fatal complications such as pulmonary embolism (11,12). Transjugular intrahepatic portosystemic shunt (TIPS) placement is effective in reducing portal pressure and has been widely used in patients with variceal bleeding or refractory ascites associated with portal hypertension (13,14). Some randomized studies comparing TIPS placement with endoscopic treatment for variceal bleeding have indicated significantly lower rebleeding rates following TIPS placement (approximately 10%–30% of cases) (15,16). However, TIPS placement has two main drawbacks: (a) a poor primary shunt patency rate (50%–60% of cases) and (b) development of postplacement hepatic encephalopathy, which occurs in about 20% of patients (13,14). It has been suggested that bleeding gastric varices associated with a large gastrorenal shunt occur at lower portosystemic pressure gradients than do bleeding esophageal varices (17,18). Some groups have reported that TIPS placement is less effective for gastric varices associated with a large gas-trorenal shunt (19,20). However, other investiga-tors did not find any difference in rebleeding rates between esophageal varices and gastric varices treated with TIPS placement (21,22). The clinical effectiveness of TIPS placement for gastric varices is still obscure. Other treatments have proved to be inconsistently effective or too invasive.
Balloon-occluded retrograde transvenous obliteration (BRTO) has been the treatment of choice for gastric varices with a gastrosystemic venous shunt at many institutions in Japan (23–30). In standard BRTO, thrombi were created in the gastric varices with 5% ethanolamine oleate iopamidol (EOI) injected via a balloon catheter, a procedure that occludes the outlet of the gastrosystemic shunt. Since 1994, we have treated 60 cases of gastric varices with transcatheter techniques based on BRTO, and all patients were treated successfully. However, we have found that the use of standard BRTO in this context may be associated with several difficulties that can lead to unfavorable results. In such cases, additional techniques are required for successful treatment. In this article, we describe these additional techniques and our strategy for using them based on the anatomic classification system described in Part 1 (31).
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Strategy Based on Types of Afferent Gastric Veins
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Type 1 Gastric Varices
Type 1 gastric varices can easily be treated with BRTO when the draining veins from the gastric varices can be completely occluded with a balloon catheter. EOI injected via the catheter fills the entire variceal complex and stagnates well within the varices during occlusion. The left gastric vein is often the source of gastric varices as well as esophageal or paraesophageal varices (32). Obliteration of gastric varices from the left gastric vein results in increased flow in (para)esophageal varices (33). Therefore, the potential development or growth of esophageal varices after treatment of gastric varices should be monitored.
Type 2 Gastric Varices
In type 2 gastric varices, unequal pressure among gastric veins may lead to insufficient filling of the variceal complex with EOI or unexpected flow of EOI into the portal vein.
In the next few paragraphs, we describe several techniques that are designed to prevent insufficient filling and unexpected flow of EOI in type 2 varices.
Stepwise Injection.—
To avoid insufficient filling of the varices, we use stepwise injection of EOI at intervals of 3–15 minutes. The portion of the gastric varices or gastric vein that initially fills with EOI is obliterated by the thrombus that forms during these intervals, and further injections of EOI then fill another portion of the varices.
Selective Injection via a Microcatheter.—
When EOI only partially fills large varices even with stepwise injection, we sometimes use a microcatheter, which is selectively advanced through a balloon catheter into the nonopacified portion of the varices (30). EOI is subsequently injected via the microcatheter to fill the residual varices (Fig 1a).
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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.
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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.
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Coil Embolization of the Afferent Gastric Veins.—
Coil embolization of the afferent gastric veins with a transhepatic or transileocolic venous approach either prior to or concurrent with BRTO is useful in preventing both insufficient variceal filling and unexpected flow of EOI (Figs 1b, 2). Although these two approaches are invasive, their use in combination with BRTO should be considered in the treatment of large type 2 gastric varices. Transvenous afferent vein occlusion with microcoils positioned via a microcatheter advanced from the draining venous side through the gastric varices is less invasive but is often difficult.
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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.
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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.
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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.
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Type 3 Gastric Varices
In type 3 gastric varices, EOI injected via a balloon catheter will fill the gastric veins that are directly contiguous with the inferior phrenic vein.
The following techniques can help ensure successful treatment of type 3 varices.
Selective Injection via a Microcatheter.—
When a microcatheter can be advanced beyond the connection of the shunting vein with the draining vein of the gastric varices, EOI injected via the microcatheter will fill the varices (Fig 3a). However, it is sometimes difficult to advance the microcatheter into the true draining route of the varices.
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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.
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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.
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Combined Treatment with BRTO and Portal Venous Access–Transileocolic Venous Access.—
In type 3 gastric varices, combined treatment with BRTO and portal venous access–transileocolic venous access yields better results than treatment with BRTO alone (Figs 3b, 4). Pre-BRTO coil embolization of the gastric veins that are directly contiguous with the inferior phrenic vein allows sufficient filling of the varices with EOI.
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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.
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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.
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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.
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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.
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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.
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Strategy Based on Types of Draining Veins
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Type A Gastric Varices
Type A gastric varices can easily be treated with BRTO when the draining vein from the varices is not very large. When the gastric varices are opacified at balloon-occluded venography with injec-tion of less than 15 mL of contrast medium, we proceed to inject EOI via a balloon catheter (standard BRTO method). Ethanolamine oleate causes hemolysis in the blood vessels. As a result, free hemoglobin is released, which may cause renal tubular disturbances and acute renal failure. Because excessive amounts of EOI will cause acute renal failure, the total amount of EOI used in each procedure should be reduced if possible. When the gastric varices do not opacify owing to a large shunt, we try to advance the balloon catheter into the more proximal portion of the draining vein, after which EOI is injected via the catheter (Fig 5a). However, it is sometimes difficult to advance the catheter through a tortuous draining vein. In such cases, if the varices do not opacify, a microcatheter is advanced through the balloon catheter into the varices. Next, EOI is injected via the microcatheter and should fill the varices (Fig 5b) (30). Hirota et al (29) suggested the injection of 50% glucose solution prior to injection of EOI as a means of reducing the toxicity and dosage of EOI in cases of large varices or a large shunt. Because 50% glucose solution injected into the varices will replace the red blood cells, EOI will attach to the endothelium of the varices and destroy endothelial cells but will not attach to the red blood cells. In addition, 50% glucose solution will cause direct injury to the endothelial cells because of its high osmolarity. Although we have no experience with the combined injection of 50% glucose solution and EOI in BRTO, this method may be effective for giant varices with a large shunt.
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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.
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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.
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Type B Gastric Varices
The difficulty of treating type B gastric varices depends on the characteristics of coexistent collateral draining veins in terms of flow, size, and accessibility.
Subtype B-1: Small Low-Flow Collateral Vessels.—
Because their collateral veins can easily be obliterated with EOI, subtype B-1 gastric varices can be treated with standard BRTO (Fig 6). A microcatheter system can be used to reduce the required amount of EOI.
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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.
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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.
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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.
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Subtype B-2: Medium-sized Low-Flow Collateral Vessels.—
Although their collateral veins can be obliterated with EOI, a relatively large amount of EOI is needed for obliteration and for sufficient opacification of subtype B-2 gastric varices. Selective injection via a microcatheter is useful in reducing the required amount of EOI (Fig 7).
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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.
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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.
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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.
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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.
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Subtype B-3: High-Flow Collateral Vessels.—
Even with the selective injection technique, EOI will not stagnate in subtype B-3 gastric varices. Therefore, the high-flow collateral veins associated with these varices should be occluded with coils. We usually do so with microcoils via a microcatheter advanced into each vein (Fig 8b). After occlusion of these high-flow collateral veins, we inject EOI via the microcatheter with selective injection (Fig 8c). The majority of cases can be treated with this combination technique (Fig 9). Some authors use a small amount of absolute ethanol along with EOI for obliteration of these collateral veins (33). However, absolute ethanol can be toxic and cannot be visualized with fluoroscopy. In addition, serious complications such as coma or ventricular fibrillation may occur, probably due to the inflow of absolute ethanol into the pericardiophrenic vein.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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When the microcatheter cannot be advanced into these high-flow collateral veins (Fig 10a), we obliterate the varices with selective injection of a mixture of NBCA and lipiodol (Figs 10, 11) (28). The technique used for selective retrograde injection of this mixture is as follows: (a) two catheters are introduced into the shunt (one from each femoral vein), (b) a microcatheter is advanced into the varices through one of the two catheters (Fig 10b), (c) the main draining shunt is oc-cluded with coils placed via the other catheter (Fig 10c), (d) the NBCA-lipiodol mixture (1:3) is injected via the microcatheter until the entire variceal complex is opacified (Fig 10d), and (e) the microcatheter is rapidly withdrawn.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Type C Gastric Varices
In type C gastric varices, either coil embolization of the smaller shunt (Fig 12) or double-balloon catheterization (Fig 13) is required for sufficient opacification with EOI. The diameter of the smaller shunt is the primary determinant of which method is more suitable.
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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.
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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.
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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.
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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.
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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.
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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.
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Embolization of the Smaller Shunt (Subtype C-1).—
The procedure for embolization of the smaller shunt (<5 mm) is the same as that for embolization of high-flow collateral veins described earlier. The small shunt is easily occluded with coils (Fig 12).
Double-Balloon Catheterization (Subtype C-2).—
Double-balloon catheterization (Fig 13) is used for varices with two large main shunts that can be clearly identified at contrast-enhanced CT. Although coil embolization of such large shunts is possible, it requires a large number of coils and takes a long time. On the other hand, these shunts are large enough to allow the introduction of balloon catheters, and injection of EOI during balloon occlusion of both main shunts is easily performed (26,28). A gastrocaval shunt is usually associated with collateral draining veins such as the pericardiophrenic vein and subcostal veins. Concurrent embolization of these collateral veins with coils is often required.
Type D Gastric Varices
Type D gastric varices cannot be treated with BRTO because they have no catheterizable draining vein.
Recent technologic advances in microcatheters and micro–guide wires allow the navigation of a microcatheter very close to or into the varices with a transhepatic approach. We treat type D gastric varices with selective antegrade obliteration using an NBCA-lipiodol mixture (Figs 14, 15) as follows:
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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.
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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.
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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.
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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.
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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.
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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.
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1. A 4-F catheter is inserted into the splenic vein from a portal branch with a transhepatic approach (Fig 14a).
2. Portography is performed to evaluate the contribution of gastric veins to the gastric varices. One afferent gastric vein is selected for accessing the varices. If other major afferent veins exist, they are occluded with coils.
3. Two or three Gianturco coils are placed in the major afferent vein to reduce flow (Fig 14a).
4. A microcatheter is advanced through the 4-F catheter close to or within the varices (Fig 14b). If the microcatheter can be advanced through the varices into the draining vein, the coils are placed in the draining vein to prevent the migration of NBCA, and the microcatheter is retracted to the varices.
5. An NBCA-lipiodol mixture (1:3) is injected via the microcatheter until the entire variceal complex is opacified (Figs 14b, 15c).
6. The microcatheter is rapidly withdrawn.
This technique is invasive compared with endoscopic injection or BRTO, but it has an advantage over endoscopic injection of NBCA in that the flow from the varices to the shunt can be controlled with coil embolization of the afferent vein (and draining vein) prior to injection. Therefore, this technique carries less risk of migration of NBCA into the systemic vein, which could cause fatal pulmonary embolism, than does endoscopic injection.
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Conclusions
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In this article, we described the strategy and techniques of transcatheter obliteration of gastric varices based on the afferent and draining venous patterns of the varices. The majority of gastric varices can be treated successfully with a combination of these techniques. However, accurate assessment of the variceal hemodynamic pattern is the most important factor in ensuring successful treatment.
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Abstract
Introduction
