DOI: 10.1148/rg.234025044
(Radiographics. 2003;23:911-920.)
© RSNA, 2003
Transcatheter Obliteration of Gastric Varices
Part 1. Anatomic Classification1
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).
 |
Abstract
|
|---|
Since its introduction in the mid-1990s, balloon-occluded retrograde transvenous obliteration (BRTO) has become widely accepted in Japan as a minimally invasive, highly effective treatment for gastric varices. Sufficient filling and stagnation of the sclerosing agent in the entire variceal complex is essential for successful BRTO of gastric varices. However, the success of BRTO in this context also requires familiarity with the hemodynamic features of the varices, including the patterns of their afferent and draining veins, which affect the degree of difficulty in performing BRTO. Thus, accurate assessment of the hemodynamic pattern before and during each procedure is essential for successful treatment. Sixty cases of gastric varices that were successfully treated with transcatheter techniques over the past 5 years were reviewed and analyzed. From this study, a classification system for gastric varices was developed that is based on the hemodynamic pattern of the varices.
© RSNA, 2003
Index Terms: Catheters and catheterization • Stomach, interventional procedures • Stomach, varices, 72.1269, 72.75 • Veins, gastric, 72.75 • Venography, 95.124
|
Introduction
|
|---|
Although the risk of bleeding from gastric varices is relatively low (10%–36% of cases), gastric variceal rupture carries a high mortality rate (14%–45%) (1–4). Therefore, various forms of treatment for gastric varices, including surgery, percutaneous transhepatic obliteration, endoscopic injection sclerotherapy, and transjugular intrahepatic portosystemic shunt placement, have been described (2–7).
Since its introduction by Kanagawa et al (8), balloon-occluded retrograde transvenous obliteration (BRTO) has become widely accepted in Japan as a minimally invasive, highly effective treatment for gastric varices (8–15). Sufficient filling with and stagnation of the sclerosing agent in the entire variceal complex is essential for successful BRTO of gastric varices. However, the success of BRTO in this context also requires familiarity with the hemodynamic features of the varices, including the patterns of their afferent and draining veins.
We reviewed and analyzed 60 cases of gastric varices that were treated with transcatheter techniques in our department over the past 5 years. In this article, we describe standard BRTO technique and an anatomic classification system for gastric varices that is based on their hemodynamic features during balloon occlusion of the draining vein.
|
Anatomic Considerations
|
|---|
Afferent Veins
Although a gastric varix could potentially be formed by any gastric vein (Fig 1a), most gastric varices are formed by the left gastric or posterior gastric vein (16–18). Gastric varices of the left gastric vein are frequently located at the cardia and sometime extend cephalad to coalesce with the (para)esophageal varices (Fig 1b) (17,19). Gastric varices of the posterior gastric and short gastric veins are frequently located at the fundus (Fig 1c) and drain into the major gastrosystemic shunt (16,17). Varices of the gastroepiploic vein are rare but often occur after treatment of other gastric varices with surgery or coil embolization (Fig 1d) (20).
View larger version (76K):
[in this window]
[in a new window]
[Download PPT slide]
|
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 this window]
[in a new window]
[Download PPT slide]
|
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 this window]
[in a new window]
[Download PPT slide]
|
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 this window]
[in a new window]
[Download PPT slide]
|
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.
|
|
Draining Veins
The majority of gastric varices located at the fundus drain into the inferior phrenic vein (Fig 2a), which later joins with the left renal vein to form the gastrorenal shunt (80%–85% of cases) or with the inferior vena cava just below the diaphragm to form the gastrocaval shunt (10%–15%) (Fig 2b) (11,17). The gastrorenal shunt sometimes unites with the phrenicopericardial vein and intercostal veins and frequently with small retroperitoneal veins (Fig 2c) (21). It rarely communicates with the ascending lumbar vein, (para)vertebral plexus, or azygos venous system. The left adrenal vein joins the gastrorenal shunt at the outlet to the renal vein. The gastrocaval shunt is frequently contiguous with the phrenicopericardial vein and intercostal veins but rarely with the azygos venous system (Fig 2d) (21).
View larger version (75K):
[in this window]
[in a new window]
[Download PPT slide]
|
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 this window]
[in a new window]
[Download PPT slide]
|
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 this window]
[in a new window]
[Download PPT slide]
|
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 this window]
[in a new window]
[Download PPT slide]
|
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).
|
|
Cardiac varices sometimes drain through the (para)esophageal vein but may or may not demonstrate azygos venous drainage (17,19).
|
Standard BRTO Technique
|
|---|
We use balloon catheters of two different shapes. Both catheters have a wide lumen and therefore allow passage of a microcatheter. A 7-F Simmons-shaped catheter (Clinical Supply, Gifu, Japan) with a balloon having a maximum diameter of 20 mm is used for occlusion of the outlet of the gastrorenal shunt. Two 5-F simple hook-shaped catheters (Hanako Medical, Tokyo, Japan) with a balloon having a maximum diameter of 10 and 25 mm, respectively are used for occlusion of the gastrocaval shunt or of the proximal portion of the gastrorenal shunt.
The sclerosing agent used for BRTO, 5% ethanolamine oleate iopamidol (EOI), consists of a mixture of 10% ethanolamine oleate (Oldamin; Grelan Pharmaceutical, Tokyo, Japan) and the same dose of a contrast medium (Iopamidol 300; Schering Japan, Osaka) (8). 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. To prevent renal insufficiency, 4,000 U of haptoglobin (Green Cross, Osaka, Japan) is administered intravenously and combines with free hemoglobin. Despite the use of haptoglobin, we encountered one case of acute renal failure after BRTO was performed with 45 mL of EOI (13). Other complications associated with the use of EOI, including cardiogenic shock, pulmonary edema, and disseminated intravascular coagulation, have also been reported (14,22,23). Therefore, if possible, less than 40 mL of EOI should be used in each procedure.
The standard technique for BRTO as introduced by Kanagawa et al (8) (Fig 3) is as follows: Under fluoroscopic guidance, a balloon catheter is inserted into the outlet of the gastrorenal or gastrocaval shunt through a sheath placed in the right femoral vein. Following balloon occlusion of the shunt, venography is performed with injection of 10–15 mL of contrast material (Iopamidol 370; Schering Japan) via the balloon catheter. Next, 5% EOI is injected slowly and intermittently via the catheter until the gastric varices are completely filled with EOI. Thirty to 50 minutes after injection, as much EOI as possible is aspirated via the catheter. Finally, the balloon is deflated and the catheter withdrawn.
View larger version (47K):
[in this window]
[in a new window]
[Download PPT slide]
|
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.
|
|
|
Classification System for Gastric Varices
|
|---|
Gastric varices can be formed from several gastric veins and drain into single or multiple veins as described earlier. In this regard, Hirota et al (14) emphasized the importance of the characteristics of draining veins for successful BRTO. Technical difficulty will be affected, not only by the pattern of draining veins, but also by the pattern of afferent veins. In the following paragraphs, we present and discuss a classification system for gastric varices that is based on the patterns of their afferent and draining veins.
Classification on the Basis of Afferent Veins
Gastric varices are classified into three types according to the pattern of their afferent veins. Type 1 gastric varices are supplied by a single afferent gastric vein; type 2, by multiple afferent gastric veins; and type 3, by single or multiple gastric veins with coexistent gastric veins that are directly contiguous with the shunt but do not contribute to the varices (Fig 4).
View larger version (37K):
[in this window]
[in a new window]
[Download PPT slide]
|
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.
|
|
Type 1.—
In type 1 gastric varices, following occlusion of the draining veins, the flow within the varices and the afferent gastric vein is determined by the balance between portal venous pressure and draining venous pressure from the gastric wall to the varices. In patients with gastric varices, the portal venous pressure is usually higher than the draining venous pressure from the gastric wall. Consequently, EOI injected via a balloon catheter fills the whole variceal complex and stagnates well within the varices during balloon occlusion (Fig 5).
View larger version (42K):
[in this window]
[in a new window]
[Download PPT slide]
|
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 this window]
[in a new window]
[Download PPT slide]
|
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.
|
|
Type 2.—
In type 2 gastric varices, when the draining veins are completely occluded with the balloon catheter, the direction of blood flow in each gastric vein will change depending on intraluminal pressure. When the pressure in all of the gastric veins is equal, stasis of flow within the veins will occur. In this situation, EOI injected via a balloon catheter fills the entire variceal complex and stagnates well, as in type 1 varices. On the other hand, if pressure varies among the gastric veins, blood flow in the afferent gastric vein with lower pressure will change direction to match the direction of blood flow in the portal vein according to the pressure gradient (Figs 6, 7). Because this altered flow is usually very slow, this condition is not clinically significant in most cases (13). However, it may cause insufficient filling of the variceal complex with EOI (Fig 8), or the sclerosing agent could unexpectedly flow into the portal vein (Fig 7).
View larger version (51K):
[in this window]
[in a new window]
[Download PPT slide]
|
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 this window]
[in a new window]
[Download PPT slide]
|
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 this window]
[in a new window]
[Download PPT slide]
|
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 this window]
[in a new window]
[Download PPT slide]
|
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 this window]
[in a new window]
[Download PPT slide]
|
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 this window]
[in a new window]
[Download PPT slide]
|
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.
|
|
Type 3.—
In type 3 gastric varices, even if the draining veins are completely occluded with the balloon catheter, EOI injected via a balloon catheter will not sufficiently fill the varices and will flow into the gastric vein directly connected with the inferior phrenic vein (Fig 9). Further injection of EOI carries the risk of flow into the portal vein.
View larger version (47K):
[in this window]
[in a new window]
[Download PPT slide]
|
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 this window]
[in a new window]
[Download PPT slide]
|
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).
|
|
Classification on the Basis of Draining Veins
Gastric varices are classified into four types 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 (Fig 10).
View larger version (71K):
[in this window]
[in a new window]
[Download PPT slide]
|
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.
|
|
Type A.—
In type A gastric varices, unless the draining vein is very large, EOI injected via a balloon catheter will fill the varices. If the draining vein is particularly large, standard BRTO requires a generous amount of EOI, which increases the risk of complications (eg, renal insufficiency).
Type B.—
The difficulty of treating type B gastric varices depends on the characteristics of coexistent collateral draining veins in terms of flow, size, and accessibility.
Type B gastric varices are further subdivided into three subtypes. B-1 gastric varices are characterized by small low-flow collateral vessels; B-2, by medium-sized low-flow collateral vessels; and B-3, by high-flow collateral vessels (Fig 11).
View larger version (36K):
[in this window]
[in a new window]
[Download PPT slide]
|
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.
|
|
Because the small low-flow collateral vessels in subtype B-1 gastric varices (Fig 12) can easily be obliterated with EOI, a small amount (2–5 mL) is initially injected via the balloon catheter to obliterate the small collateral veins and fill the varices.
The medium-sized low-flow collateral draining veins in subtype B-2 gastric varices can be obliterated with EOI; however, a relatively large amount of EOI is needed for obliteration and for sufficient opacification of the varices.
In contrast, the high-flow collateral draining veins in subtype B-3 gastric varices (Fig 13) are difficult to obliterate with EOI. Consequently, EOI injected with the standard BRTO method will flow into the systemic vein and will not fill the varices (Fig 13a). Therefore, these high-flow collateral veins should be occluded before injection of EOI (Fig 13b).
View larger version (161K):
[in this window]
[in a new window]
[Download PPT slide]
|
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 this window]
[in a new window]
[Download PPT slide]
|
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.
|
|
Type C.—
Type C gastric varices are contiguous with both the gastrorenal shunt and the gastrocaval shunt (Fig 14). Unless both draining veins are occluded, EOI injected with the standard BRTO method will flow into the systemic vein as with subtype B-3 gastric varices.
View larger version (117K):
[in this window]
[in a new window]
[Download PPT slide]
|
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.
|
|
Type D.—
Because type D gastric varices have no catheterizable main draining veins, BRTO cannot be performed. In some cases, these varices can be treated with endoscopic sclerotherapy performed with n-butyl-2-cyanoacrylate. However, transcatheter obliteration is required for varices that are difficult to treat with endoscopic sclerotherapy owing to their location or high flow (Fig 15).
|
Conclusions
|
|---|
In this article, we have described an anatomic classification system for gastric varices that is based on their hemodynamic features. The degree of difficulty in performing BRTO depends on the afferent and draining venous patterns of the varices. Therefore, accurate assessment of the hemodynamic pattern before and during each procedure is essential for successful treatment.
|
Footnotes
|
|---|
Abbreviations: BRTO = balloon-occluded retrograde transvenous obliteration,
EOI = ethanolamine oleate iopamidol
See also the article by Kiyosue et al (pp 921–936)
and the commentary by Coldwell (p 937)
in this issue.
|
References
|
|---|
- Sarin SK, Lahoti D, Sacena SP, et al. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992; 16:1343-1349.[Medline]
- Trudenau W, Prindiville T. Endoscopic injection sclerosis in bleeding gastric varices. Gastrointest Endosc 1986; 32:264-268.[Medline]
- Abdel-Wahab M, el-Ebidy G, Gad el-Hak N, et al. Fundal varices: problem and management. Hepatogastroenterology 1999; 46:849-854.[Medline]
- Gerig JD, Garden OJ, Anderson JR, et al. Management of gastric variceal hemorrhage. Br J Surg 1990; 77:297-299.[Medline]
- Binmoeller KF, Borsatto R. Variceal bleeding and portal hypertension. Endoscopy 2000; 32:189-199.[CrossRef][Medline]
- Keller FS, Dotter CT, Rösch J. Percutaneous transhepatic obliteration of gastroesophageal varices: some technical aspects. Radiology 1978; 129:327-332.[Abstract]
- Henderson JM, Nagle A, Curtas S, Geisinger M, Barnes D. Surgical shunt and tips for variceal decompression in the 1990s. Surgery 2000; 128:540-546.[CrossRef][Medline]
- Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol 1996; 11:51-58.[Medline]
- Matsumoto A, Hamamoto N, Nomura T, et al. Balloon-occluded retrograde transvenous obliteration of high risk gastric fundal varices. Am J Gastroenterol 1999; 94:643-649.[CrossRef][Medline]
- Akahane T, Iwasaki T, Kobayashi N, et al. Changes in liver function parameters after occlusion of gastrorenal shunts with balloon-occluded retrograde transvenous obliteration. Am J Gastroenterol 1997; 92:1026-1030.[Medline]
- Koito K, Namieno T, Nagakawa T, Morita K. Balloon-occluded retrograde transvenous obliteration for gastric varices with gastrorenal or gastrocaval collaterals. AJR Am J Roentgenol 1996; 167:1317-1320.[Abstract/Free Full Text]
- Sonomura T, Sato M, Kishi K, et al. Balloon-occluded retrograde transvenous obliteration for gastric varices: a feasibility study. Cardiovasc Intervent Radiol 1998; 21:27-30.[CrossRef][Medline]
- Kiyosue H, Matsumoto S, Onishi R, et al. Balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices: therapeutic results and problems. Nippon Igaku Hoshasen Gakkai Zassi 1999; 59:12-19. [Japanese].
- Hirota S, Matsumoto S, Tomita M, Sako M, Kono M. Retrograde transvenous obliteration of gastric varices. Radiology 1999; 211:349-356.[Abstract/Free Full Text]
- Takahashi K, Yamada T, Hyodoh H, et al. Selective balloon-occluded retrograde sclerosis of gastric varices using a coaxial microcatheter system. AJR Am J Roentgenol 2001; 177:1091-1093.[Free Full Text]
- Watanabe K, Kimura K, Matsutani S, Ohto M, Okuda K. Portal hemodynamics in patients with gastric varices: a study in 230 patients with esophageal and/or gastric varices using portal vein catheterization. Gastroenterology 1988; 95:434-440.[Medline]
- Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Correlation between endoscopic and angiographic findings in patients with esophageal and isolated gastric varices. Dig Surg 2001; 18:176-181.[CrossRef][Medline]
- Kimura K, Ohto M, Matsutani S, Furuse J, Hoshino K, Okuda K. Relative frequencies of portosystemic pathways and renal shunt formation through the "posterior" gastric vein: portographic study in 460 patients. Hepatology 1990; 12:725-728.[Medline]
- Hashizume M, Kitano S, Yamaga H, Higashi H, Sugimachi K. Angioarchitectural classification of esophageal varices and paraesophageal veins in selective left gastric venography. Arch Surg 1989; 124:961-966.[Abstract]
- Saeki H, Hashizume M, Yanaga K, et al. Giant gastric varices after a left gastric venous caval shunt operation for esophageal varices: a case report. Hepatogastroenterology 1998; 45:700-704.[Medline]
- Netter FH. Anatomy of the esophagus. The CIBA collection of medical illustrations. Vol. 3. Digestive system. Part 1. Upper digestive tract. 4th ed. New York, NY: CIBA-GEIGY, 1975; 42.
- Uchibori S. Pulmonary circulation disturbance following endoscopic injection sclerotherapy. Nippon Kyobu Shikkann Gakkai Zasshi 1993; 31:833-839. [Japanese].
- Bellary SV, Isaacs P. Disseminated intravascular coagulation (DIC) after endoscopic injection sclerotherapy with ethanolamine oleate (letter). Endoscopy 1990; 22:151.[Medline]
Related Articles
-
Transcatheter Obliteration of Gastric Varices: Part 2. Strategy and Techniques Based on Hemodynamic Features
- Hiro Kiyosue, Hiromu Mori, Shunro Matsumoto, Yasunari Yamada, Yuzo Hori, and Yuriko Okino
RadioGraphics 2003 23: 921-937.
[Abstract]
[Full Text]
[PDF]
-
Invited Commentary
- Douglas M. Coldwell
RadioGraphics 2003 23: 937.
[Full Text]
[PDF]
This article has been cited by other articles:
|
|
|
|
 
N. Nishida, T. Ninoi, T. Kitayama, M. Tokunaga, Y. Sakai, M. Hamuro, K. Nakamura, Y. Inoue, and R. Yamada
Selective balloon-occluded retrograde transvenous obliteration of gastric varix with preservation of major portacaval shunt.
Am. J. Roentgenol.,
April 1, 2006;
186(4):
1155 - 1157.
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. M. Coldwell
Invited Commentary
RadioGraphics,
July 1, 2003;
23(4):
937 - 937.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
