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Invited Commentary

¹ Department of Radiology, Fox Chase Cancer Center, Philadelphia, Pennsylvania

Gastric varices are an uncommon and difficult therapeutic challenge of portal hypertension. These varices are appreciably less common than the usual esophageal ones, occurring in only about 5% of patients, but have a more serious prognosis. About one-third of patients with gastric varices hemorrhage and have a high risk of death. Until recently, these patients were not well treated with endoscopic methods and were candidates for TIPS placement. In the past few years, with the development of banding or injection of NBCA, endoscopists have been more successful in treating gastric varices. The use of injected glue is not without complications, such as glue emboli that form when the glue is injected into fundal varices, adherence of the needle to the glue, and rebleeding. Because no one therapy is clearly better than the others, new methods of treatment, particularly transcatheter methods, continue to be investigated. Finally, there are patients who do not qualify for endoscopic therapy or would prefer to undergo treatment with transcatheter methods.

The anatomy of the gastric veins has never been exceptionally clear, and, to our knowledge, the hemodynamic influence of the collateral vessels, although intuitively important, has not been previously investigated. Kiyosue et al (1,2) have developed a classification system that is both anatomically and therapeutically relevant. Anatomic classification on the basis of both afferent and draining (efferent) gastric veins is attractive in that it takes into account anatomic, physiologic, and potential therapeutic considerations. Once the relevant venous anatomy has been clarified, optimal treatment with transcatheter methods such as BRTO can be identified. BRTO, a common procedure in Japan, is well described in these articles.

Ethanolamine oleate is used as the sclerotic agent in BRTO. This agent is not used in endoscopic therapy because it is associated with serious complications. However, its use in transcatheter procedures has been described (3). BRTO is an aggressive therapeutic approach to the treatment of gastric varices; in most situations, however, additional specialized techniques are needed for successful treatment, especially double-balloon catheterization, intermittent injections, use of microcatheters, and embolization of afferent and high-flow collateral veins.

Kiyosue et al have done the interventional radiology community a great service by examining this difficult anatomic area with a rational system that can be used to evaluate both physiology and therapy.

	References

Top References

 

1. Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori Y, Okino Y.. Transcatheter obliteration of gastric varices. Part 1. Anatomic classification. RadioGraphics 2003; 23:911-920.[Abstract/Free Full Text]
2. Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori Y, Okino Y.. Transcatheter obliteration of gastric varices. Part 2. Strategy and techniques based on hemodynamic features. RadioGraphics 2003; 23:921-937.[Abstract/Free Full Text]
3. Choi YH, Han MH, O-Ki K, Cha SH, Chang KH. Craniofacial cavernous venous malformations: percutaneous sclerotherapy with use of ethanolamine oleate. J Vasc Intervent Radiol 2002; 13:475-482.[Medline]

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