Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Fundal Varices with Hemorrhage
Mikiya Kitamoto1,2,
Michio Imamura1,
Koji Kamada1,
Hiroshi Aikata1,
Yoshiiku Kawakami1,
Akiko Matsumoto1,
Yoshika Kurihara1,
Hirotaka Kono1,
Hiroo Shirakawa1,
Toshio Nakanishi1,3,
Katsuhide Ito4 and
Kazuaki Chayama1
1 First Department of Internal Medicine, Hiroshima University School of
Medicine, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
2 Present address: Department of Gastroenterology, Hiroshima Prefectural
Hospital 1-5-54 Ujina-Kanda, Minami-ku, Hiroshima 734-8530, Japan.
3 Department of Clinical Radiology, Hiroshima University School of Medicine,
Hiroshima 734-8551, Japan.
4 Department of Radiology, Hiroshima University School of Medicine, Hiroshima
734-8551, Japan.
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Fig. 1. —Schematic diagram shows clinical courses and results of
patients with bleeding gastric fundal varices. Hypovolemic shock, present at
admission, was defined as systolic blood pressure less than 100 mm Hg and
pulse rate greater than 100 beats per minute. Bleeding involved presence of
active bleeding (spurting or oozing) from gastric varices or signs of recent
bleeding such as clot or fibrin clot. (+) = positive, (-) = negative.
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Fig. 2A. —67-year-old woman with alcohol-related liver cirrhosis and
gastric fundal varices. Gastric fundal varices with acute bleeding were
successfully treated with balloon-occluded retrograde transvenous
obliteration. Endoscopic image at admission reveals huge gastric fundal
varices with presence of fresh blood.
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Fig. 3A. —Illustrations show reshaping of balloon catheter. Balloon
catheter was inserted into right atrium over guidewire. SVC = superior vena
cava, IVC = inferior vena cava, RA = right atrium, RV = right ventricle.
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Fig. 3B. —Illustrations show reshaping of balloon catheter. After
guidewire was pulled out, catheter was reshaped by pushing on interatrial
septum.
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Fig. 3C. —Illustrations show reshaping of balloon catheter. Clockwise
rotation of balloon catheter was performed until tip of catheter was twisted
around catheter itself.
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Fig. 3D. —Illustrations show reshaping of balloon catheter. Balloon
catheter was placed in inferior vena cava, and tip of catheter was released by
insertion of guidewire.
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Fig. 3E. —Illustrations show reshaping of balloon catheter. Balloon
catheter was inserted into left renal vein, cannulating gastrorenal shunt.
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Fig. 2C. —67-year-old woman with alcohol-related liver cirrhosis and
gastric fundal varices. Gastric fundal varices with acute bleeding were
successfully treated with balloon-occluded retrograde transvenous
obliteration. Retrograde venogram obtained during balloon occlusion reveals
pericardiophrenic vein (small arrow), but gastric varices (large
arrow) are only partially observed and disappeared soon.
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Fig. 2D. —67-year-old woman with alcohol-relatedliver liver cirrhosis
and gastric fundal varices. Gastric fundal varices with acute bleeding were
successfully treated with balloon-occluded retrograde transvenous
obliteration. Venogram shows retrograde obliteration. Gastric varices were
completely obliterated by 5% ethanolamine oleate iopamidol injected in
retrograde manner during balloon occlusion. After insertion of embolic coils
into pericardiophrenic vein (small arrow), gastric varices (large
arrow) were delineated by 5% ethanolamine oleate iopamidol. Subsequently,
short gastric vein (small arrowhead) and posterior gastric vein
(large arrowhead) were retrogradely opacified.
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Fig. 2E. —67-year-old woman with alcohol-related liver cirrhosis and
gastric fundal varices. Gastric fundal varices with acute bleeding were
successfully treated with balloon-occluded retrograde transvenous
obliteration. Retrograde venogram obtained 1 day after treatment reveals
almost completely obliterated gastrorenal shunt (large arrow) and no
evidence of gastric varices. Small arrow indicates embolic coils inserted into
pericardiophrenic vein.
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Fig. 2F. —67-year-old woman with alcohol-related liver cirrhosis and
gastric fundal varices. Gastric fundal varices with acute bleeding were
successfully treated with balloon-occluded retrograde transvenous
obliteration. Contrast-enhanced CT scan obtained 10 days after procedure
reveals gastric varices with low attenuation (arrow), suggesting
complete obliteration.
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Fig. 2B. —67-year-old woman with alcohol-related liver cirrhosis and
gastric fundal varices. Gastric fundal varices with acute bleeding were
successfully treated with balloon-occluded retrograde transvenous
obliteration. Enhanced CT scan reveals large gastric fundal varices
(arrow). Arrowheads indicate balloon tamponade inserted into gastric
fundus.
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Fig. 2G. —67-year-old woman with alcohol-related liver cirrhosis and
gastric fundal varices. Gastric fundal varices with acute bleeding were
successfully treated with balloon-occluded retrograde transvenous
obliteration. Endoscopic image obtained 3 months after treatment reveals
eradication of gastric varices.
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Copyright © 2002 by the American Roentgen Ray Society.
