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1
First Department of Internal Medicine, Hiroshima University School of
Medicine, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
2
Department of Radiology, Hiroshima University School of Medicine, Hiroshima
734-8551, Japan.
Received August 3, 2000;
accepted after revision September 27, 2000.
Address correspondence to M. Kitamoto.
Abstract
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SUBJECTS AND METHODS. We compared 3D helical CT portography and conventional angiographic portography in 30 consecutive patients with gastric fundic varices. We assessed whether 3D helical CT portography is useful in selecting patients and in evaluating the results of balloon-occluded retrograde transvenous obliteration.
RESULTS. Three-dimensional helical CT portography simultaneously depicted second or third branches of the intrahepatic portal vein and provided images of entire portosystemic collaterals. On 3D helical CT portography, gastric fundic varices were seen in 30 patients (100%), left gastric veins in 19 (63%), posterior gastric veins or short gastric veins in 28 (93%), gastrorenal shunts in 27 (90%), paraumbilical veins in three (10%), and inferior phrenic veins in two patients (7%). Findings of 3D helical CT portography and conventional angiographic portography were in close agreement. However, in four patients, posterior gastric veins or short gastric veins were not seen on conventional angiographic portography images of the spleen, but they were clearly revealed on 3D helical CT portography. Treatment was successful in all patients except one. Three-dimensional helical CT portography could easily evaluate therapeutic results.
CONCLUSION. Three-dimensional helical CT portography proved so effective that it can be considered a less invasive alternative than conventional angiographic portography in assessing portosystemic collaterals. CT portography is useful in selecting candidates from patients with gastric fundic varices for retrograde transvenous obliteration and also in evaluating therapeutic results.
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The purpose of our study was to investigate the usefulness of contrast-enhanced 3D CT portography in patients with gastric fundic varices for evaluating portosystemic collaterals before and after retrograde transvenous obliteration. The results of 3D CT portography were compared with those of conventional angiographic portography.
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Twenty-eight patients had clinical evidence of liver cirrhosis. The cause of cirrhosis was viral in 22 patients (one patient had positive findings for hepatitis B surface antigen and 21 had positive findings for anti-hepatitis C virus antibody), alcoholic in four, and unknown in two (negative findings for viral markers). By Child's classification [11], 16 patients were grade A; six, grade B; and six, grade C. In the two patients who did not have liver cirrhosis, gastric fundic varices developed as a result of splenic vein occlusion and a malignant tumor of the pancreas. At entry into our study, 14 patients also had hepatocellular carcinoma that was unresectable because of the severity of liver dysfunction. No tumor had arterioportal shunts or portal venous tumor embolisms.
3D CT
CT was performed initially without contrast medium to identify the liver
location. With the use of a power injector (Auto Enhance A-250;
Nemoto-Kyorindo, Tokyo, Japan), 100 mL of iopamidol 300 (Iopamiron 300;
Schering, Berlin, Germany) heated to 37°C was injected at a rate of 3.5
mL/sec through a 22-gauge IV tube into a medially located antecubital vein.
Four sets of images were acquired in the craniocaudal direction at 25, 45, 65,
and 180 sec after initiation of contrast medium injection. The first and
second acquisitions were used for hepatic arterial phase images, the third
acquisition for portal venous phase images, and the fourth acquisition for
hepatic venous phase images. The third set of images was obtained during
suspended respiration in 20 sec, and the other acquisitions, in 10 sec. This
protocol is available for patients with hepatic diseases at our institution,
and the data of the third acquisition were used for obtaining 3D images of
portosystemic collaterals. All scans were performed on a LightSpeed (QX/i CT
scanner (General Electric Medical Systems, Milwaukee, WI) with scan parameters
including 0.8-sec gantry rotation speed, high-quality scan mode (pitch, 3),
2.5-mm slice thickness, 7.5 mm per rotation table speed, and reconstruction
intervals of 1.25 mm for portal venous phase images. Three-dimensional CT
portography was performed with an Advantage workstation 3.1 (General Electric
Medical Systems). Both maximum intensity projection and shaded-surface display
were used for image reconstruction.
Conventional Digital Subtraction Angiography
Angiography was performed from a femoral approach in all patients using a
standard angiography unit (Polydoros 80; Siemens, Erlangen, Germany). The
superior mesenteric artery and celiac axis were selected. A 5-French selective
catheter was advanced into the splenic and left gastric arteries over a
guidewire. Digital subtraction angiography was performed using iohexol 300
(Omnipaque 300; Daiichi, Tokyo, Japan).
Balloon-Occluded Retrograde Transvenous Obliteration
Balloon-occluded retrograde transvenous obliteration was performed
according to the method of Kanagawa et al.
[1]. Briefly, a 6.5-French
balloon catheter (Artec Balloon Catheter, B-RTV type I SML; Create Medic,
Tokyo, Japan) was inserted into the inferior vena cava via the right femoral
vein and was advanced into a gastrorenal shunt via the left renal vein. After
blood flow into the renal vein was blocked by inflating the balloon,
retrograde venography was performed to determine the hemodynamics of gastric
fundic varices and collateral veins. While blood flow was blocked by the
balloon, 9-40 mL (mean, 22.4 mL) of 5% ethanolamine oleate iopamidol (Oldamin;
Grelan Pharmaceutical, Tokyo, Japan) was injected gradually under fluoroscopy.
If occlusion of collateral veins was necessary, a 50% glucose solution and
embolic coils were also used
[4]. The catheter was left in
the vein for about 20 hr and was removed after re-retrograde venography.
Systemic IV human haptoglobin was administered prophylactically before the 5%
ethanolamine oleate iopamidol infusion.
Examination and Statistical Analysis
Study 1.—We compared portosystemic collaterals such as the
gastric fundic varices, the left gastric vein, the posterior gastric vein, the
short gastric vein, the gastrorenal shunt, the paraumbilical vein, and the
inferior phrenic vein on 3D CT portography images with those on conventional
angiographic portography images. Images were analyzed by two experienced
radiologists who were unaware of the clinical information. The quality of all
conventional angiographic portography and 3D CT portography images was graded
on a scale of 1-4 (1, not visible; 2, fair; 3, good; 4, excellent). Separate
analyses were performed for each portosystemic collateral. Image quality score
was assessed for abdominal vessels including the splenic vein, the left
gastric vein, the posterior gastric vein, the short gastric vein, and the
gastrorenal shunt. Subjective image quality of 3D CT portography was also
examined and was classified into three grades according to vessel diameter
(small, smaller than half the diameter of the portal trunk; large, greater
than the diameter of the portal trunk; medium, between small and large). Kappa
values were calculated to measure concordance between the results of
conventional angiographic portography and 3D CT portography
[12]. Kappa values greater
than 0 were considered positive agreement; those less than 0.2, positive but
poor agreement; 0.21-0.40, fair agreement; 0.41-0.60, moderate agreement;
0.61-0.80, good agreement; and greater than 0.81, excellent agreement.
Study 2.—For 12 patients treated for gastric fundic varices with retrograde transvenous obliteration, we examined whether 3D CT portography is useful to select patients and to evaluate the treatment results. After completing treatment, patients were followed up at intervals of 1 week and 1, 3, 6, and 12 months thereafter using 3D CT portography and upper gastrointestinal endoscopy. We also compared 3D CT portography images with retrograde venography images obtained during balloon occlusion.
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Comparison of 3D CT Portography and Conventional Angiographic
Portography
The splenic vein was shown by both examinations to be patent in 28 patients
(93%) and occluded in two (7%). The left gastric vein was imaged in 19
patients (63%) on 3D CT portography and in 20 patients (67%) on conventional
angiographic portography. The posterior gastric vein/short gastric vein was
imaged in 28 patients (93%) on 3D CT portography and in 24 patients (80%) on
conventional angiographic portography. A gastrorenal shunt was imaged in 27
patients (90%) on 3D CT portography and in 26 patients (87%) on conventional
angiographic portography. The paraumbilical vein was imaged on both
examinations as patent in three patients (10%). The inferior phrenic vein was
imaged on both examinations as patent in two patients (7%) (Fig.
4A,4B).
In these two patients, no gastrorenal shunt was imaged. Among 30 patients with
gastric fundic varices, outflow vessels were mainly revealed as a gastrorenal
shunt in 27 patients and as an inferior phrenic vein in two
(Table 1). In the remaining one
patient with splenic vein occlusion, neither examination revealed either a
gastrorenal shunt or an inferior phrenic vein; the outflowing vessel was the
left gastric vein as seen on conventional angiographic portography.
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The average image quality of 3D CT portography was equivalent to or better than that of conventional angiographic portography. Especially for depicting the posterior gastric vein/short gastric vein, 3D CT portography revealed higher image quality than conventional angiographic portography (Table 2). Image quality was good even for small vessels (average score, 3.6) and was close to excellent for medium collaterals (average score, 3.9).
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The overall agreement between 3D CT portography and conventional
angiographic portography for depicting portosystemic collaterals was excellent
(
= 0.92). The agreement was excellent for the splenic vein ( =
1.00), the left gastric vein ( = 0.91), the paraumbilical vein (
= 1.00), and the inferior phrenic vein ( = 1.00). The agreement was
good for the posterior gastric vein/short gastric vein ( = 0.61) and
gastrorenal shunts ( = 0.71). In four patients (13%), the posterior
gastric vein/short gastric vein was not imaged on conventional angiographic
portography but was clearly seen on 3D CT portography. An image of the spleen
covered the posterior gastric vein/short gastric vein on conventional
angiographic portography. Comparison of findings of 3D CT portography and
conventional angiographic portography revealed close agreement. With respect
to depicting the posterior gastric vein/short gastric vein, 3D CT portography
was superior to conventional angiographic portography.
Comparison of Findings Before and After Treatment of Varices
Eight patients had previous episodes of bleeding from gastric fundic
varices. In four patients, the procedure was prophylactically performed
because of the appearance of signs of impending hemorrhage on endoscopy. Of
eight patients with a history of bleeding, seven underwent 3D CT portography
during hemostasis, five spontaneously and two with endoscopic injection
sclerotherapy. In the remaining patient, the presence of a gastrorenal shunt
had already been confirmed on 3D CT portography performed before hemorrhage
from the gastric fundic varices. This patient was rapidly treated with
retrograde transvenous obliteration, and both hemostasis and eradication of
gastric fundic varices were obtained.
The representative course of retrograde transvenous obliteration is shown in Figure 5A,5B,5C,5D,5E,5F. During the treatment, we administered 5% ethanolamine oleate iopamidol until images of entire gastric fundic varices appeared. Three-dimensional CT portography could depict images of entire gastric varices at one time, whereas even retrograde venography performed during balloon occlusion did not depict entire images because of the presence of small collaterals such as the inferior phrenic vein (Fig. 5C). In 11 of 12 patients, the inferior phrenic vein was depicted on retrograde venography performed during balloon occlusion. After gastric varices were delineated corresponding to images obtained on 3D CT portography, inflowing veins such as the left gastric vein and the posterior gastric vein/short gastric vein were retrogradely delineated (Fig. 5D). Thus, we stopped the injection of 5% ethanolamine oleate iopamidol under fluoroscopy, and retrograde transvenous obliteration was successful in all patients but one.
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Three-dimensional CT portography can evaluate therapeutic results. The posterior gastric vein/short gastric vein, the gastric fundic varices, and gastrorenal shunts disappeared 1 week after treatment. Simultaneously performed endoscopy showed slightly discolored gastric varices without a change in size, but these varices disappeared 3 months later in 10 patients (Fig. 5F). In one patient who had large gastric fundic varices with many collaterals including the left gastric vein, the posterior gastric vein/short gastric vein, the inferior phrenic vein, and a gastro-renal shunt, 3D CT portography performed 1 week after retrograde transvenous obliteration showed disappearance of the gastrorenal shunt but the continuing presence of the left gastric vein and reduced gastric fundic varices. Three-dimensional CT portography and endoscopy followed by treatment revealed enlargement of esophageal varices but the sustained shape of the gastric varices. In two patients with a remaining left gastric vein, including the incompletely treated patient, esophageal varices became larger; the patients were therefore treated with prophylactic endoscopic injection sclerotherapy 1 year after the retrograde obliteration. Three-dimensional CT portography performed 1 month after endoscopic injection sclerotherapy revealed that the left gastric vein had disappeared.
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Although small collateral vessels could not be seen on 3D CT portography, it could depict portosystemic collaterals larger than approximately 3 mm in diameter. In our study, among vessels delineated on 3D CT portography, subjective image quality was good regardless of vessel diameter. With respect to the position of collaterals, subjective image quality of the posterior gastric vein/short gastric vein in conventional angiographic portography was only fair compared with that in 3D CT portography. Images of the spleen may cover images of the posterior gastric vein/short gastric vein on conventional angiographic portography. On the other hand, 3D CT portography can depict these collaterals regardless of the image of spleen, because 3D positional relationships can be shown from multiple directions by rearranging images to allow evaluation of the overall portosystemic collateral circulation, including the outflow tract. In view of these advantages and because it is less invasive, 3D CT portography might be superior to conventional angiographic portography for roughly depicting portosystemic collaterals. With 3D CT portography, however, we could not define very small vessels as well as with percutaneous transhepatic portography or retrograde venography performed during balloon occlusion. Indeed, in 11 of 12 patients, the inferior phrenic vein was depicted on retrograde venography performed during balloon occlusion, whereas 3D CT portography could not delineate these inferior phrenic veins.
In considering balloon-occluded retrograde transvenous obliteration for the treatment of patients with gastric fundic varices, 3D CT portography is useful first for selecting patients as candidates, second for planning, and third for evaluating the results. For example, when a gastrorenal shunt is seen on 3D CT portography, the patient can be considered a good candidate for the treatment. In particular, a patient with gastric fundic varices who already had a gastrorenal shunt as revealed on 3D CT portography could be treated rapidly despite hemorrhage. Indeed, we could perform emergency retrograde transvenous obliteration for bleeding gastric fundic varices, and both hemostasis and eradication of the varices were successful. When a gastrorenal shunt is obscure, another portosystemic shunt from the gastric fundic varices to the vena cava (such as the inferior phrenic vein) must be detected to perform retrograde transvenous obliteration. As shown in Figure 4A,4B, in a patient without a gastrorenal shunt the inferior phrenic vein could be imaged on 3D CT portography.
Three-dimensional CT portography may contribute to the procedure of retrograde transvenous obliteration. Even retrograde venography performed during balloon occlusion may not provide images of entire gastric fundic varices because of the presence of many other collateral veins [4]. On the other hand, 3D CT portography provided images of entire gastric fundic varices in all patients. During retrograde transvenous obliteration, obtaining images of entire varices is helpful in determining whether to suspend injection of 5% ethanolamine oleate iopamidol under fluoroscopy. Indeed, after gastric varices were delineated that corresponded to images obtained with 3D CT portography, inflowing vessels such as the left gastric vein and the posterior gastric vein/short gastric vein were retrogradely opacified, and the treatment was then finished. Retrograde transvenous obliteration was successful in all patients but one on the basis of images of entire gastric fundic varices obtained using 3D CT portography.
Efficacious treatment with retrograde transvenous obliteration is seen on axial CT images as nonenhanced vascular structures soon after treatment. Although axial CT images can show the patency of gastric fundic varices and gastrorenal shunts, it is difficult to discern the remaining small vessels after treatment on axial CT images. Three-dimensional CT portography can provide clear evaluation of both gastric fundic varices and small collaterals, and it is useful in estimating the efficacy of the treatment.
Moreover, information about the remaining collateral vessels may predict the clinical outcome after treatment. In two patients with a remnant left gastric vein revealed on 3D CT portography, esophageal varices became larger but were successfully treated with prophylactic endoscopic injection sclerotherapy. On the other hand, nine patients without a left gastric vein exhibited no worsening of esophageal varices after the treatment. Aggravation of esophageal varices after retrograde transvenous obliteration is possible because of the increased portal pressure and blood flow into the esophageal vein [1, 2]. Our study suggests that the presence of the left gastric vein might be related to the recurrence of esophageal varices.
In summary, 3D CT portography proved so effective that it can be considered a less invasive alternative to conventional angiographic portography for assessing portosystemic collaterals. The protocol used in our study can be routinely performed for patients with hepatic diseases to assess the vascularity of hepatic tumors using a multiphase dynamic study and simultaneously performing 3D angiography. We can obtain excellent images of entire portosystemic collaterals using third acquisition (60 sec after the initiation of the contrast medium injection) regardless of the individual variations in the timing of enhancement. On the basis of the results presented here, we believe that 3D CT portography is useful for assessing portal hemodynamics. Moreover, it is useful in selecting candidates for balloon-occluded retrograde transvenous obliteration from patients with gastric fundic varices and also in evaluating therapeutic results. However, because our study consisted mainly of patients with viral cirrhosis, further study is necessary to confirm whether 3D CT portography images can be effectively used for liver cirrhosis from all causes.
Acknowledgments
We thank M. Ishifuro and Y. Akiyama for their assistance in obtaining
three-dimensional portography images.
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