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Technical Innovation |
1
Department of Radiology, Asahiakawa Medical College, 2-1-1-1
Midorigaoka-higashi, Asahikawa, Japan, 078-8510.
2
Department of Radiology, Sapporo Medical University, Minami1-nishi 16 Chuo-ku,
Sapporo, 060-8543, Japan.
3
Department of Radiology, Sapporo Higashi Tokushukai Hospital, Kita 33-higashi
13-3-21 Higashi-ku, Sapporo, 065-0033, Japan.
4
Department of Radiology, Sapporo Tokushukai Hospital, 18-4-10 Sakaedori,
Shiroishi-ku, Sapporo, 003, Japan.
Received April 2, 2001;
accepted after revision May 29, 2001.
Address correspondence to K. Takahashi.
Introduction
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We developed a method of balloon-occluded retrograde sclerosis, using a coaxial microcatheter, with which we can selectively obliterate the gastric varices while maintaining patency of the gastrorenal shunt. Compared with a standard method of balloon-occluded retrograde sclerotherapy, an advantage of our procedure is that we can sclerose the varices while still maintaining the patent shunt. Our objective is to describe a new way of performing balloon-occluded retrograde sclerosis of gastric varices.
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In the standard method of balloon-occluded retrograde sclerosis (Fig. 1A), a balloon catheter was inserted into and inflated at the left adrenal vein just above its confluence into the left renal vein. Varicography was performed with the inflated balloon catheter to evaluate the size and location of gastric varices, the collateral vessels to the systemic circulation, the amount of sclerosant to be injected, and the position of the balloon catheter. The sclerosant was injected into the left adrenal vein until it completely filled the gastric varices, and both structures were obliterated after the procedure. In patients in whom a varicography showed prominent collateral vessels, including superior phrenic vein and pericardial vein, embolization of these collateral vessels was occasionally needed to prevent inflow of the sclerosant to the systemic circulation.
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In balloon-occluded retrograde sclerosis with a coaxial microcatheter (Fig. 1B), IV catheterization was performed from the right internal jugular vein with an 8-French J-shaped long introducer (S-one sheath; Clinical Supply, Gifu, Japan). A 5-French balloon catheter (Selecon balloon catheter; Clinical Supply) was advanced into the left adrenal vein at the highest position possible to prevent its occlusion by sclerotherapy. A 2.9-French microcatheter was then selectively inserted into the gastric varices through an inflated balloon catheter. Sclerosant was injected through the microcatheter to fill the gastric varices, and it remained in the varices for 40 min during balloon occlusion. We left the microcatheter in the gastric varices during those 40 min, and then we withdrew as much of the sclerosant as possible through the microcatheter. During sclerotherapy, 4000 U of human haptoglobin were administered IV to prevent renal insufficiency. The patients remained in the angiography room during the procedure, which included 40 min of occlusion time.
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The mean amount of injected 5% ethanolamine oleate was 25 mL, in the range of 16-35 mL. Collateral vessels that were small in diameter and few in number were easily occluded by injection of the sclerosant. Embolization of collateral vessels with spring coils was not needed in any of the patients. Complications associated with this procedure, mild epigastric pain and transient hemoglobinuria, were present in all 12 patients. Epigastralgia and hemoglobinuria were transient and had almost disappeared by the end of procedure and during the following 24 hr, respectively.
Patency of the gastrorenal shunt vessels was confirmed in eight of 12 patients with contrast-enhanced CT performed after the procedure. In the 10 patients in whom sclerotherapy was effective, endoscopic examination performed during the follow-up period showed no evidence of regrowth of varices.
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TopIntroductionMaterials and MethodsResultsDiscussionReferences |
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In comparison with the standard procedure, balloon-occluded retrograde sclerosis with a coaxial microcatheter provides the following benefits. In the standard method, retrograde injection of sclerosant with positive pressure to fill the gastric varices may be associated with some risk of variceal rupture, whereas with our method, the gastric varices can be directly filled with sclerosant. Our method allows the selective obliteration of the gastric varices, retaining the patent gastrorenal shunt.
When balloon-occluded retrograde sclerosis is applied for the treatment of bleeding from gastric varices rather than for that of hepatic encephalopathy, obliteration of the limited portion of the varices protruding into the gastric lumen is sufficient. The gastrorenal shunt vessels should remain patent because obliteration of these vessels may result in aggravation of the existing esophageal varices and massive ascites due to rapid increase in portal venous pressure. Aggravation of esophageal varices has been reported in 10% to 16% of patients after the procedure [1, 2, 4,5,6], but it was not present in our patients.
In the standard procedure, embolization is occasionally performed on the branches of the gastrorenal shunt vessels, including the inferior phrenic vein, the phrenicocardinal vein, and the adrenal vein, to prevent inflow of ethanolamine oleate to the systemic circulation. In our method, a microcatheter is advanced into the gastric varices beyond most of these collateral branches, and we can avoid embolization before sclerotherapy.
In our sclerotherapy localized to gastric varices, we can reduce the amount of sclerosant to fill the varices, and we can additionally inject a small amount of sclerosant during the procedure to maintain a high concentration of sclerosant in the varices. With the traditional method, withdrawal of the sclerosant through the balloon catheter is occasionally difficult because the catheter tip attaches to the vascular wall. In our method, we can efficiently withdraw sclerosant, using a microcatheter and changing its position.
In two patients with varices of large size (18 and 20 mm in diameter), balloon-occluded retrograde transvenous obliteration was not effective, and some modification of the procedure, such as prolongation of the occlusion time or an increase in the amount of sclerosant, may be needed.
Although the number of subjects in our report is limited and further evaluation is needed, the major advantage of our procedure is that one can sclerose the varices while still retaining the patent shunt vessels.
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