AJR 2003; 181:725-727
© American Roentgen Ray Society
Ruptured Duodenal Varices Successfully Treated with Balloon-Occluded Retrograde Transvenous Obliteration: Usefulness of Microcatheters
Tetsuo Sonomura1,
Koushi Horihata1,
Kunihiro Yamahara2,
Toshio Dozaiku2,
Takashi Toyonaga2,
Takashi Hiroka2 and
Morio Sato3
1 Department of Radiology, Kishiwada Tokushukai Hospital, 4-27-1, Kamori-cho,
Kishiwada-shi 596-8522, Japan.
2 Department of Internal Medicine, Kishiwada Tokushukai Hospital, Kishiwada-shi
596-8522, Japan.
3 Department of Radiology, Wakayama Medical University, 811-1, Kimiidera,
Wakayama-shi 641-8510, Japan.
Received December 6, 2002;
accepted after revision March 4, 2003.
Address correspondence to T. Sonomura.
Introduction
Duodenal varices rarely develop in patients with portal hypertension.
Bleeding from duodenal varices is often massive and life-threatening
[1]. Treatment for duodenal
varices includes endoscopic procedures, surgery, and interventional radiology.
Recently, several studies have reported the success of balloon-occluded
retrograde transvenous obliteration (BRTO) for duodenal varices
[2-4].
In these studies, BRTO was combined with endoscopic treatment and coil
embolization. In our patient, a ruptured duodenal varix was successfully
treated by BRTO using a microcatheter, without the need for endoscopic
treatment and coil embolization.
Case Report
A 77-year-old woman had been treated for idiopathic liver cirrhosis in
another hospital. Several times since September 2001, she had complained of
tarry stools. On October 2 of that year, endoscopy was performed that showed
large varices in the second portion of the duodenum. In one of the varices, a
small ulcer was detected, suggesting hemorrhage. She also had esophageal
varices, but these did not show any signs of hemorrhage. Hemorrhage from the
duodenal varices was thus diagnosed. Frequent blood transfusions transiently
improved the patient's anemia. However, on October 13, melena recurred. On
October 15, the patient was referred to our hospital.
Laboratory findings on admission showed the following: RBC, 268 x
104/µL; hemoglobin, 7.5 g/dL; hematocrit, 22.6%; platelets,
80,000/mL; total bilirubin, 1.38 mg/dL; serum albumin, 3.1 g/dL; and
prothrombin time, 15.1 sec (reference, 11.3 sec). Neither ascites nor
encephalopathy was observed. Liver function was evaluated as grade A according
to the Child-Pugh classification. Contrast-enhanced CT revealed duodenal
varices and collateral veins (Fig.
1A). The varices were located in the second and third portions of
the duodenum. Dilated collateral veins appeared to flow into the inferior vena
cava, suggesting that the right ovarian vein played an important role as a
draining vein. Because this provided an approach route for BRTO, we selected
this procedure to treat the duodenal varix.
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Fig. 1A. —77-year-old woman with duodenal varices. Contrast-enhanced CT
scan obtained before balloon-occluded retrograde transvenous obliteration
(BRTO) shows duodenal varices (arrow) and dilated draining veins.
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An 8-French sheath (Cobra type, Medikit, Tokyo, Japan) was inserted into
the inferior vena cava via the right femoral vein. A 6-French balloon catheter
(Cobra type, balloon diameter, 20 mm, Clinical Supply, Gifu, Japan) was
inserted into the right ovarian vein. During balloon occlusion, retrograde
right ovarian venography was performed. As a result, the dilated collateral
vein was imaged. However, the duodenal varices were not imaged. Therefore, a
3-French microcatheter was advanced to the duodenal varices via the right
femoral vein, and contrast medium was infused through the microcatheter to
enable imaging. No contrast medium leaked into the systemic circulation or the
portal vein. During balloon occlusion, a sclerosing agent, 5% ethanolamine
oleate, with iopamidol, was slowly and intermittently infused through the
microcatheter (Fig. 1B).
Infusion was continued (total dose, 20 mL) until the duodenal varices and a
feeding vein, the pancreaticoduodenal vein, were entirely imaged.
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Fig. 1B. —77-year-old woman with duodenal varices. Angiogram shows
duodenal varices and dilated right ovarian vein. Balloon catheter was inserted
into right ovarian vein via right femoral vein. During balloon occlusion, 5%
ethanolamine oleate with iopamidol (20 mL) was infused through microcatheter
(arrow).
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The following morning, complete thrombosis of the duodenal varices was
confirmed on contrast-enhanced CT (Fig.
1C) and the catheters were removed. During and after the infusion,
4000 U of haptoglobin was administered IV to prevent renal damage from
ethanolamine oleate-iopamidol-induced hemolysis
[5]. After BRTO, no serious
complications such as liver failure or renal failure occurred. One week after
BRTO, endoscopy showed three varices (one large with redness) in the second
portion of the duodenum (Fig.
1D). However, 4 months later, endoscopy showed the size of the
varices was markedly reduced (Fig.
1E). After BRTO, the esophageal varices enlarged and endoscopic
treatment was successfully performed.
Discussion
The hemodynamics of duodenal varices are complicated, and the hemodynamics
of any varix should be accurately understood before attempting BRTO. To
evaluate the hemodynamics, we perform contrast-enhanced CT, contrast-enhanced
MR angiography, transarterial portography, and percutaneous transhepatic
portography. Angiography is useful for evaluating the direction of blood flow.
Our patient's duodenal varices were not imaged on transarterial portography.
Enhanced CT showed inflow of a collateral vein connecting the duodenal varices
to the inferior vena cava. We selected BRTO via the right femoral vein. Often,
a common feeding vein for duodenal varices is the pancreaticoduodenal vein,
with the right gonadal vein and right superior capsular vein functioning as
draining veins. In this patient, the pancreaticoduodenal vein functioned as
the main feeding vein, and the right ovarian vein as the draining vein.
Treatments for duodenal varices include endoscopic procedures (e.g.,
endoscopic variceal ligation, endoscopic injection sclerotherapy, and
clipping), surgery (e.g., variceal ligation, duodenal resection, and
extrahepatic portosystemic shunts), and interventional radiologic procedures
(e.g., percutaneous transhepatic obliteration, transileocolic vein
obliteration, transjugular intrahepatic portosystemic shunt, and BRTO).
Endoscopic treatments are only transiently effective; recurrence and
rebleeding of the varices easily develop. Surgical treatments carry a high
risk in patients with liver hypofunction. Generally, patients with ruptured
duodenal varices show liver hypofunction and a tendency to bleed.
Percutaneous transhepatic obliteration or transileocolic vein obliteration
alone may induce leakage of sclerosing agents into the systemic circulation,
and general anesthesia should be administered for transileocolic vein
obliteration. The transjugular intrahepatic portosystemic shunt has
limitations such as a significant mortality rate, shunt occlusion, and hepatic
encephalopathy [6]. Because a
transjugular intrahepatic portosystemic shunt creates a bypass from a
high-pressure area (portal vein) to a low-pressure area (inferior vena cava),
it relieves the portal hypertension, which is the underlying cause of the
varices. Yet, because a transjugular intrahepatic portosystemic shunt does not
target specific varices, but rather is more general, it seldom eliminates
varices completely. The improvement rate of gastric fundal varices after
transjugular intrahepatic portosystemic shunt is only 50%
[7]. Transjugular intrahepatic
portosystemic shunts do target the cause of the varices, but BRTO is more
effective in the long term because it completely embolizes each specific
targeted varix. BRTO is a noninvasive treatment without major complications
[8].
Haruta et al. [2] initially
performed BRTO to treat duodenal varices that did not respond to endoscopic
variceal ligation with successful results. Ota et al.
[3] combined transileocolic
vein obliteration with BRTO to treat duodenal varices, because endoscopic
injection sclerotherapy with a tissue adhesive agent (cyanoacrylate monomer)
achieved a temporary benefit. This combination therapy with 5% ethanolamine
oleate with iopamidol achieved successful results.
Ohta et al. [4] reported a
patient in whom temporary endoscopic hemostasis using three metallic clips was
performed to treat a hemorrhagic duodenal varix, and then BRTO was performed
with successful results. In the patient, the draining vein for the duodenal
varix was the right ovarian vein. During balloon occlusion, the duodenal varix
was not imaged on right ovarian venography. Contrast medium leaked to the
distal (ovarian) side of the right ovarian vein. Therefore, the distal side
was embolized with four steel coils before the 5% ethanolamine oleate with
iopamidol was infused. The duodenal varix was successfully thrombosed. Thus,
BRTO for duodenal varices is combined with endoscopic treatments and coil
embolization in many patients.
However, in our patient, a 3-French microcatheter was advanced to the
duodenal varices, and 5% ethanolamine oleate with iopamidol was infused
through the microcatheter. Treatment was successful with BRTO alone. In some
patients, it may be easy to insert a microcatheter adjacent to the duodenal
varix, so this procedure may be useful in selected cases.
In our patient, the esophageal varices worsened after BRTO. Occlusion of
the duodenal varices and dilated draining veins may have induced esophageal
varices as another collateral route. The esophageal varices were readily
treated by endoscopic procedures. Therefore, the status of esophageal varices
should be endoscopically checked after BRTO.
References
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Introduction
Case Report
