DOI:10.2214/AJR.04.1971
AJR 2006; 186:1155-1157
© American Roentgen Ray Society
Selective Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varix with Preservation of Major Portacaval Shunt
Norifumi Nishida1,
Teruhisa Ninoi1,
Toshiaki Kitayama1,
Masahiro Tokunaga1,
Yukimasa Sakai1,
Masao Hamuro1,
Kenji Nakamura1,
Yuichi Inoue1 and
Ryusaku Yamada1
1 All authors: Department of Radiology, Osaka City University Graduate School of
Medicine, 1-4-3, Asahimachi, Abeno-bu, Osaka, Japan 545-8585.
Received December 28, 2004;
accepted after revision February 22, 2005.
Address correspondence to N. Nishida
(norifumin{at}med.osakacu.ac.jp).
Keywords: angiography • CT • embolization • interventional radiology • splenoportography • stomach
Introduction
Balloon-occluded retrograde transvenous obliteration (B-RTO) has been
performed instead of endoscopic and surgical treatment in the management of
gastric varix. The procedure is indicated for gastric varix with a major
portacaval shunt, such as a gastrorenal shunt or a shunt involving the left
inferior phrenic vein, and usually obliterates the gastric varix and the
connecting major portacaval shunt. B-RTO is safe, feasible, and effective in
the treatment of patients with gastric varix; however, aggravation of
esophageal varix is an important complication caused by increasing portal
pressure
[1-3].
We report the first case, to our knowledge, of selective B-RTO with
preservation of the major portacaval shunt. MDCT during splenic and superior
mesenteric arterial portography was useful for confirming the morphologic
features and developing a precise therapeutic plan.
Case Report
A 76-year-old man with Child class B cirrhosis of the liver caused by
hepatitis C virus infection was admitted for management of gastric varix.
Although the patient did not have gastric bleeding, the presence of a gastric
varix in danger of rupture, located at the gastric fornix and cardia, was
confirmed during endoscopy. Endoscopic sonography showed a gastric varix
(diameter, 9.5 mm) with high flow (15.6 cm/sec) that was considered difficult
to manage with an endoscopic procedure. No esophageal varix was found at
endoscopic examination.
Before the procedure, MDCT (Aquilion Multi scanner, Toshiba) was performed
to evaluate the gastric varix and connecting collateral pathways. Iopamidol
370 (100 mL) (Iopamiron, Schering Japan) was injected into an antecubital vein
at an injection rate of 5 mL/sec. Scan acquisition was performed 50 sec after
initiation of the injection of contrast material. The coronal partial maximum
intensity projection reconstructed images clearly revealed a gastric varix
around the gastric fornix and cardia, a dilated short gastric vein, the left
gastric vein, and a gastrorenal shunt (Fig.
1A). The intrahepatic portion of the portal vein was narrowed.
B-RTO was thought to be technically feasible, but we feared portal pressure
elevation after occlusion of a major portacaval shunt could result in severe
effects of portal hypertension, such as aggravation of an esophageal varix or
ascites.
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Fig. 1A —76-year-old man with Child class B cirrhosis of the liver. Coronal
partial maximum intensity projection MDCT image obtained after injection of
contrast medium through peripheral vein shows gastric varix (large
arrowheads), dilated gastrorenal shunt (small arrowheads)
draining into left renal vein, dilated short gastric vein (large
arrow), and dilated left gastric vein (small arrows). It was
difficult to evaluate communicating patterns of veins and gastric varix.
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Because the coronal partial maximum intensity projection reconstructed
image seemed to show a short gastric vein as the only afferent vein of the
gastric varix and the left gastric vein as directly contiguous with the
gastrorenal shunt, MDCT during arterial portography via the splenic and
superior mesenteric arteries and splenic and superior mesenteric arterial
portography were scheduled for further investigation of the hemodynamics and
morphologic features of the gastric varix. MDCT scans during arterial
portography were obtained after injection of 90 mL of diluted contrast medium
(approximately 120 mg iodine per milliliter) at an injection rate of 3 mL/sec
through the catheter placed in the proximal superior mesenteric artery or
splenic artery. Scan acquisition was performed 25 sec after initiation of the
contrast injection for MDCT during superior mesenteric arterial portography
and 20 sec after initiation of the injection for MDCT during splenic arterial
portography. Splenic arterial portography showed a short gastric vein and a
gastrorenal shunt. Superior mesenteric arterial portography showed the left
gastric vein and a gastrorenal shunt. Neither form of arterial portography
showed the precise location of the gastric varix or the relation between the
gastric varix and connecting veins. MDCT during arterial portography, however,
showed in detail the location of the gastric varix and the connecting veins.
MDCT during splenic arterial portography enhanced the splenic vein, the short
gastric vein, the gastric varix, which protruded from the gastric wall, and
the gastrorenal shunt (Fig.
1B). MDCT during superior mesenteric arterial portography showed
enhancement of the left gastric vein and the gastrorenal shunt but not of the
gastric varix. These findings suggested the short gastric vein was the only
afferent vein of the gastric varix and that the left gastric vein was directly
contiguous with the gastrorenal shunt but did not contribute to the varix
(Fig. 1C). We planned
obliteration of the gastric varix and the short gastric vein, but not of the
left gastric vein or gastrorenal shunt, by the retrograde transvenous
technique with balloon occlusion of the selective draining vein of the gastric
varix.
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Fig. 1B —76-year-old man with Child class B cirrhosis of the liver. Coronal
partial maximum intensity projection MDCT image obtained during splenic
arterial portography shows enhancement of splenic vein, dilated short gastric
vein (arrow), and gastric varix (arrowhead), which protrudes
from gastric wall.
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Fig. 1C —76-year-old man with Child class B cirrhosis of the liver. Coronal
partial maximum intensity projection MDCT image obtained during superior
mesenteric arterial portography shows enhancement of dilated left gastric vein
(arrow) and gastrorenal shunt (arrowhead) without
enhancement of the gastric varix.
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Fig. 1D —76-year-old man with Child class B cirrhosis of the liver.
Retrograde venogram obtained during balloon occlusion of draining vein
immediately behind gastric varix via left adrenal vein shows gastric varix
(arrowheads) and short gastric vein (arrow).
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Fig. 1E —76-year-old man with Child class B cirrhosis of the liver. Coronal
partial maximum intensity projection of MDCT image obtained with contrast
injection through peripheral vein 3 months after selective ballon-occluded
retrograde transvenous obliteration shows no enhancement of gastric varix but
enhancement of left gastric vein (arrows) and gastrorenal shunt
(arrowheads), indicating patency.
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A 6-French balloon catheter (20-mm balloon) (MOIYAN, Miyano) was passed
through the left renal vein into the left adrenal vein from the right femoral
vein under local anesthesia. Retrograde venography with balloon inflation from
the left adrenal vein showed the gastrorenal shunt, the left gastric vein, the
gastric varix, and the short gastric vein. To avoid embolization of the
gastrorenal shunt and the left gastric vein, the balloon catheter was further
advanced selectively into the draining vein immediately behind the gastric
varix. The sclerosing agent was a 5% ethanolamine oleate-iopamidol mixture
consisting of 10% ethanolamine oleate (Oldamin, Takeda Pharmaceutical) and the
same dose of nonionic contrast medium (350 mg of iodine, iopamidol). After
retrograde venography (Fig.
1D), the sclerosing agent was injected slowly through the balloon
catheter and wedged into the draining vein immediately behind the gastric
varix with balloon inflation under fluoroscopic monitoring. The gastric varix
was completely filled after a total of 23 mL of 5% ethanolamine
oleate-iopamidol mixture had been injected. The next day, after confirmation
of clot formation in the draining vein and the gastric varix with a test
contrast medium injection, the balloon was deflated, and the catheter was
withdrawn. Before injection of 5% ethanolamine oleate-iopamidol mixture, 4,000
units of human haptoglobin (Green Cross), 1 unit of which binds 1 mg of
hemoglobin, was administered IV to prevent hemolysis and renal failure
[4], which can be induced by
ethanolamine oleate.
Lack of flow in the gastric varix was confirmed at endoscopic sonographic
examination 1 week after the procedure. Reduction of the gastric varix was
confirmed at endoscopic examination 3 months later. Enhanced MDCT performed 3
months after the endoscopic examination showed no enhancement of the gastric
varix but showed enhancement of the left gastric vein and the gastrorenal
shunt (Fig. 1E). There were no
complications during the procedure. The patient's hepatic function and blood
cell counts were not significantly changed after the procedure. No aggravation
of an esophageal varix was found at endoscopic examination 1 year after the
B-RTO procedure.
Discussion
B-RTO is effective in coagulation of gastric varices because the sclerosant
is injected directly into the gastric varix through a draining vein while
blood flow in the varix is stopped by retrograde balloon occlusion
[1-3].
Because sufficient filling and stagnation of sclerosant in the entire variceal
complex are essential for successful B-RTO, not only the gastric varix but
also the draining vein usually are obliterated, even when the draining vein is
a major shunt. Consequently, a very high initial success rate is achieved;
however, aggravation of an esophageal varix due to increased portal pressure
is an important complication, reported in 10% to 66%
[1-3]
of procedures. Because B-RTO embolizes the portacaval shunt flow that acts to
reduce portal hypertension, portal pressure elevation is inevitable after
treatment. The ideal procedure would obliterate only the gastric varix and its
minimal complex while preserving as much of the portacaval shunt as is
possible. We were successful in managing gastric varix using B-RTO while
preserving the gastrorenal shunt, which to our knowledge has never been
reported.
Before B-RTO, it is important to recognize whether a dilated draining vein
is present and to assess the anatomic features of the gastric varix
[5]. Because MDCT with contrast
injection from a peripheral vein is reliable for revealing a gastric varix and
the draining veins around the gastric fornix
[5,
6], one can easily identify not
only a gastrorenal shunt, which is the most common draining vein of a gastric
varix, but also shunts involving other collateral veins, such as the inferior
phrenic, hemiazygos, and pericardial veins, that occasionally become draining
veins. Anatomic classification of gastric varix and therapeutic strategies and
techniques based on communicating afferent and draining veins have been
described [7,
8]. Although it has been
schematically reported [7], our
patient's anatomic pattern (dilated short gastric vein [the only afferent vein
of the gastric varix], dilated left gastric vein not contributing to the
varix, and both veins flowing into the gastrorenal shunt) to our knowledge has
not previously been clearly visualized. MDCT during arterial portography via
the splenic and superior mesenteric arteries provided more precise information
for recognizing this anatomic variation than did conventional arterial
portography and MDCT with contrast injection through a peripheral vein. MDCT
during splenic arterial portography was especially good for evaluating the
circulation of the splenic venous system, including short and retrogastric
veins arising from the splenic vein. MDCT during superior mesenteric arterial
portography was especially good for evaluating circulation in the left gastric
veins, usually arising from confluence of the portal vein and the superior
mesenteric vein. Comparing the two types of MDCT images precisely depicted
complete anatomic information about the portal venous system. The findings
were helpful for developing the therapeutic plan of selective B-RTO with
preservation of the gastrorenal shunt.
Although our report concerns only one patient, and further examination is
needed, selective B-RTO may be an effective means of preventing recurrent
variceal bleeding. MDCT during arterial portography may be worthwhile for
evaluating the flow patterns of the afferent and draining veins of gastric
varices before selective variceal obliteration.
References
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Introduction
Case Report
