Transjugular intrahepatic portosystemic shunt combined with esophagogastric variceal embolization in the treatment of a large gastrorenal shunt

AIM: To evaluate the efficacy and safety of transjugular intrahepatic portosystemic shunt(TIPS) combined with stomach and esophageal variceal embolization(SEVE) in cirrhotic patients with a large gastrorenal vessel shunt(GRVS).METHODS: Eighty-one cirrhotic patients with gastric variceal bleeding(GVB) associated with a GRVS were enrolled in the study and accepted TIPS combined with SEVE(TIPS + SEVE), by which portosystemic pressuregradient(PPG), biochemical, TIPS-related complications, shunt dysfunction, rebleeding, and death were evaluated. RESULTS: The PPGs before TIPS were greater than 12 mmH g in 81 patients. TIPS + SEVE treatment caused a significant decrease in PPG(from 37.97 ± 6.36 mmH g to 28.15 ± 6.52 mm Hg, t = 19.22, P < 0.001). The percentage of reduction in PPG was greater than 20%from baseline. There were no significant differences in albumin, alanine aminotransferase, aspartate aminotransferase, bilirubin, prothrombin time, or Child-Pugh score before and after operation. In all patients, rebleeding rates were 3%, 6%, 12%, 18%, and 18% at 1,3, 6, 12, and 18 mo, respectively. Five patients(6.2%)were diagnosed as having hepatic encephalopathy. The rates of shunt dysfunction were 0%, 4%, 9%, 26%,and 26%, at 1, 3, 6, 12, and 18 mo, respectively. The cumulative survival rates in 1, 3, 6, 12, and 18 mo were100%, 100%, 95%, 90%, and 90%, respectively.CONCLUSION: Our preliminary results indicated that the efficacy and safety of TIPS + SEVE were satisfactory in cirrhotic patients with GVB associated with a GRVS(GVB + GRVS).

Efficacy and safety of combined endoscopic cyanoacrylate injection and balloon-occluded retrograde transvenous occlusion(BRTOcc)of gastrorenal shunts in patients with bleeding gastric fundal varices

Background:Endoscopic cyanoacrylate(glue)injection of fundal varices may result in life-threatening embolic adverse events through spontaneous gastrorenal shunts(GRSs).Balloon-occluded retrograde transvenous occlusion(BRTOcc)of GRSs during cyanoacrylate injection may prevent serious systemic glue embolization through the shunt.This study aimed to evaluate the efficacy and safety of a combined endoscopic–interventional radiologic(BRTOcc)approach for the treatment of bleeding fundal varices.Methods:We retrospectively analysed the data of patients who underwent the combined procedure for acutely bleeding fundal varices between January 2010 and April 2018.Data were extracted for patient demographics,clinical and endoscopic findings,technical details,and adverse events of the endoscopic–BRTOcc approach and patient outcomes.Results:We identified 30 patients(13[43.3%]women;median age 58[range,25–92]years)with gastroesophageal varices type 2(53.3%,16/30)and isolated gastric varices type 1(46.7%,14/30)per Sarin classification,and median clinical and endoscopic follow-up of 151(range,4–2,513)days and 98(range,3–2,373)days,respectively.The median volume of octylcyanoacrylate:Lipiodol injected was 7(range,4–22)mL.Procedure-related adverse events occurred in three(10.0%)patients,including transient fever,non-life-threatening pulmonary glue embolism,and an injection-site ulcer bleed.Complete gastric variceal obturation was achieved in 18 of 21 patients(85.7%)at endoscopic follow-up.Delayed variceal rebleeding was confirmed in one patient(3.3%)and suspected in two patients(6.7%).Although no procedure-related deaths occurred,the overall mortality rate was 46.7%,primarily from liver-disease progression and co-morbidities.Conclusion:The combined endoscopic–BRTOcc procedure is a relatively safe and effective technique for bleeding fundal varices,with a high rate of variceal obturation and a low rate of serious adverse events.

Difference between type 2 gastroesophageal varices and isolated fundic varices in clinical profiles and portosystemic collaterals

BACKGROUND There is significant heterogeneity between gastroesophageal varices(GOV2)and isolated gastric varices(IGV1).The data on the difference between GOV2 and IGV1 are limited.AIM To determine the etiology,clinical profiles,endoscopic findings,imaging signs,portosystemic collaterals in patients with GOV2 and IGV1.METHODS Medical records of 252 patients with gastric fundal varices were retrospectively collected,and computed tomography images were analyzed.RESULTS Significant differences in routine blood examination,Child-Pugh classification and MELD scores were found between GOV2 and IGV1.The incidence of peptic ulcers in patients with IGV1(26.55%)was higher than that of GOV2(11.01%),while portal hypertensive gastropathy was more commonly found in patients with GOV2(22.02%)than in those with IGV1(3.54%).Typical radiological signs of cirrhotic liver were more commonly observed in patients with GOV2 than in those with IGV1.In patients with GOV2,the main afferent vessels were via the left gastric vein(LGV)(97.94%)and short gastric vein(SGV)(39.18%).In patients with IGV1,the main afferent vessels were via the LGV(75.61%),SGV(63.41%)and posterior gastric vein(PGV)(43.90%).In IGV1 patients with pancreatic diseases,spleno-gastromental-superior mesenteric shunt(48.15%)was a major collateral vessel.In patients with fundic varices,the sizes of gastric/esophageal varices were positively correlated with afferent vessels(LGVs and PGVs)and efferent vessels(gastrorenal shunts).The size of the esophageal varices was negatively correlated with gastrorenal shunts in GOV2 patients.CONCLUSION Significant heterogeneity in the etiology and vascular changes between GOV2 and IGV1 is useful in making therapeutic decisions.

Balloon-occluded retrograde transvenous obliteration with lauromacrogol sclerosant foam for gastric varices

Objectives:To evaluate the safety and efficacy of balloon-occluded retrograde transvenous obliteration(BRTO)using lauromacrogol sclerosant foam for gastric varices(GVs)with gastrorenal venous shunts.Methods:Data of GV patients treated with BRTO using lauromacrogol sclerosant foam in 2016–2020 were retrospectively analyzed along with procedural success rate,complications,and follow-up efficacy.Results:A total of 31 patients were treated with BRTO.The sclerosant foam was prepared by mixing iodinated oil,lauromacrogol,and air at a 1:2:3 ratio.The BRTO procedure was successfully completed in 93.5%of patients.One patient was allergic to the lauromacrogol injection.A mild postoperative fever occurred in three patients.One patient experienced grand mal seizures after the procedure.There was no significant difference in the median Child-Turcotte-Pugh scores before versus after BRTO.Complete GV resolution was observed in 93.1%of patients.One patient underwent endoscopic treatment for the development of high-risk esophageal varices.Another patient underwent transjugular intrahepatic portosystemic shunt placement for the aggravation of ascites.Conclusions:Lauromacrogol sclerosant foam is safe and effective in patients undergoing BRTO for GV.