Evaluation of the efficacy and safety of endoscopic band ligation in the treatment of bleeding from mild to moderate gastric varices type 1

BACKGROUND According to practice guidelines,endoscopic band ligation(EBL)and endoscopic tissue adhesive injection(TAI)are recommended for treating bleeding from esophagogastric varices.However,EBL and TAI are known to cause serious complications,such as hemorrhage from dislodged ligature rings caused by EBL and hemorrhage from operation-related ulcers resulting from TAI.However,the optimal therapy for mild to moderate type 1 gastric variceal hemorrhage(GOV1)has not been determined.Therefore,the aim of this study was to discover an individualized treatment for mild to moderate GOV1.AIM To compare the efficacy,safety and costs of EBL and TAI for the treatment of mild and moderate GOV1.METHODS A clinical analysis of the data retrieved from patients with mild or moderate GOV1 gastric varices who were treated under endoscopy was also conducted.Patients were allocated to an EBL group or an endoscopic TAI group.The differences in the incidence of varicose relief,operative time,operation success rate,mortality rate within 6 wk,rebleeding rate,6-wk operation-related ulcer healing rate,complication rate and average operation cost were compared between the two groups of patients.RESULTS The total effective rate of the two treatments was similar,but the efficacy of EBL(66.7%)was markedly better than that of TAI(39.2%)(P<0.05).The operation success rate in both groups was 100%,and the 6-wk mortality rate in both groups was 0%.The average operative time(26 min)in the EBL group was significantly shorter than that in the TAI group(46 min)(P<0.01).The rate of delayed postoperative rebleeding in the EBL group was significantly lower than that in the TAI group(11.8%vs 45.1%)(P<0.01).At 6 wk after the operation,the healing rate of operation-related ulcers in the EBL group was 80.4%,which was significantly greater than that in the TAI group(35.3%)(P<0.01).The incidence of postoperative complications in the two groups was similar.The average cost and other related economic factors were greater for the EBL than for the TAI(P<0.01).CONCLUSION For mild to moderate GOV1,patients with EBL had a greater one-time varix eradication rate,a greater 6-wk operation-related ulcer healing rate,a lower delayed rebleeding rate and a lower cost than patients with TAI.

Reinforcing the management of type 1 gastric esophageal varices

Variceal bleed represents an important complication of cirrhosis,with its presence reflecting the severity of liver disease.Gastric varices,though less frequently seen than esophageal varices,present a distinct clinical challenge due to its higher intensity of bleeding and associated mortality.Based upon the Sarin classification,GOV1 is the most common subtype of gastric varices seen in clinical practice.

Endoscopic band ligation or endoscopic tissue adhesive injection in the treatment of gastric varices:Which is better?

The combination of endoscopic ultrasound with endoscopic treatment of type 1 gastric variceal hemorrhage may improve the robustness and generalizability of the findings in future studies.Moreover,the esophageal varices should also be included in the evaluation of treatment efficacy in subsequent studies to reach a more convincing conclusion.

Endoscopic ultrasound-guided treatment of isolated gastric varices entwined with arteries:A case report

BACKGROUND Interventional endoscopic ultrasound is clinically used for the treatment of isolated gastric varices(IGVs)owing to its precise visualization.CASE SUMMARY A 39-year-old man was diagnosed with a large IGV during a routine physical examination.Endoscopic ultrasonography showed gastric varices entwined with an artery,which greatly increased the difficulty of treatment.We successfully treated the patient with endoscopic ultrasonography-guided coil embolization combined with cyanoacrylate injection.CONCLUSION Endoscopic ultrasonography-guided coil embolization combined with cyanoacrylate injection was safe and effective for the treatment of an IGV entwined with an artery.

Safety and efficacy of modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension

BACKGROUND Gastric variceal hemorrhage is one of the primary manifestations of left-sided portal hypertension(LSPH).The hemorrhage is fatal and requires safe and effective interventions.AIM To evaluate the clinical safety and efficacy of modified endoscopic ultrasound(EUS)-guided selective N-butyl-2-cyanoacrylate(NBC)injections for gastric variceal hemorrhage in LSPH.METHODS A retrospective observational study of patients with LSPH-induced gastric variceal hemorrhage was conducted.Preoperative EUS evaluations were performed.Enrolled patients were divided into modified and conventional groups according to the NBC injection technique.The final selection of NBC injection technique depended on the patients’preferences and clinical status.The technical and clinical success rates,operation time,NBC doses,perioperative complications,postoperative hospital stay,and recurrent bleeding rates were analyzed,respectively.RESULTS A total of 27 patients were enrolled.No statistically significant differences were observed between the two groups regarding baseline characteristics.In comparison to patients in the conventional group,patients in the modified group demonstrated significantly reduced NBC doses(2.0±0.6 mL vs 3.1±1.0 mL;P=0.004)and increased endoscopic operation time(71.9±11.9 min vs 22.5±6.7 min;P<0.001).Meanwhile,the two groups had no significant difference in the technical and clinical success rates,perioperative complications,postoperative hospital stay,and recurrent bleeding rates.CONCLUSION Modified EUS-guided selective NBC injections demonstrated safety and efficacy for LSPH-induced gastric variceal hemorrhage,with advantages of reduced injection dose and no radiation risk.Drawbacks were time consumption and technical challenge.

Aluminum phosphate gel reduces early rebleeding in cirrhotic patients with gastric variceal bleeding treated with histoacryl injection therapy

BACKGROUND Esophageal-gastro varices bleeding(EGVB)is the most widely known cause of mortality in individuals with cirrhosis,with an occurrence rate of 5%to 15%.Among them,gastric varices bleeding(GVB)is less frequent than esophageal varices bleeding(EVB),but the former is a more critical illness and has a higher mortality rate.At present,endoscopic variceal histoacryl injection therapy(EVHT)is safe and effective,and it has been recommended by relevant guidelines as the primary method for the treatment of GVB.However,gastric varices after endoscopic treatment still have a high rate of early rebleeding,which is mainly related to complications of its treatment,such as bleeding from drained ulcers,rebleeding of varices etc.Therefore,preventing early postoperative rebleeding is very important to improve the quality of patient survival and outcomes.AIM To assess the efficacy of aluminium phosphate gel(APG)combined with proton pump inhibitor(PPI)in preventing early rebleeding after EVHT in individuals with GVB.METHODS Medical history of 196 individuals with GVB was obtained who were diagnosed using endoscopy and treated with EVHT in Shenzhen People's Hospital from January 2016 to December 2021.Based on the selection criteria,101 patients were sorted into the PPI alone treatment group,and 95 patients were sorted into the PPI combined with the APG treatment group.The incidences of early rebleeding and corresponding complications within 6 wk after treatment were compared between both groups.Statistical methods were performed by two-sample t-test,Wilcoxon rank sum test andχ2 test.RESULTS No major variations were noted between the individuals of the two groups in terms of age,gender,Model for End-Stage Liver Disease score,coagulation function,serum albumin,hemoglobin,type of gastric varices,the dose of tissue glue injection and EV that needed to be treated simultaneously.The early rebleeding rate in PPI+APG group was 3.16%(3/95),which was much lower than that in the PPI group(12.87%,13/101)(P=0.013).Causes of early rebleeding:the incidence of gastric ulcer bleeding in the PPI+APG group was 2.11%(2/95),which was reduced in comparison to that in the PPI group(11.88%,12/101)(P=0.008);the incidence of venous bleeding in PPI+APG group and PPI group was 1.05%(1/95)and 0.99%(1/101),respectively,and there was no significant difference between them(0.999).The early mortality rate was 0 in both groups within 6 wk after the operation,and the low mortality rate was related to the timely hospitalization and active treatment of all patients with rebleeding.The overall incidence of complications in the PPI+APG group was 12.63%(12/95),which was not significantly different from 13.86%(14/101)in the PPI group(P=0.800).of abdominal pain in the PPI+APG group was 3.16%(3/95),which was lower than that in the PPI group(11.88%,12/101)(P=0.022).However,due to aluminum phosphate gel usage,the incidence of constipation in the PPI+APG group was 9.47%(9/95),which was higher than that in the PPI group(1.98%,2/101)(P=0.023),but the health of the patients could be improved by increasing drinking water or oral lactulose.No patients in either group developed spontaneous peritonitis after taking PPI,and none developed hepatic encephalopathy and ectopic embolism within 6 wk of EVHT treatment.CONCLUSION PPI combined with APG can significantly reduce the incidence of early rebleeding and postoperative abdominal pain in cirrhotic patients with GVB after taking EVHT.

New methods for the management of gastric varices

Bleeding from gastric varices has been successfully treated by endoscopic modalities. Once the bleeding from the gastric varices is stabilized, endoscopic treatment and/or interventional radiology should be performed to eradicate varices completely. Partial splenic artery embolization is a supplemental treatment to prolong the obliteration of the veins feeding and/or draining the varices. The overall incidence of bleeding from gastric varices is lower than that from esophageal varices. No studies to date have defi nitively characterized the causal factors behind bleeding from gastric varices. The initial episodes of bleeding from esophageal varices or gastric varices without prior treatment may be at least partly triggered by a violation of the mucosal barrier overlying varices. This is especially likely in the case of varices of the fundus. In view of the high rate of hemostasis achieved among bleeding gastric varices, treatment should be administered in selective cases. Among untreated cases, steps to prevent gastric mucosal injury confer very important protection against gastric variceal bleeding.

Human thrombin for the treatment of gastric and ectopic varices

AIM:To evaluate the efficacy of human thrombin in the treatment of bleeding gastric and ectopic varices.METHODS:Retrospective observational study in a Tertiary Referral Centre.Between January 1999-October 2005,we identified 37 patients who were endoscopically treated with human thrombin injection therapy for bleeding gastric and ectopic varices.Patient details including age,gender and aetiology of liver disease/segmental portal hypertension were documented.The thrombin was obtained from the Scottish National Blood Transfusion Service and prepared to give a solution of 250 IU/mL which was injected via a standard injection needle.All patient case notes were reviewed and the total dose of thrombin given along with the number of endoscopy sessions was recorded.Initial haemostasis rates,rebleeding rates and mortality were catalogued along with the incidence of any immediate complications which could be attributable to the thrombin therapy.The duration of follow up was also listed.The study was conducted according to the United Kingdom research ethics guidelines.RESULTS:Thirty-seven patients were included.33 patients(89%) had thrombin(250 U/mL) for gastric varices,2(5.4%) for duodenal varices,1 for rectal varices and 1 for gastric and rectal varices.(1) Gastric varices,an average of 15.2 mL of thrombin was used per patient.Re-bleeding occurred in 4 patients(10.8%),managed in 2 by a transjugular intrahepatic portosystemic shunt(TIPSS)(one unsuccessfully who died) and in other 2 by a distal splenorenal shunt;(2) Duodenal varices(or type 2 isolated gastric varices),an average of 12.5 mL was used per patient over 2-3 endoscopy sessions.Re-bleeding occurred in one patient,which was treated by TIPSS;and(3) Rectal varices,an average of 18.3 mL was used per patient over 3 endoscopy sessions.No re-bleeding occurred in this group.CONCLUSION:Human thrombin is a safe,easy to use and effective therapeutic option to control haemorrhage from gastric and ectopic varices.

Successful endoscopic sclerotherapy for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol

Two patients with liver cirrhosis and portal hyper-tension related to hepatitis infection were admitted to Shanghai Ruijin Hospital due to recurrent melena and hematemesis. Isolated gastric varices were observed in the gastric fundus during the retroflexion of gastroscope. We carried out endoscopic sclerotherapy successfully for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol, which disappeared dramatically several months after two courses of sclerotherapy for each patient. No complication and clinical signs of gastrointestinal re-bleeding were observed during the 6-mo endoscopic follow-up. CT portal angiography (CTPA) has been widely used in the assessment of variceal treatment and improves the results of endoscopic injection therapy.

Prevalence of gastric varices and results of sclerotherapy with N-butyl 2 cyanoacrylate for controlling acute gastric variceal bleeding

AIM： To study the prevalence, predictors and control of bleeding following N-butyl 2 cyanoacrylate （NBC） sclerotherapy of gastric varix （GV）. METHODS： We analyzed case records of 1436 patients with portal hypertension, who underwent endoscopy during the past five years for variceal screening or upper gastrointestinal （GI） bleeding. Fifty patients with bleeding GV underwent sclerotherapy with a mean of 2 mL NBC for control of bleeding. Outcome parameters were primary hemostasis （bleeding control within the first 48 h）, recurrent bleeding （after 48 h of esophagogastro-duodenoscopy） and in-hospital mortality were analyzed. RESULTS： The prevalence of GV in patients with portal hypertension was 15% （220/1436） and the incidence of bleeding was 22.7% （50/220）. Out of the 50 bleeding GV patients, isolated gastric varices （IGV-Ⅰ） were seen in 22 （44%）, gastro-oesophageal varices （GOV） on lesser curvature （GOV-Ⅰ） in 16 （32%）, and GOV on greater curvature （GOV-Ⅱ） in 15 （30%）. IGV-Ⅰ was seen in 44% （22/50） patients who had bleeding as compared to 23% （39/170） who did not have bleeding （P 〈 0.003）. Primary hernostasis was achieved with NBC in all patients. Re-bleeding occurred in 7 （14%） patients after 48 h of initial sclerotherapy. Secondary hemostasis was achieved with repeat NBC sclerotherapy in 4/7 （57%）. Three patients died after repeat sclerotherapy, one during transjugular intrahepatic portosystemic stem shunt （TIPSS）, one during surgery and one due to uncontrolled bleeding. Treatment failure-related mortality rate was 6% （3/50）. CONCLUSION： GV can be seen in 15% of patients with portal hypertension and the incidence of bleeding is 22.7%. NBC is highly effective in controlling GV bleeding. In hospital mortality of patients with bleeding GV is 6%.

Treatment of gastric varices with partial splenic embolization in a patient with portal vein thrombosis and a myeloproliferative disorder

Therapeutic options for gastric variceal bleeding in the presence of extensive portal vein thrombosis associated with a myeloproliferative disorder are limited.We report a case of a young woman who presented with gastric variceal bleeding secondary to extensive splanchnic venous thrombosis due to a Janus kinase 2 mutation associated myeloproliferative disorder that was managed effectively with partial splenic embolization.

Ruptured high flow gastric varices with an intratumoral arterioportal shunt treated with balloon-occluded retrograde transvenous obliteration during temporary balloon occlusion of a hepatic artery

A patient presented with hematemesis due to gastric variceal bleeding with an intratumoral arterioportal shunt. Contrast-enhanced CT revealed gastric varices and hepatocellular carcinoma with tumor thrombi in the right portal vein. Angiography and angio-CT revealed a marked intratumoral arterioportal shunt accompanied with reflux into the main portal vein and gastric varices. Balloon-occluded retrograde venography from the gastro-renal shunt showed no visualization of gastric varices due to rapid blood flow through the intratumoral arterioportal shunt. The hepatic artery was temporarily occluded with a balloon catheter to reduce the blood flow through the arterioportal shunt, and then concurrent balloon-occluded retrograde transvenous obliteration （BRTO） was achieved. Vital signs stabilized immediately thereafter, and contrast-enhanced CT revealed thrombosed gastric varices. Worsening of hepatic function was not recognized. BRTO combined with temporary occlusion of the hepatic artery is a feasible interventional procedure for ruptured high flow gastric varices with an intratumoral arterioportal shunt.

Autoimmune pancreatitis complicated by gastric varices:A report of 3 cases

We present three cases of autoimmune pancreatitis(AIP) complicated by gastric varices.Case 1:A 57-yearold man was diagnosed with AIP complicated by gastric varices and splenic vein obstruction.Splenomegaly was not detected at the time of the diagnosis.The AIP improved using steroid therapy,the splenic vein was reperfused,and the gastric varices disappeared;case 2:A 55-year-old man was diagnosed with AIP complicated by gastric varices,splenic vein obstruction,and splenomegaly.Although the AIP improved using steroid therapy,the gastric varices and splenic vein obstruction did not resolve;case 3:A 68-year-old man was diagnosed with AIP complicated by gastric varices,splenic vein obstruction,and splenomegaly.The gastric varices,splenic vein obstruction,and AIP did not improve using steroid therapy.These three cases suggest that gastric varices or splenic vein obstruction without splenomegaly may be an indication for steroid therapy in patients with AIP because the complications will likely become irreversible over time.

Update on management of gastric varices

Gastric varices(GV) have different physiology and clinical characteristics compared to oesophageal varices(OV). There is little information about the management of GV. Most part of the recommendations is extrapolated from studies where the majority of participants had OV. Thus, most recommendations lack of strong evidence. This is a comprehensive review on all aspects of management of GV, i.e., primary, secondary prophylaxis and management of acute bleeding. The papers on which international societies' recommendations are based are scrutinised in this review and areas of research are identified.

Efficacy of balloon-occluded retrograde transvenous obliteration, percutaneous transhepatic obliteration and combined techniques for the management of gastric fundal varices

AIM： To evaluate the effect of three interventional treatments involving transvenous obliteration for the treatment of gastric varices, and to compare the efficacy and adverse effects of these methods, METHODS： From 1995 to 2004, 93 patients with gastric fundal varices underwent interventional radiologic embolotherapy at our hospital. Of the 93 patients, 75 were treated with the balloon-occluded retrograde transvenous obliteration （BRTO） procedure; 8 were with the percutaneous transhepatic obliteration （PTO） procedure; and 10 were with the combined BRTO and PTO therapy. A follow-up evaluation examined the rates of survival, recurrence and rebleeding of the gastric varices, worsening of esophageal varices and complications in each group. RESULTS： The BRTO, PTO, and combined therapy were technically successful in 81% （75/93）, 44% （8/18）, and 100% （10/10） patients, respectively. Recurrence of gastric varices was found in 3 patients in the BRTO group and in 3 patients in the PTO group. Rebleeding was observed in 1 patient in the BRTO group and in 1 patient in the PTO group. The 1- and 3-year survival rates were 98% and 87% in the patients without hepatocellular carcinoma （HCC） in the BRTO group, 100% and 100% in the PTO group, and 90% and 75% in the combined therapy group, respectively. CONCLUSION： Combined BRTO and PTO therapy may rescue cases with uncontrollable gastric fundal varices that remained even after treatment with BRTO and/or PTO, though there were limitations of our study, including retrospective nature and discrepancy in sample size between the BRTO, PTO and combined therapy groups.

CT-maximum intensity projection is a clinically useful modality for the detection of gastric varices

AIM： To evaluate the efficacy of CT-maximum intensity projection （CT-MIP） in the detection of gastric varices and their infiowing and outflowing vessels in patients with gastric varices scheduled to undergo balloonoccluded retrograde transvenous obliteration （B-RTO）. METHODS： Sixteen patients with endoscopically confirmed gastric varices were included in this study. All patients were evaluated with CT-MIP using threedimensional reconstructions, before and after B-RTO. RESULTS： CT-MIP clearly depicted gastric varices in 16 patients （100%）, the left gastric vein in 6 （32.5%）, the posterior gastric vein in 12 （75.0%）, the short gastric veins in 13 （81.3%）, gastrorenal shunts in 16 （100%）, the hemiazygos vein （HAZV） in 4 （25.0%）, the pericardiophrenic vein （PCPV） in 9 （56.3%）, and the left inferior phrenic vein in 9 patients （56.3%）. Although flow direction itself cannot be determined from CT-MIP, this modality provided clear images of the inflowing and the outflowing vessels. Moreover, in one patient, short gastric veins were not seen on conventional angiographic portography images of the spleen, but were clearly revealed on CT-MIP. CONCLUSION： We suggest that CT-MIP should be considered as a routine method for detecting and diagnosing collateral veins in patients with gastric varices scheduled for B-RTO. Furthermore, CT-MIP is more useful than endoscopy in verifying the early therapeutic effects of B-RTO.

N-butyl-2-cyanoacrylate, iso-amyl-2-cyanoacrylate and hypertonic glucose with 72% chromated glycerin in gastric varices

cyanoacrylate and a mixture of 72% chromated glycerinwith hypertonic glucose solution in management ofgastric varices.METHODS： Ninety patients with gastric varicespresented to Endoscopy Unit of Ain Shams UniversityHospital were included. They were randomly allocatedinto three groups; each group included 30 patients treatedwith intravariceal sclerosant injections in biweeklysessions till complete obturation of gastric varices;Group I （n-butyl-2-cyanoacrylate; Histoacryl？）, GroupII （iso-amyl-2-cyanoacrylate; Amcrylate？） and GroupIII （mixture of 72% chromated glycerin; Scleremo？with glucose solution 25%）. All the procedures wereperformed electively without active bleeding. Recruitedpatients were followed up for 3 mo.RESULTS： 26% of Scleremo group had bleeding duringpuncture vs 3.3% in each of the other two groups withsignificant difference, （P 〈 0.05）. None of Scleremogroup had needle obstruction vs 13.3% in each of theother two groups with no significant difference, （P 〉0.05）. Rebleeding occurred in 13.3% of Histoacryl andAmcrylate groups vs 0% in Scleremo group with nosignificant difference. The in hospital mortality was 6.6%in both Histoacryl and Amcrylate groups, while it was0% in Scleremo group with no significant difference. Inthe first and second sessions, the amount of Scleremoneeded for obturation was significantly high, while the amount of Histoacryl was significantly low. Scleremo was the less costly of the two treatments. CONCLUSION： All used sclerosant substances showed efficacy and success in management of gastric varices with no significant differences except in total amount,cost and bleeding during puncture.

Balloon-occluded retrograde transvenous obliteration for gastric varices via the intercostal vein

Gastric varices are usually associated with a gastrorenal(G-R) shunt.However,the gastric varices described in this case report were not associated with a G-R shunt.The inflow vessel was the posterior gastric vein and the outflow vessels were the narrow inferior phrenic vein and the dilated cardio-phrenic vein.First,percutaneous transhepatic obliteration of the posterior gastric vein was performed,but the gastric varices remained patent.Then,micro-balloon catheterization of the subphrenic vein was carried out via the jugular vein,pericardial vein and cardio-phrenic vein,however,micro-balloon-occluded inferior phrenic venography followed by micro-coil embolization of the cardio-phrenic vein revealed no delineation of gastric varices resulting in no further treatment.Thereafter,as a gastrosubphrenic-intercostal vein shunt developed,a microballoon catheter was advanced to the gastric varices via the intercostal vein and balloon-occluded retrograde transvenous obliteration(BRTO) was performed resulting in the eradication of gastric varices.BRTO for gastric varices via the intercostal vein has not previously been documented.

Emergency balloon-occluded retrograde transvenous obliteration of ruptured gastric varices

AIM: To evaluate the effectiveness and safety of emergency balloon-occluded retrograde transvenous obliteration(BRTO) for ruptured gastric varices.METHODS: Emergency BRTO was performed in 17 patients with gastric varices and gastrorenal or gastrocaval shunts within 24 h of hematemesis and/or tarry stool.The gastric varices were confirmed by endoscopy,and the gastrorenal or gastrocaval shunts were identified by contrast-enhanced computed tomography(CE-CT).A 6-Fr balloon catheter(Cobra type) was inserted into the gastrorenal shunt via the right internal jugular vein,or into the gastrocaval shunt via the right femoral vein,depending on the varices drainage route.The sclerosant,5% ethanolamine oleate iopamidol,was injected into the gastric varices through the catheter during balloon occlusion.In patients with incom plete thrombosis of the varices after the first BRTO,a second BRTO was performed the following day.Patients were followed up by endoscopy and CE-CT at 1 d,1 wk,and 1,3 and 6 mo after the procedure,and every 6 mo thereafter.RESULTS: Complete thrombosis of the gastric varices was not achieved with the first BRTO in 7/17 patients because of large gastric varices.These patients underwent a second BRTO on the next day,and additional sclerosant was injected through the catheter.Complete thrombosis which led to disappearance of the varices was achieved in 16/17 patients,while the remaining patient had incomplete thrombosis of the varices.None of the patients experienced rebleeding or recurrence of the gastric varices after a median follow-up of 1130 d(range 8-2739 d).No major complications occurred after the procedure.However,esophageal varices worsened in 5/17 patients after a mean follow-up of 8.6 mo.CONCLUSION: Emergency BRTO is an effective and safe treatment for ruptured gastric varices.

Three benefits of microcatheters for retrograde transvenous obliteration of gastric varices

AIM： To evaluate the usefulness of the microcatheter techniques in balloon-occluded retrograde transvenous obliteration （BRTO） of gastric varices.METHODS： Fifty-six patients with gastric varices underwent BRTOs using microcatheters. A balloon catheter was inserted into gastrorenal or gastrocaval shunts. A microcatheter was navigated close to the varices, and sclerosant was injected into the varices through the microcatheter during balloon occlusion. The next morning, thrombosis of the varices was evaluated by contrast enhanced computed tomography （CE-CT）. In patients with incomplete thrombosis of the varices, a second BRTO was performed the following day. Patients were followed up with CE-CT and endoscopy.RESULTS： In all 56 patients, sclerosant was selectively injected through the microcatheter close to the varices. In 9 patients, microcoil embolization of collateral veinswas performed using a microcatheter. In 12 patients with incomplete thrombosis of the varices, additional injection of sclerosant was performed through the microcatheter that remained inserted overnight. Complete thrombosis of the varices was achieved in 51 of 56 patients, and the remaining 5 patients showed incomplete thrombosis of the varices. No recurrence of the varices was found in the successful 51 patients after a median follow up time of 10.5 too. We experienced one case of liver necrosis, and the other complications were transient.CONCLUSION： The microcatheter techniques are very effective methods for achieving a higher success rate of BRTO procedures,