balloon-occluded retrograde transvenous obliteration...

Balloon-occluded Retrograde TransvenousObliteration (BRTO) of Gastric Varices

Resident(s): Ashish R. Vyas M.D., Dominic T. Semaan M.D., J.D.

Attending(s): Dr. Laurie Vance

Program/Dept(s): Providence Hospital and Medical Center, Department of Radiology , Southfield, Michigan

Chief Complaint & HPI

▪Chief Complaint▪77-year-old male with acute hematemesis

History of Present Illness

1 day history of hematemesis

No history of prior upper or lower GI bleed

Patient recalls “blacking-out” last afternoon and waking up with bright red blood on floor and all over his clothes with another episode prior to bed

Underwent endoscopic banding of actively bleeding gastric varices upon admission

VIR consulted by GI after failed endoscopic banding and multiple friable and bleeding gastric varices

Relevant History

▪Past Medical History▪Prior CVA▪Diabetes mellitus, type II▪Hypertension▪Nephrolithiasis▪Diverticulitis

▪Past Surgical History▪Partial colectomy for diverticulitis▪Left carotid endarterectomy

▪Family & Social History▪Alcohol abuse (at least 3-4 shots of whiskey/day for 20 years)

▪Review of Systems▪Pertinent for those mentioned in HPI, PSH, PMH

Relevant History

▪Medications▪Losartan 50 mg, PO, Qday

▪Ezetimibe 40 mg, PO, Qday

▪Metformin 500 mg, PO, Qid

▪Multivitamin

▪Aspirin 81 mg, PO, Qday

▪Allergies▪Penicillin

▪Donnatal

Diagnostic Workup

▪Physical Exam▪Vital signs stable, no acute distress

▪No active hematemesis at bedside

▪Lungs clear, no gynecomastia

▪Normal rate and cardiac rhythm

▪Bowel signs present, no evidence of distension to suggest ascites; no signs of caput medusa, hepatosplenomegaly,

▪No jaundice, asterixis, scleral icterus

▪Laboratory Data▪Pertinent positive/negative diagnostic studies.

Diagnostic Workup

▪Laboratory Data

▪AST/ALT: 39/55 Hepatitis panel: Negative

▪Alkaline phosphatase: 48

▪Total bilirubin: 0.6

9.8

28.1%

4.0 89

139

5.0

105

20

61

1.3

109

Diagnostic Workup

▪Non-invasive imaging▪CT-angiography of the abdomen and pelvis

Diagnostic Workup – CT-Angiography

▪Axial CTA shows multiple large gastric varices, some thrombosed. Findings of nodular liver contour and caudate lobe hypertrophy suggestive of cirrhosis are also present.

Diagnostic Workup – CT-Angiography

▪Coronal MIP image demonstrates gastric varices draining via a gastrorenal shunt.

Diagnosis

▪Diagnosis

▪Bleeding gastric varices draining via a gastrorenal shunt

▪Hepatic cirrhosis

Intervention

▪Patient underwent endoscopic banding of gastric varices▪Active variceal bleeding and multiple friable varices were seen despite multiple band placements

▪General surgery consulted for possible gastrectomy for bleeding refractory to treatment▪CTA ordered by surgery was reviewed by IR

▪Detailed discussion was had among patient, surgery, GI and IR regarding surgical and minimally invasive options

▪Patient was emergently brought down to IR for Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) of gastric varices

Intervention - BRTO

Inferior phrenic venogram confirms gastric varices draining via a gastrorenal shunt. Inferior pericardiophrenic vein also opacifies. The left adrenal vein is excluded.

Intervention - BRTO

After sheath upsizing, the inferior cardiophrenic vein was coil embolized with 0.018 Nester coils to prevent sclerosantfrom central venous drainage.

Contrast injection demonstrated no residual flow in the coiled pericardiophrenic vein with the occlusion balloon inflated.

Active hemorrhage is evident.

Intervention - BRTO

An 11.5 mm occlusion balloon was advanced into the distal inferior phrenic vein and inflated to occlude the efferent draining vein. Foam sclerotherapy was performed with 3% Sotradecol for a total dwell time of 30 minutes.

Intervention - BRTO

Sclerotherapy was also augmented by 0.018 coil embolization. Repeat injection showed stagnation of flow in the gastric varices.

The efferent draining vein was coil embolized with 0.035 coils.

The left adrenal vein remained preserved and patent.

Question

▪In the traditional method of BRTO, 5-10% ethanolamine oleate is utilized as the sclerosant of choice. What is a well-known potential side effect described in the literature in utilizing this agent and its treatment/prevention?

A. Bleeding; supportive measures including blood transfusion

B. Hemolysis and acute renal failure: intravenous haptoglobin administration and IV hydration

C. Mental status changes: immediate lactulose administration

D. Alcohol poisoning: aggressive IV resuscitation

Correct!

▪In the traditional method of BRTO, 5-10% ethanolamine oleate is utilized as the sclerosant of choice. What is a well-known potential side effect described in the literature in utilizing this agent and its treatment/prevention?

A. Bleeding; supportive measures including blood transfusion

B. Hemolysis and acute renal failure: intravenous haptoglobin administration and IV hydration

C. Mental status changes: immediate lactulose administration

D. Alcohol poisoning: aggressive IV resuscitation

Return to Case

Sorry, That’s Incorrect

▪In the traditional method of BRTO, 5-10% ethanolamine oleate is utilized as the sclerosant of choice. What is a well-known potential side effect described in the literature in utilizing this agent and its treatment/prevention?

A. Bleeding; supportive measures including blood transfusion

B. Hemolysis and acute renal failure: intravenous haptoglobin administration and IV hydration

C. Mental status changes: immediate lactulose administration

D. Alcohol poisoning: aggressive IV resuscitation

Return to Case

Clinical Follow Up

▪Post-embolization, no additional episodes of hematemesis were noted and the patient was discharged on POD#1

▪The patient was seen in IR clinic in 2 weeks for follow-up and evaluation for transvenous intrahepatic portosystemic shunt (TIPS) placement

Summary & Teaching Points

▪Classically, when endoscopic management of gastric variceal bleeding fails, TIPS has been performed to decompress the portal system

▪BRTO, however, offers a minimally invasive option for the treatment of gastric variceal bleeding as it is:▪Minimally invasive

▪Performed in patients with poor hepatic reserve

▪Lower rebleeding rates than TIPS

▪Management of gastric varices requires a multidisciplinary approach

▪The interventional radiologist plays a key role in identifying and selecting patients who would benefit from BRTO

References & Further Reading

▪Kiyosue H, Mori H, Shunro M, Yamada Y, Hori Y, Okino Y. “Transcatheterobliteration of gastric varices.” Radiographics. 2003 Jul-Aug; 23(4): 911-20.

▪Saad, W. “Balloon-occluded retrograde transvenous obliteration of gastric varices: concept, basic techniques and outcomes.” Semin Intervent Radiol. Jun 2012; 29(2): 118-128.

▪Darcy M, Saad W. “Transjugular intrahepatic portosystemic shunt (TIPS) versus balloon-occluded retrograde transvenous obliteration (BRTO) for the management of gastric varices.” Semin Intervent Radiol. Sept 2011; 28(3): 339-349.