Douglas M. Coldwell, Kaj H. Johansen, MD,

MD, PhD

PhD

Aynsley

D. A. Moore,

#{149}

MB,

ChB

Yoram

#{149}

Ben-Menachem,

MD

Bleeding Gastroesophageal Varices: Gastric Vein Embolization after Partial Portal Decompression’ Shunts that decompress the portal vein are effective in the treatment of bleeding esophageal varices. Use of large-caliber portacaval shunts, however, results in the complete decompression of the portal system and the risk of subsequent development of hepatic encephalopathy. Use of small-caliber portacaval shunts results in mild portal hypertension and less frequent hepatic encephalopathy but may increase the risk of recurrent bleeding. Thirty-three patients underwent angiography after partial decompression portacaval shunting (median transshunt pressures, 8 mm Hg). Embolization of residual varices, noted in 13 patients, was performed. Results included one complication with no sequelae and no bleeding a mean of 13 months after the procedure was performed. Transshunt embolization of esophageal varices effectively prevents bleeding varices after partial portal decompression. Index

terms:

Esophagus.

varices,

71.75

#{149} Shunts,

portacaval.

95.4532

therapeutic

blockade,

Radiology

1991;

95.711, #{149} Veins,

D

of the

ECOMPRESSION

portal

nous system effectively vaniceal hemorrhage.

trols

nately,

complete

system

to the

shunts vena

ye-

conUnfortu-

of the

cava

portal

accelerate

he-

patic failure and portal systemic encephalopathy (1-4). To retard the development of hepatic failure, the selective shunt (5-7), and subsequently the

small-caliber

portacaval

appear

with

to occur

these

less

shunts,

is a potential

recurrent

bleeding

complication

of

vanices that may remain distended ten incomplete portal decompression. Indeed, this complication occurred at least one of our first 50 patients whom small-caliber portacaval

af-

were

placed

(8).

embolization of these prevent such bleeding. describe our experience form

95.1299

in in

Transcaval

vanices should Herein, we with this

We

AND

reviewed

tal records

whom

the

METHODS

madiologic

and

of 33 consecutive

postoperative

hospi-

patients

in

angiogmaphy

of

small-caliber (10-12-mm) side-to-side portacaval shunts was performed during the previous 30 months. All shunts were examined with Doppler ultrasound immediately

after

Shunts cally

tency

were

surgery

then

to assess

evaluated

varices.

The

patency.

angiogmaphi-

1 -4 days after surgery and allow embolization

sidual

to assess of any

angiographic

I

From

University

the

Department of Washington.

of Radiology, Seattle,

SB-05. WA

98195

(D.M.C., ADAM.); and the Departments of Radiology (Y.B.M.) and Surgery (K.H.J.), Harborview Medical Center, Seattle. Received March 26, 1990; revision requested May 1; revision received August 20; accepted August 22. Address reprint requests to D.M.C. RSNA, 1991

of the

portal,

splenic,

pame-

evalua-

tion, performed after transfemomal transcaval catheterization, included ing

and

imag-

superior

mesenteric veins; measurement of the pressure gradient across the shunt; and embolization of varices arising via comonary (left gastric) or short gastric veins. Giantumco

and agents ethanol

coils

95% ethanol were was

used used,

were

was

used

in

used

in two;

in one an

followed

monthly

patient.

occlusion

10 patients,

both When

balloon

up

in

the

surgeon

surgery

and

un-

evaluations. RESULTS

Among the 33 patients, 12 were women, and 21 were men. The median age for men was 47 years (range, 33-78

ent was

years),

while

that

56 years (range, mean pontacaval Hg

during (median,

1-20

mm

Hg).

tients

underwent

for

women

33-66 years). pressure gmadi-

determined 8.7 mm

range,

of intervention.

PATIENTS

178:249-251

were

by the attending

derwent

was The

frequently because

shunts

Patients

clinic

shunt

(8,9), have been developed. With these shunts, a residual pressure gradient remains between the portal systern and the inferior vena cava. While liver failure and encephalopathy

was placed in the varices and the ethanol was allowed to remain static for 10 mmutes before the balloon was deflated. In one patient, the persistent varix was too large to use coils, and 20-cm pieces of hollow-come guide wire were used (Figure).

angiography 8.0 mm

Thirteen

Hg;

pa-

transcatheten

em-

bolization of visualized vanices; in each case, the embolized vanjces arose from the left gastric or short gastric

veins.

Manometry

performed

after embolization showed that shunt pressure gradients were unchanged from preembolization measurements. One patient underwent repeated embolization 2 months after the initial procedure because of vanices seen at repeated endoscopy. No patient suffered

The was

bleeding

after

embolization.

mean follow-up for all patients 13 months (13 months for pa-

tients who underwent embolization and 12 months for those who did not). A single complication could be ascribed to the use of coronary vein embolization after shunt placement in our patients: partial misplacement

of a hollow quelae. The mean the

shunt

mm

Hg

tients

guide

wire

pressure before

(mange,

who

0-20

underwent

with 6 mm 1 1 mm Hg) in patients undergo embolization. an unpaired one-tailed were

se-

gradient

across

intervention

compared

results

without

significant

mm

was

Hg)

11

in pa-

embolization,

Hg (range, 0who did not With use of t test, these at P

=

.015.

249

The

mean

the

pressure

shunt

was

gradient

8 mm

across

Hg

after

emboli-

zation (mange, 0-15 mm Hg). The difference between the pre- and postembolization pressure gradients was not

statistically

significant.

DISCUSSION Massive

hemorrhage

esophageal threatening hypertension. different

modalities

bleeding

esophageal

mony to the satisfactory.

py can sequent 12).

from

for

The

fact that Endoscopic

mole

treatment

vanices

palliate the mebleeding

zation

gastro-

vanices is the major lifecomplication of portal The large number of

none

is entirely sclerothera-

a.

for the

emboli-

short-term

control of hemorrhage is controversial (13-15). Because the underlying portal hypertension persists, nebleeding usually occurs (13), and portal vein thrombosis may develop (16). Standard operative portacaval decompression substantially reduces deaths due to bleeding, but overall survival is not substantially altered

because of increased deaths due to liver failure (1-4). Furthermore, many of these patients also develop incapacitating portosystemic encephalopathy (2,17). Most (6,8,10), but not all (18), studies shunt operations the incidence

suggest that significantly of portosystemic

b.

Postoperative

problem, but subis common (10-

of transhepatic

of vanices

of

is testi-

selective reduce en-

embolization

of residual

gastric

of patients

in our

However,

initial

because

pressures persist phy frequently tent opacification

al vanices

shunt

we have

sub-

remains in one of

dune.

Liver

promising

ble

but

in most

alcoholics,

We

cirrhotic with

have

for

vanices

stoma

with

use

portal

and

experience,

no

has

experienced

vein

anas-

to the

While mined

shunt with

Hg,

naphy, ography sidual

we

10 mm

thus

pontosystemic

encepha-

promise

ample,

of this

(20) and suggested

approach.

postoperative

encephalopa-

thy,

which

occurs

in 25%-100%

tients

who

undergo

standard

val shunting, 250

Radiology

#{149}

For ex-

developed

pontaca-

in only

6%

portal and has proved

patency the use

bolic

easier

treated from

var-

complications procedure.

can be deterof duplex sonog-

continue to perform angibecause embolization of mevanices can then be performed

agent

of choice

to use

and

venogram

the

em-

they

are

patient no

was

achieved

were

used.

In

gastric

vein

was

the

8-mm

maxi-

of the Gianturco larger than other

dard

vascular-occlusion

ure). wire

Segments of hollow-core were used, and the vessel

the

vein

lumen of the left the splenic vein.

into

no evidence the

splenic

Re-

1 month later adverse effects, occluded, the patent, and

of thrombus

small

(Fig-

guide was case, the

In this wine protruded

peated angiography showed no apparent with the gastric vein splenic vein completely on

coils stan-

devices

occluded. of guide

within

formation

segment

of wire

in the

vein.

vanices were angiognaphy Patients

who

underwent

vamiceal

tion

had

mean

sure

gradients

who

did

higher

not,

embolizaresidual

pres-

compared

with

suggesting

that

those the

higher portal pressure is conducive to the retention of substantial vances. While vaniceal embolization has not

changed

the

gradient,

the

the

to

exit

shunt

up

in

patients

have

We

a residual

pressure

dynamics

the

the

than

have

blood

portal

rather

path. These indications shunts. giographic

tnansshunt

flow

so that

forced

been

vanices

than

even

changed

To date,

of the

ethanol.

less

cannot

recanalization of the vanices has seen at endoscopy, and satisfactory occlusion

than

cause

because

was

left

Only patients whose visible at postoperative underwent embolization.

In so

rebleeding

ac-

splenic to be

successful. patient

diameter

gastric

ye-

to be an

and, occasionally, the shunt be adequately depicted. Gianturco coils have been

discomfort

of pa-

portal

and no significant resulted from the

is to obgradi-

failure

the

ices, have

of these branches

larger

mum

from

pa-

use conindication.

found

our

of a small-

Results of animal (8,21) studies have

been

straightforward

enabling decompresportal system and reducrisk of subsequent liver

lopathy. human

has

de-

of bleed-

simultaneously sion of the tion of the

and

postoperative

nognaphy

portal

The goal pressure

of approximately

However,

accurate-

shunt

no longer for that

occlusion venous

mostly

side-to-side

of the

(22,23), we angiogmaphy

(19).

partial the

tency trast

can

portacaval

vanices

treatment

inferior vena cava. tam a postoperative

ent

feasi-

patients,

(10-12-mm)

tomosis

not

bleeding

studied

compression

ing

is probably

sonogmaphy

ly demonstrate

much

completely last segment

demonstrated

curate way to identify persistent gastroesophageal variceal filling, and selective cannulation and transcatheter

seems

shunt

coils

the

patient,

and

the

transplantation

(a) Transcaval

Gianturco

one

limit

proce-

duplex

when

placement,

vaniceal hemorrhage risk, occurring 50 patients (8).

Because

(8).

portal

and portal venogmademonstrates pensisof gastroesophage-

after

sequent a potential our first

series

increased

that

of this

veins.

shows massive dilatation of the left gastric vein with large lower-esophageal and paraesophageal varices. The shunt pressure gradient is 14 mm Hg. (b) Embolization of the left gastric vein and its varices was performed on postoperative day 4 with the use of multiple Gianturco coils placed on a matrix that was formed from four 20-cm segments of hollow-core guide wire. Three of these segments were placed correctly (solid arrows), but the fourth continued to protrude into the splenic vein (open arrow) without undue immediate effects. Because of the endoscopic appearance of additional small varices, the patient was reexamined 6 weeks after surgery. A short gastric varix was detected and successfully embolized (arrowheads).

cephalopathy. However, numerous relative or absolute contraindications to selective shunting-including tense ascites, Child C status, unfavorable splenic or renal vein anatomy, and retrograde portal vein flowapplications

varicose

flow

with

pressure

via

by another

results have for angiographic currently evaluation

is

system

altered

the follow-

portacaval

recommend of shunts gradient

January

anthat of

1991

9

Hg or more, which should patients whose shunts are

mm

nate

ly patent

the

and

are

thus

not

elimiwide-

at risk

cess

to

and the

branches

Our

nary

reliable and

5.

ac6.

madithat

portal

de-

and tnansshunt conoembolization provides pro-

vein

tection against ceal nebleeding hepatic cirrhosis tension.

liven failure in patients and portal

and vanwith hyper-

7.

8.

U 9.

References 1.

Jackson clinical shunt. peutic

FC, Perrin investigation V. Survival operation.

EB, Felix WR et al. A of the portacaval analysis of the theraAnn Surg 1971; 174:672-

701.

2.

Mutchnick tal-systemic val

3.

MG, Lerner encephalopathy

anastomosis:

Results

of a 12-year

al of portacaval coholic liver Gastroenterology

Volume

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randomized

Number

1

F, Degos

JD, et al.

of therapeutic

in alcoholic

A con-

14.

portacaval

cirrhosis.

Lancet

1976; 15.

Warren WD, Zeppa R, Fomon JJ. Selective trans-splenic decompression of gastroesophageal vanices by distal splenore-

12. WP, tn-

13.

shunt.

Ann

Sung

1967;

16.

Sarfeh

IJ, Rypins

EB,

Fardi

M.

et al.

18.

L’Hermin#{233}

C, Chastanet

P. Delemazure

Distal

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vs. hemorrhage

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by

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a

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19.

Neuberger JM. Transplantation for alcoholic liver disease (editorial). Br Med 1989; 301:693-694. Johansen K, Girod C, Lee 55, et al. Mesenteric monemia

21.

22.

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Eniksson LS. Hepatic encephalopathy and treatment of oesophageal vanices. Scand J Gastroenterol 1988; 23:641-649. Grace ND, Conn HO, Resnick RH, et al. shunts

20.

JM, Millikan WJ, shunt versus enfor long-term bleeding. Ann

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Warren WD, Henderson et al. Distal splenorenal doscopic sclerotherapy management of vaniceal Sung 1986; 203:454-462.

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Sos TA. Transhepatic portal venous embolization of varices: pros and cons. Radiology 1983; 148:569-570. Athanasoulis CA. Therapeutic applications of angiography. N EngI J Med 1980; 302:1117-1125. Bengmark 5, Borjesson B, Hoevels J, et al. Obliteration

166:437-455.

Inokuchi K, Kobayashi M, Ogawa Y, et al. Results of left gastric vena caval shunt for esophageal vanices: analysis of one hundred clinical cases. Surgery 1975; 78:628636. Orozco H, Ju#{225}rezF, Santill#{225}n P. et al. Ten years of selective shunts for hemorrhagic portal hypertension. Surgery 1988; 103: 27-31. Johansen K. Partial portal decompression for vaniceal hemorrhage. Am J Sung 1989; 157:479-482.

tol

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#{149}

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10.

E, Conn HO. Porand portaca-

a prospective.

study

nal

suggests

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B, Degos

trolled 1:655-659.

its

interventional

experience

combination

compression

offers system

for the

ologist.

the

portal

Rueff shunt

for

development of residual vanices. Portacaval shunting reduces portal

hypertension

4.

venous in

stenosis the

reduces

portacaval-shunted

hyperamrat.

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23.

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Radiology

.

251

Bleeding gastroesophageal varices: gastric vein embolization after partial portal decompression.

Shunts that decompress the portal vein are effective in the treatment of bleeding esophageal varices. Use of large-caliber portacaval shunts, however,...
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