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.
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251