Gastrointestinal and Urinary
Procedure Guide
Indications
Isolated gastric varices (GVs) that have bled or at risk of bleeding (occurs in 5-33% of patients with portal hypertension)
Four subtypes of GVs: cardial contiguous with esophageal varices (EVs), isolated in fundus without EVs, combined gastroesophageal and isolated GVs, and ectopic varices secondary to splenic vein thrombosis
Most suitable for isolated G-1 or G-2 GVs draining via inferior phrenic to left renal vein (80-85%, aka “gastrorenal shunt”) vs. directly into the IVC (10-15%, aka “gastrocaval shunt”)
Hirota classification: (G-1) no collateral drainage; (G-2) few small collaterals with stagnation of contrast for >3 min; (G-3) medium to large collaterals with stagnation of contrast <3 min; (G-4) large collaterals without contrast filling the varices
Need appropriate systemic venous drainage or portal shunt to access, e.g., gastrorenal shunt
Contraindications
Uncorrected severe coagulopathy
Inability to safely control collateral variceal flow to prevent non-target embolization
Prominent esophageal varices, ascites, or hydrothorax as these will likely worsen post-transvenous obliteration. These patients would be better served with TIPS +/- variceal embolization. Similarly, if you embolize a 10 mm gastrorenal shunt and place a 10 mm TIPS, the portal hypertension should theoretically stay the same assuming similar flow.
Portal venous thrombosis
Efficacy and alternatives
Transvenous obliteration: technical success 90-100%; GV eradication in 88-100%; rebleeding in 0-7% (GV) 13% (EV) in 24 mo
12 mo survival 76%, 24 mo survival 70%, worse prognosis if HCC or MELD >13 (47% vs 95% and 35% vs 92%, respectively)
PARTO and CARTO are more efficient, cheaper, and with less complications than BRTO and modified BRTO. One US study estimated the average procedure costs of $6000 for PARTO with one plug, $8500 for CARTO with 7 coils, and $18000 for BRTO. Using a plug can also be more efficient and reduce streak artifact on follow up imaging.
TIPS:
Gastric varices tend to bleed at lower portal pressures than esophageal varices, so embolization or transvenous obliteration are thought to be more effective. However, TIPS is likely equally effective for GVs fed by a left gastric vein closer to the TIPS than shunt arising from the splenic vein.
Most patients who receive a RTO need TIPS within 3 years, so can perform together. Downsides of RTO is worsening portal HTN (ascites, etc). Downsides of TIPS is hepatic encephalopathy (particularly if patient is a CEO, pilot, etc) and reduced hepatic reserve. Need to tailor to specific patient.
Endoscopic cyanoacrylate injection: GV eradication in 95%; rebleeding in 19%
Endoscopic banding: often fails due to acidity of gastric juices
Partial splenic embolization: effective alternative for gastric varices particularly if inability to access the shunt but high complication rate
Splenic vein embolization: can be effective for patients with a splenorenal shunt in diverting mesenteric flow to the liver and splenic flow through the shunt to reduce encephalopathy without substantially increasing portal hypertension and potentially improve hepatic function.
Pre-procedure care
Hepatology/Gastroenterology evaluation with LFTs and CMP. Discussion of endoscopic options.
Endoscopy and cross-sectional imaging (CT or MRI) to characterize variceal anatomy.
CBC and PT/INR to assess bleeding risk.
procedure
Lots of variation
Retrograde via systemic circulation (e.g. Balloon-assisted Retrograde Transvenous Obliteration or BRTO) or antegrade (BATO) via portal system via a TIPS or percutaneous access.
Traditional BRTO was performed with balloon up for 5 hrs to >24 hrs. Now accelerated forms are more common with placement of coils (CARTO) or a plug (PARTO). Many use a combination, e.g., sclerosis of varices with balloon catheter followed by coil or plug embolization of variceal outflow (retrograde) or inflow (antegrade) at the end. Others place the coils or plug prior to sclerosis instead of using a balloon.
AASLD Guidance Statement recommends CARTO or PARTO due to less complications than BRTO in addition to be faster. Advocates for PARTO over CARTO feel that it’s faster (one plug vs multiple coils), similar cost, and less streak artifact on subsequent CTs.
Various combinations of sclerosis (STS, air, gelfoam, lipiodol, or contrast). Some suggest using 3% STS for gastric varices and 1% for others such as parastomal or pararectal. Others use gelfoam and contrast alone with CARTO and PARTO for gastric varices noting that it is safer with similar outcomes. For example, if the mixture refluxes into the portal system, the sclerosant can cause permanent thrombosis of the splenic or portal veins whereas the thrombosis caused by gelfoam only can resolve with anticoagulation.
General retrograde approach
Obtain right CFV or IJV access. CFV may be better for angulation and length.
Advance working wire into vessel draining the GVs, e.g., curved catheter and glidewire to select the left renal vein followed by exchanging the glidewire for a Rosen or Amplatz.
Advance sheath with sufficient sheath size to accommodate balloon catheter or other devices into the draining vessel, e.g., 10 Fr 40-45 cm.
Select the variceal outflow, e.g., gastrorenal shunt often drains via a common phrenoadrenal vein into the superior aspect of the left renal vein.
Sim 2, C2, Vert, or Kumpe with a glidewire can be helpful to select the outflow.
Need to deflate Blakemore or similar tamponade balloon to see the varices if in place.
Exchange glidewire for working wire into the variceal outflow. Ideal to advance sheath into the outflow for stable access but not absolutely necessary.
Can drop plug/coil with microcatheter passed for the sclerosant (“plug n’ fill”) or advance balloon occlusion catheter (e.g. Python) to occlude the outflow.
Confirm occlusion of outflow with contrast injection.
Mix sclerosant/embolic, e.g., 3-2-1 air-STS-lipiodol or just Gelfoam for pure PARTO or ethanolamine oleate-iopamidol (EOI) or other sclerosant (lots of variation)
Optional embolization of collaterals with coils or glue vs stepwire injection of sclerosant. Alternatively, can just inject sclerosant mixture into the variceal system, pause 5 min, and inject some more and the sclerosant with tend to take out the collaterals allowing you to fill the target varix but this is more advanced and less controlled.
If using balloon occlusion catheter, embolize outflow with coils or plug.
Optional cone beam CT to assess distribution. Optional because people tend not really to do anything with this information.
Removed catheter and sheath and obtain hemostasis.
Complications
More prevalent if ethanol is used: gross hematuria (15-100%), anaphylaxis (2.2-5.0%), renal failure (4.8%)
Hepatic failure (4.8-7.0%), DIC (up to 9%), portal or renal vein thrombosis (5.0%), GV rupture (2.0%), pulmonary embolism (1.5-4.1%, symptomatic ~0.5%), arrhythmia (0.5-1.5%), stroke (0.5%, due to subclinical PFO, could do a bubble study but a 3rd will have a right to left shunt due to hepatopulmonary syndrome)
Complications are lower with CARTO or PARTO particularly if gelfoam alone is used rather than sclerosant: No hematuria, PE, hepatic failure, or renal failure
Post-procedure care & Follow Up
Admit 1-2 days if not already inpatient to assess for GI bleed, LTFs, CBC, ammonia, and worsening portal hypertension
Repeat endoscopy and triphasic liver CT in 2 days to 1 week
Follow up CT at 1, 3, and 6 months
Additional Resources
Decision Aid for Patients and Consent
Backtable Articles and Podcasts on Balloon-Occluded Retrograde Transvenous Obliteration and Plug-Assisted Retrograde Transvenous Obliteration