BALLOON-OCCLUDED RETROGRADE TRANSVENOUS OBLITERATION (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 , Southeld, Michigan

CHIEF COMPLAINT & HPI

Chief Complaint and/or reason for consultation 77-year-old male with acute hematemesis secondary to bleeding gastric varices despite endoscopic banding

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 oor 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 conrms gastric varices draining via a gastrorenal shunt. Inferior pericardiophrenic vein also opacies. The left adrenal vein is excluded.

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

Contrast injection demonstrated no residual ow in the coiled pericardiophrenic vein with the occlusion ballooon inated.

Active hemorrhage is evident.

INTERVENTION - BRTO

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

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

The eerent draining vein was coil embolized with 0.035 coils.

The left adrenal vein remained preserved and patent.

QUESTION SLIDE

In the traditional method of BRTO, 5-10% ethanolamine oleate is utilized as the sclerosant of choice. What is a well-known potential side eect 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

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, oers 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 benet from BRTO

REFERENCES & FURTHER READING

Kiyosue H, Mori H, Shunro M, Yamada Y, Hori Y, Okino Y. Transcatheter obliteration 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.