Interventional procedure overview of transvenous obliteration for gastric varices
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Description of the procedure
Indications and current treatment
Varices are dilated veins. Gastric varices form in approximately 20% of people with portal hypertension. Portal hypertension can occur in cirrhosis or in people without cirrhosis who develop thrombosis of the splanchnic circulation, such as portal vein thrombosis. Gastric varices are prone to bleeding, and this is associated with high mortality and poor prognosis.
Treatment for gastric varices includes non-selective β-blockers, balloon tamponade, band ligation, endoscopic cyanoacrylate or thrombin injection, transjugular intrahepatic portosystemic shunt (TIPS), and transvenous obliteration.
What the procedure involves
Cross-sectional imaging is done to identify and confirm the target shunt (gastrorenal shunt is usually present). Percutaneous venous access of the femoral or jugular vein using standard angiographic technique is done. An occlusion balloon catheter is inserted and navigated into the target shunt under fluoroscopic guidance. The balloon is inflated to occlude the shunt and venography is then done to define the variceal anatomy and type of varices. Sclerosant is slowly injected into the varices to fill the full extent of the varices, with the embolisation end point being minimal filling of the afferent vein or portal vasculature. The injection of sclerosant can be done with or without using a microcatheter for more selective injection. The occlusion balloon catheter is left in situ until satisfactory embolisation of the varices is achieved. This procedure is called balloon-occluded retrograde transvenous obliteration (BRTO). The aim is to obliterate the varices and manage acutely bleeding gastric varices or those at high risk of bleeding.
Modified techniques, such as balloon-occluded antegrade transvenous obliteration (BATO; a collective term for portal venous access routes to the varices), vascular plug-assisted retrograde transvenous obliteration (PARTO) and coil-assisted retrograde transvenous obliteration (CARTO), follow a similar procedure to BRTO. However, for PARTO and CARTO, shunt occlusion is achieved by vascular plugging or coiling. These 2 techniques can reduce procedure time and eliminate the risk of balloon rupture.
Outcome measures
Liver disease measures
Child-Pugh Score
System to predict mortality in people with cirrhosis. Scored based on assessment of severity of encephalopathy, severity of ascites, bilirubin concentration, albumin concentration, and prothrombin time or international normalized ratio. The severity of cirrhosis is then scored out of 15:
Child-Pugh A: 5 to 6 points (least severe)
Child-Pugh B: 7 to 9 points
Child-Pugh C: 10 to 15 points (most severe)
Model for end-stage liver disease (MELD) score
Score to predict mortality in people with cirrhosis. Scored on assessment of aetiology, bilirubin concentration, creatinine concentration, sodium concentration, and prothrombin time or international normalized ratio. Higher scores indicate worse prognosis, in particular those with MELD >19.
Classification of gastric varices
Sarin classification
System to classify gastric varices based on the relationship with oesophageal varices and their location in the stomach. Gastric varices are classified into 4 types:
Gastroesophageal varix (GOV) type 1: varices in continuity with oesophageal varices along lesser curvature of the stomach.
GOV type 2: extension of oesophageal varices along greater curvature of the stomach.
Isolated gastric varix (IGV) type 1: isolated cluster of gastric varices in the gastric fundus.
IGV type 2: isolated gastric varices in the other parts of the stomach.
Hashizume classification
System to classify gastric varices based on size, shape, location, and colour:
Hirota classification
System to classify gastric varices based on the results of balloon-occluded retrograde venography:
Grade 1: gastric varices are well opacified without evidence of collateral veins.
Grade 2: collateral veins were small and few, and the contrast medium remained in the gastric varices for 3 minutes or more.
Grade 3: collateral veins were medium to large, there were few veins, and the contrast medium filled the gastric varices only partially and disappeared within 3 minutes.
Grade 4: there were many large collateral veins, and the gastric varices were not opacified.
Grade 5: the shunt could not be occluded with the balloon catheter because of the large size of the shunt and the rapid blood flow.
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