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Balloon-occluded retrograde transvenous obliteration combined with EUS-guided coil embolization and endoscopic cyanoacrylate injection therapy of gastric varices with huge gastrorenal shunt (with videos)


1 Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
2 Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China

Date of Submission30-Jun-2021
Date of Acceptance26-Dec-2021
Date of Web Publication02-May-2022

Correspondence Address:
Mingkai Chen,
Department of Gastroenterology, Renmin Hospital of Wuhan University. 99 Zhangzhidong Road, Wuhan 430060, Hubei Province
China
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EUS-D-21-00157



How to cite this URL:
Xiao Y, Huang Z, Cao J, Wang Z, Zhang F, Wang Y, Ke G, Liu J, Chen M. Balloon-occluded retrograde transvenous obliteration combined with EUS-guided coil embolization and endoscopic cyanoacrylate injection therapy of gastric varices with huge gastrorenal shunt (with videos). Endosc Ultrasound [Epub ahead of print] [cited 2022 Sep 24]. Available from: http://www.eusjournal.com/preprintarticle.asp?id=344250

Dr. Yong Xiao and Ziyin Huang contributed equally and are joint the first authors.


A 66-year-old man who presented with repeated hematemesis three times for 7 days with a history of cirrhosis and schistosomiasis was admitted to our department. The Child-Pugh score was A/6, and MELD score was 9. Computed tomography angiography (CTA) of the portal vein revealed gastric varices (GVs) and gastrorenal shunt (GRS) (9–18 mm in diameter). Endoscopy showed gastric fundal varices (diameter in 5 cm). Balloon-occluded retrograde transvenous obliteration (BRTO) was planned to undertake as a secondary prophylaxis.

BRTO was performed by using a 14-mm balloon catheter inserted via the right femoral vein. However, the GRS cannot be completely occluded and the blood flow signals can still be obviously observed by angiography [Figure 1]. At that time, immediate endoscopic therapy will result in a higher risk of glue embolization. Thus, EUS-guided coil placement combined with endoscopic cyanoacrylate injection therapy was employed to reduce the possibility of ectopic embolism.
Figure 1: Gastrorenal shunt still cannot be completely occluded by replacing for a 14-mm balloon and changing the balloon position

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The angiography showed that the velocity of blood flow in the GRS was slower than before after leaving the balloon in place for 24 h [Figure 2]. The EUS-guided color Doppler flow imaging presented active blood flow signals in the GV and GRS, and the minimum diameter of GRS across the muscularis propria of the gastric wall was 9 mm. Then, punctured the gastric fundal variceal vein, placed a 12-mm coil with a 19G needle, and injected with 3 mL sclerosant and 1.5 mL cyanoacrylate under the guidance of EUS [Video 1 [Additional file 1]]. Finally, 3 mL sclerosant and 1 mL cyanoacrylate were injected into the gastric fundal varices at two points by a sandwich method (sclerosant, cyanoacrylate, and hypertonic glucose) via endoscope [Video 2 [Additional file 2]]. After the procedure, there was the absence of flow in the gastric fundal varices during EUS-Doppler examination [Figure 3]. Complete obliteration has achieved, and the balloon was deflated and removed under DSA half an hour later [Video 3 [Additional file 3]].
Figure 2: After the balloon remained in position for 24 h, the angiography showed that the velocity of blood flow in gastrorenal shunt was slower than the previous day in spite of incomplete obliteration

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Figure 3: EUS-guided color Doppler flow imaging showing the gastric variceal veins with few blood signals

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At follow-up 4 months later, although the patient developed ascites, no other serious complications occurred. The Child-Pugh score had no change. MELD score was 8. The CTA of the portal vein showed that there was no embolism in the portal vein system and the GRS still existed [12 mm in diameter, [Figure 4]]. Endoscopy revealed that esophageal varices and portal hypertensive gastropathy aggravated [Figure 5], but no treatment was required. The patient's ascites can be relieved by diuretic, so no further intervention was needed for now.
Figure 4: Comparison of the imaging manifestation before (a and c) and 4 months after treatment (b and d). The shunt still remained and gastric fundal varices was partial embolized

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Figure 5: Comparison of the endoscopic manifestation before (a, c, e) and 4 months after (b, d, f) treatment. The esophageal varices and portal hypertensive gastropathy worsened

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GRS is one of the portosystemic shunts arising from portal hypertension, and it is an important factor causing ectopic embolism in endoscopic cyanoacrylate injection therapy.[1] Many studies have evaluated the efficacy and safety of the treatment of GV with GRS.[2],[3],[4] However, the management of GV with huge GRS (diameter greater than 15 mm) is still challenging.[1] It is associated with a limitation of the size of the embolization tools and a higher risk of ectopic embolism.

This method provides a novel method for the patient with huge GRS. When the traditional treatment BRTO cannot completely occlude the huge GRS, EUS-guided coil embolization and endoscopic cyanoacrylate injection may become an assisted method. It has the following advantages. First, the hemodynamics in GRS change although the largest diameter balloon in BRTO cannot completely occlude GRS, which causes the fully effective flow restriction after the balloon is kept inflated for 24 h and reduces the possibility of ectopic embolism. Secondary, EUS-guided coil embolization and cyanoacrylate injection are associated with a lower risk of ectopic embolism and the precise targeting of vessel. It can keep the shunt and reduce the impact on portal pressure. Third, it requires fewer amount of cyanoacrylate and is more cost-effective. As a precision endoscopic therapy, the cyanoacrylate can be accurately injected into the targeting vein under the guidance of EUS. Moreover, the velocity of blood flow slows down after the shunt was blocked by BRTO, so the cyanoacrylate injected into the variceal vein can be remained. Moreover, at follow-up, no serious complications occurred. The shunt is remained which contributes to reducing the increase of portal hypertension caused by the treatment. These all suggest that the approach is safe, feasible, and effective.

In summary, the treatment of this case provides a meaningful exploration for the treatment of such patients in the future.

Acknowledgment

Thanks for the assistance of Prof. Yuzheng Zhuge and Dr. Ming Zhang come from Nanjing Drum Tower Hospital affiliated Nanjing University Medical School in this study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

The work in this paper is supported by The Key Research and Development Program of Hubei Province (No. 2020BCB007).

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Simón-Talero M, Roccarina D, Martínez J, et al. Association between portosystemic shunts and increased complications and mortality in patients with cirrhosis. Gastroenterology 2018;154:1694-705.e4.  Back to cited text no. 1
    
2.
Bhat YM, Weilert F, Fredrick RT, et al. EUS-guided treatment of gastric fundal varices with combined injection of coils and cyanoacrylate glue: A large U.S. experience over 6 years (with video). Gastrointest Endosc 2016;83:1164-72.  Back to cited text no. 2
    
3.
Downing TM, Khan SN, Zvavanjanja RC, et al. Portal venous interventions: How to recognize, avoid, or get out of trouble in Transjugular Intrahepatic Portosystemic Shunt (TIPS), Balloon Occlusion Sclerosis (ie, BRTO), and Portal Vein Embolization (PVE). Tech Vasc Interv Radiol 2018;21:267-87.  Back to cited text no. 3
    
4.
Lee EW, Shahrouki P, Alanis L, et al. Management options for gastric variceal hemorrhage. JAMA Surg 2019;154:540-8.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

 
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