Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Varix with Both Gastrorenal and Gastrocaval Shunts: A Case Report

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Abstract

INTRODUCTION

Gastric varices occur in 20%–30% of patients with portal hypertension due to liver cirrhosis [1,2]. Gastric variceal bleeding is less common than esophageal variceal bleeding [3]. But, gastric variceal bleeding has a poor prognosis and a high mortality rate [2]. Moreover, endoscopic treatment of gastric variceal bleeding is less effective than the treatment of esophageal variceal bleeding [1]. Therefore, Balloon-occluded retrograde transvenous obliteration (BRTO), which injects a sclerosing agent into gastric varix through a gastrorenal shunt, has traditionally been widely applied for the treatment of gastric varices [4].

Recently, Gwon et al. [5] reported the plug-assisted retrograde transvenous obliteration (PARTO) procedure, and PARTO has been popularly applied to the treatment of gastric varices.

Gastric varices can form various types of shunts with systemic veins [6], and both PARTO and BRTO are procedures that embolize gastric varix by retrograde approach through shunts with systemic veins [4,5].

To our knowledge, there is no case report in which PARTO was performed in a patient with both gastrorenal shunt and gastrocaval shunt. We report a case of gastric varix treatment with PARTO in a patient with both gastrorenal shunt and gastrocaval shunt.

CASE REPORT

A 54-year-old man visited the outpatient clinic with gastric varix diagnosed at an outside hospital. He was diagnosed with hepatitis B and liver cirrhosis. A gastroscopy performed at an outside hospital revealed gastric varix at the gastric fundus.

He underwent computed tomography (CT) examination. CT showed tortuous and dilated veins in the gastric fundus (Fig. 1A). A gastrorenal shunt connecting gastric varix and the left renal vein was also observed (Fig. 1B). However, not only the gastrorenal shunt but also the gastrocaval shunt connecting gasrtic varix and the inferior vena cava (IVC) were found on CT (Fig. 1C). Because of the large gastric varix, the risk of variceal bleeding was high, and he decided to undergo PARTO.

Fig. 1

(A) Computed tomography (CT) scan demonstrates large and tortuous gastric varix (arrow) at the gastric fundus. (B) The coronal reconstruction image of the CT scan shows the gastrorenal shunt (arrow) of the gastric varix connected to the left renal vein. (C) CT scan show also gastrocaval shunt (arrow) of gastric varix connected to the inferior vena cava.

One month later, he was hospitalized for PARTO and PARTO was performed in the angiography suite. Right common femoral vein puncture was done under US guidance. A 7F guiding sheath (Flexor Raabe guiding sheath; Cook Medical, Bloomington, IN, USA) was inserted into IVC through the right common femoral vein. Gastrorenal shunt selection was performed using 0.889-mm hydrophilic guide wire (Terumo, Tokyo, Japan) negotiation, and then a 5F catheter (Cobra; Cook Medical) was inserted into gastrorenal shunt. And venography was done (Fig. 2A). A 7F guiding sheath was introduced into the gastrorenal shunt along the 5F catheter and guide wire. A 12 mm Amplazer vascular plug type II (Abbott Medical, Plymouth, MN, USA) was placed in the gastrorenal shunt through a 7F guiding sheath. And 5F catheter was placed in the proximal portion of the gastrorenal shunt rather than the vascular plug, and a Gelatin sponge (Cutanplast; Mascia Brunelli Spa, Milano, Italy) particles were injected until gastric varix was opacified.

Fig. 2

(A) Venogram performed through the 5F catheter shows a gastrorenal shunt. (B) Venogram demonstrates gastrocaval shunt. (C) After plug-assisted retrograde transvenous obliteration, the fluoroscopy image shows the vascular plugs inside the gasgrorenal shunt (blanck arrow) and gastrocaval shunt (white arrow), and the gastric varix filled with a mixture of contrast agent and Gelatin sponge particles.

And then, the right internal jugular vein was punctured for the approach to the gastrocaval shunt. A 7F guiding sheath was inserted into IVC through the right internal jugular vein. A 0.889-mm guide wire and a 5F catheter were inserted in gastrocaval shunt (Fig. 2B), and a 7F guiding sheath was introduced into gasgtrocaval shunt along the guide wire and the 5F catheter. And then, an 8 mm Amplazer vascular plug type II (Abbott Medical) was placed into the gastrocaval shunt through the 7F guiding sheath. The 5F catheter was placed in the proximal portion of the gastrocaval shunt rather than the vascular plug, and Gelatin sponge particles were injected through the 5F catheter.

PARTO was performed successfully and the vascular plugs in the gastrorenal shunt and in the gastrocaval shunt were positioned normally (Fig. 2C). The patient was discharged without any abnormal symptoms after the PARTO procedure.

A CT scan performed 2 weeks after PARTO showed that the gastric varix was filled with thrombus (Fig. 3A), and a CT scan performed 6 months after gastric varix completely disappeared (Fig. 3B).

Fig. 3

(A) Computed tomography (CT) scan 2 weeks after plug-assisted retrograde transvenous obliteration (PARTO) shows that the gastric varix is completely filled with thrombus (arrow). (B) CT scan 6 months after PARTO shows complexly disappeared gastric varix.

The patient provided written informed consent for the publication of clinical details and images.

DISCUSSION

The mortality rate of gastric variceal bleeding has been reported up to 45% [2]. Therefore, various methods have been developed for the treatment of gastric varix. However, endoscopic treatments such as endoscopic injection sclerotherapy and variceal ligation are effective for esophageal varices but less effective for gastric varices because of the large volume and fast blood flow of gastric varices [1]. Therefore, BRTO has been widely applied to the treatment of gastric varices.

BRTO is a procedure that embolizes gastric varix by injecting a sclerosing agent such as ethanolamine oleate (EO) or 3% sodium tetradecyl sulfate (STS) through the gastrorenal shunt [5,7]. However, BRTO using EO had several complications such as pulmonary edema, disseminated intravascular coagulation, anaphylactic reaction, and severe renal dysfunction [8]. Also, prolonged ballooning of occlusion balloons for vascular sclerosis is the disadvantage of BRTO [4,9].

In PARTO, a vascular plug and gelatin sponge are used instead of the occlusion balloon catheter and EO or STS. Compared to BRTO, PARTO has the advantages of short procedure time and technical ease [5]. Therefore, PARTO has recently been widely applied as a substitute for BRTO in the treatment of gastric varices.

The majority (80%–85%) of gastric varices located at the gastric fundus drain into the inferior phrenic vein, which later joins with the left adrenal vein and forms the gastrorenal shunt, and then drains into the left renal vein. However, 10%–15% of gastric varices drain into the IVC via the gastrocaval shunt [8]. The gastrocaval shunt passes below the diaphragm transversely and terminates in the IVC or left hepatic vein [6].

Koito et al. [10] reported a study in which BRTO was performed on gastrorenal shunts and gastrocaval shunts. But there was no report of a case in which PARTO was performed on a patient with gastric varix who had both gastrorenal shunt and gastrocaval shunt.

A study of PARTO by Gwon et al. [5] suggested that the end point of gel foam injection is until visualization of afferent veins such as the left gastric vein or posterior gastric vein. However, we think when PARTO is performed only through the gastrorenal shunt without recognizing the presence of the gastrocaval shunt, the embolic materials leak into the IVC through the gastrocaval shunt, and complications such as pulmonary thromboembolism may occur. Therefore, it is necessary to check not only the presence of gastrorenal shunt but also the presence of gastrocaval shunt on CT before the PARTO procedure.

In conclusion, PARTO can be applied to the treatment of gastric varix in patients with both gastrorenal shunt and gastrocaval shunt.

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