Indian J Gastroenterol 2010(March–April):29(2):88–89 doi: 10.1007/s12664-010-0021-4
TECHNIQUE
Balloon retrograde transvenous occlusion of fundic varix Sanjeev Kumar Thakur · Siba Sankar Dalai
Abstract
Technique
A middle-aged woman presented with massive upper gastrointestinal bleed. The source of bleeding was a large fundic varix; a large splenorenal shunt was also present. The fundic varix was treated safely and effectively with balloon retrograde transvenous occlusion.
Venography was done through right femoral venous access. It demonstrated the spleno renal shunt and a bunch of fundic varices (Fig. 2). A Bard Atlas balloon (Bard Peripheral Vascular, Inc, Tempe, USA; 20 mm x 400 mm) was navigated across the shunt and inflated. The total volume of contrast needed to opacify the varix was estimated using an occlusion gram. After confirmation of complete occlusion of the shunt by the inflated balloon, 65 mL of 2% sodium tetra-decyl sulphate (STD) was injected into the shunt through the central lumen of the balloon catheter. Deflation was attempted once at 30 and 45 minutes but it had to be reinflalted and further STD was injected because of partial varix occlusion. The balloon was removed one hour later after confirmation of complete obliteration of the fundic varix (Fig. 3). The total volume of contrast needed was 75 mL. The patient experienced mild left upper abdominal pain during the procedure. The post-procedure period was uneventful except for transient hematuria. She was discharged on day 3 after the procedure.
Keywords CT angiography · portal hypertension · sodium tetra-decyl sulphate Introduction A 50-year-old woman presented with two episodes of significant gastrointestinal bleeding. The second episode was one week ago, and she had severe anemia at presentation. Upper gastrointestinal endoscopy showed a large fundic varix (Fig. 1) and no esophageal varices. Her liver functions were within normal limits. CT angiography of the abdomen showed a dilated portal vein, (size: 16 mm), patent splenic vein and normal pancreas. The fundic varix volume was nearly 45 mL and she had a large splenorenal shunt (1.2 cm). In view of large volume of fundic varix and splenorenal shunt, balloon retrograde transvenous occlusion (BRTO) of the fundic varix was planned.
S. K. Thakur1 · S. S. Dalai2 Departments of 1Gastroenterology, and 2Interventional Radiology, Seven Hills Hospital, Visakhapatnam 530 002, India S. S. Dalai () e-mail:
[email protected] Received: 24 April 2009 / Accepted: 8 May 2009 © Indian Society of Gastroenterology 2010
1 Springer
Fig. 1 Upper GI endoscopy showing a large fundic varix
Indian J Gastroenterol 2010(March–April):29(2):88–89
Balloon retrograde transvenous occlusion
Fig. 2 Pre BRTO, venogram with retrograde balloon occlusion demonstrating spleno-renal shunt with the fundic varices
The patient came for a routine follow-up at one month after BRTO. Upper GI endoscopy at this time reveled complete resolution of the fundic varices. Discussion (header) The risk of bleeding from gastric varices is approximately (10%–36%), the mortality is high (14%–45%).1 Since its introduction by Kanagawa et al2 BRTO has become widely accepted especially in Japan as a minimally invasive, highly effective treatment for gastric varices. Recently, it has been recommended for secondary prophylaxis of bleeding from fundic varix in cases with dominant splenorenal shunt if endoscopic therapy fails.3
Indian J Gastroenterol 2010(March–April):29(2):88–89
89
Fig. 3 Post BRTO, complete obliteration of the fundic varix
References 1.
Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992;16:1343–9. 2. Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol 1996;11:51–8. 3. APASL Consensus on Acute Variceal Bleeding. Final recommendation. Lacunae in current definition of acute variceal bleed. www.portalhypertension.info/aclf/apasl.ppt.
1 Springer
