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Balloon-occluded Retrograde TransvObliteration (BRTO) of Gastric Va

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 Radiol

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Chief Complaint & HPI

Chief Complaint

77-year-old male with acute hematemesis

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 bfloor and all over his clothes with another episode prior to bed

Underwent endoscopic banding of actively bleeding gastric varices upon adm

VIR consulted by GI after failed endoscopic banding and multiple friable andgastric varices

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Relevant History

Past Medical HistoryPrior CVA

Diabetes mellitus, type II

Hypertension

Nephrolithiasis

Diverticulitis

Past Surgical History

Partial colectomy for diverticulitisLeft carotid endarterectomy

Family & Social HistoryAlcohol abuse (at least 3-4 shots of whiskey/day for 20 years)

Review of SystemsPertinent for those mentioned in HPI, PSH, PMH

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Relevant History

MedicationsLosartan 50 mg, PO, Qday

Ezetimibe 40 mg, PO, Qday

Metformin 500 mg, PO, Qid

Multivitamin

Aspirin 81 mg, PO, Qday

Allergies

Penicillin

Donnatal

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Diagnostic Workup

Physical ExamVital 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

medusa, hepatosplenomegaly,No jaundice, asterixis, scleral icterus

Laboratory Data

Pertinent positive/negative diagnostic studies.

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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

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Diagnostic Workup

Non-invasive imagingCT-angiography of the abdomen and pelvis

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Diagnostic Workup CT-Angiography

Axial CTA shows multiple large gastric varices, some thrombosed. Findings of nodularliver contour and caudate lobe hypertrophy suggestive of cirrhosis are also present.

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Diagnostic Workup CT-Angiography

Coronal MIP image demonstrates gastric varices draining via a gastrorenal shunt.

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Diagnosis

DiagnosisBleeding gastric varices draining via a gastrorenal shunt

Hepatic cirrhosis

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Intervention

Patient underwent endoscopic banding of gastric varicesActive variceal bleeding and multiple friable varices were seen despite multipplacements

General surgery consulted for possible gastrectomy for bleeding refractotreatment

CTA ordered by surgery was reviewed by IR

Detailed discussion was had among patient, surgery, GI and IR regardingand minimally invasive options

Patient was emergently brought down to IR for Balloon-Occluded RetrogTransvenous Obliteration (BRTO) of gastric varices

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Intervention - BRTO

Inferior phrenic venogram confirms gast

via a gastrorenal shunt. Inferior pericard

opacifies. The left adrenal vein is exclude

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Intervention - BRTO

After sheath upsizing, the inferior cardicoil embolized with 0.018 Nester coils t

from central venous drainage.

Contrast injection demonstrated no res

coiled pericardiophrenic vein with the o

inflated.

Active hemorrhage is evident.

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Intervention - BRTO

An 11.5 mm occlusion balloon was advainferior phrenic vein and inflated to occ

draining vein. Foam sclerotherapy was p

Sotradecol for a total dwell time of 30 m

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Intervention - BRTO

Sclerotherapy was also augmente

embolization. Repeat injection sh

flow in the gastric varices.

The efferent draining vein was co

0.035 coils.

The left adrenal vein remained pr

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Question

In the traditional method of BRTO, 5-10% ethanolamine oleate is utilizedsclerosant of choice. What is a well-known potential side effect describeliterature in utilizing this agent and its treatment/prevention?

A. Bleeding; supportive measures including blood transfusion

B. Hemolysis and acute renal failure: intravenous haptoglobin administraIV hydration

C. Mental status changes: immediate lactulose administration

D. Alcohol poisoning: aggressive IV resuscitation

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Correct!

In the traditional method of BRTO, 5-10% ethanolamine oleate is utilizedsclerosant of choice. What is a well-known potential side effect describeliterature in utilizing this agent and its treatment/prevention?

A. Bleeding; supportive measures including blood transfusion

B. Hemolysis and acute renal failure: intravenous haptoglobin administraIV hydration

C. Mental status changes: immediate lactulose administration

D. Alcohol poisoning: aggressive IV resuscitation

Return to Case

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Sorry, Thats Incorrect

In the traditional method of BRTO, 5-10% ethanolamine oleate is utilizedsclerosant of choice. What is a well-known potential side effect describeliterature in utilizing this agent and its treatment/prevention?

A. Bleeding; supportive measures including blood transfusion

B. Hemolysis and acute renal failure: intravenous haptoglobin administraIV hydration

C. Mental status changes: immediate lactulose administration

D. Alcohol poisoning: aggressive IV resuscitation

Return to Case

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Clinical Follow Up

Post-embolization, no additional episodes of hematemesis were noted apatient was discharged on POD#1

The patient was seen in IR clinic in 2 weeks for follow-up and evaluationtransvenous intrahepatic portosystemic shunt (TIPS) placement

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Summary & Teaching Points

Classically, when endoscopic management of gastric variceal bleeding fahas been performed to decompress the portal system

BRTO, however, offers a minimally invasive option for the treatment of gvariceal 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 selectingwho would benefit from BRTO

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References & Further Reading

Kiyosue H, Mori H, Shunro M, Yamada Y, Hori Y, OkinoY. Transcatheterobliteration of gastric varices. Radiographics. 2003 Jul-Aug; 23(4): 911-2

Saad, W. Balloon-occluded retrograde transvenous obliteration of gastrconcept, basic techniques and outcomes. Semin Intervent Radiol. Jun 20118-128.

Darcy M, Saad W. Transjugular intrahepatic portosystemic shunt (TIPS)

balloon-occluded retrograde transvenous obliteration (BRTO) for the maof gastric varices. Semin Intervent Radiol. Sept 2011; 28(3): 339-349.