medigraphic.com
Órgano Oficial de la Asociación Mexicana de Hepatología

2015, Number 3

<< Back Next >>

Ann Hepatol 2015; 14 (3)

Safety and efficacy of angiographic occlusion of duodenal varices as an alternative to TIPS: review of 32 cases

Copelan A, Chehab M, Dixit P, Cappell MS

Language: English
References: 42
Page: 369-379
PDF size: 164.71 Kb.


ABSTRACT

Backgroud/rationale of study. Analyze safety and efficacy of angiographic-occlusion-with-sclerotherapy/ embolotherapy-without-transjugular-intrahepatic-portosystemic-shunt (TIPS) for duodenal varices. Although TIPS is considered the best intermediate-to-long term therapy after failed endoscopic therapy for bleeding varices, the options are not well-defined when TIPS is relatively contraindicated, with scant data on alternative therapies due to relative rarity of duodenal varices. Prior cases were identified by computerized literature search, supplemented by one illustrative case. Favorable clinical outcome after angiography defined as no rebleeding during follow-up, without major procedural complications. Results. Thirty-two cases of duodenal varices treated by angiographic-occlusion-with-sclerotherapy/embolotherapy- without-TIPS were analyzed. Patients averaged 59.5 ± 12.2 years old (female = 59%). Patients presented with melena-16, hematemesis & melena-5, large varices-5, growing varices-2, ruptured varices-1, and other- 3. Twenty-nine patients had cirrhosis; etiologies included: alcoholism-11, hepatitis C-11, primary biliary cirrhosis- 3, hepatitis B-2, Budd-Chiari-1, and idiopathic-1. Three patients did not have cirrhosis, including hepatic metastases from rectal cancer-1, Wilson’s disease-1, and chronic liver dysfunction-1. Thirty-one patients underwent esophagogastroduodenoscopy before therapeutic angiography, including fifteen undergoing endoscopic variceal therapy. Therapeutic angiographic techniques included balloon-occludedretrograde- transvenous-obliteration (BRTO) with sclerotherapy and/or embolization-21, DBOE (double-balloon-occluded-embolotherapy)-5, and other-6. Twenty-eight patients (87.5%; 95%-confidence interval: 69-100%) had favorable clinical outcomes after therapeutic angiography. Three patients were therapeutic failures: rebleeding at 0, 5, or 10 days after therapy. One major complication (Enterobacter sepsis) and one minor complication occurred. Conclusions. This work suggests that angiographic-occlusion-withsclerotherapy/ embolotherapy-without-TIPS is relatively effective (~90% hemostasis-rate), and relatively safe (3% major-complication-rate). This therapy may be a useful treatment option for duodenal varices when endoscopic therapy fails and TIPS is relatively contraindicated.


REFERENCES

  1. Schmeltzer PA, Smith MT. Duodenal variceal bleeding successfully treated with endoscopic banding (with video). Gastrointest Endosc 2011; 74: 716-7.

  2. Gunnerson AC, Diehl DL, Nguyen VN, Shellenberger MJ, Blansfield J. Endoscopic duodenal variceal ligation: a series of 4 cases and review of the literature (with video). Gastrointest Endosc 2012; 76: 900-4.

  3. Mora-Soler A, Velasco-Guardado A, Acosta-Materán R, Umaña-Mejía J, Jamanca-Poma Y, Calderón-Begazo R, Legido-Gil J, et al. Endoscopic treatment of duodenal varices with cyanoacrylate. Rev Esp Enferm Dig 2013; 105: 629-32.

  4. Okoli A, Raymond P, Ammannagari N, Merrell N. Isolated duodenal varices as the initial presentation of hepatocellular carcinoma. BMJ Case Rep 2013 [Epub Dec 17, 2013].

  5. Norton ID, Andrews JC, Kamath PS. Management of ectopic varices. Hepatology 1998; 28: 1154-8.

  6. Hashizume M, Tanoue K, Ohta M, Ueno K, Sugimachi K, Kashiwagi M, Sueishi K. Vascular anatomy of duodenal varices: angiographic and histopathological assessments. Am J Gastroenterol 1993; 88:1942-5.

  7. Rana SS, Bhasin DK, Sharma V, Chaudhary V, Sharma R, Singh K. Clinical, endoscopic and endoscopic ultrasound features of duodenal varices: A report of 10 cases. Endosc Ultrasound 2014; 3: 54-7.

  8. Kakutani H, Sasaki S, Ueda K, Takakura K, Sumiyama K, Imazu H, Hino S, et al. Is it safe to perform endoscopic band ligation for the duodenum? A pilot study in ex vivo porcine models. Minim Invasive Ther Allied Technol 2013; 22: 80-3.

  9. Kim MJ, Jang BK, Chung WJ, Hwang JS, Kim YH. Duodenal variceal bleeding after balloon-occluded retrograde transverse obliteration: treatment with transjugular intrahepatic portosystemic shunt. World J Gastroenterol 2012; 18: 2877-80.

  10. Sort P, Elizalde I, Llach I, Feu F, Garcia-Pagan JC, Salmeron JM, Mas A, et al. Duodenal variceal bleeding treated with a transjugular intrahepatic portosystemic shunt. Endoscopy 1995; 27: 626.

  11. Lopera JE, Arthurs B, Scheuerman C, Sandoz C, Petersosn S, Castaneda-Zuniga W. Bleeding duodenal varices: treatment by TIPS and transcatheter embolization. Cardiovasc Intervent Radiol 2008; 31: 431-4.

  12. Kinzel J, Pichetshote N, Dredar S, Aslanian H, Nagar A. Bleeding from a duodenal varix: a unique case of variceal hemostasis achieved using EUS-guided placement of an embolization coil and cyanoacrylate. J Clin Gastroenterol 2014; 48: 362-4.

  13. Levy MJ, Wong Kee Song LM, Kendrick ML, Misra S, Gostout CJ. EUS-guided coil embolization for refractory ectopic variceal bleeding (with videos). Gastrointest Endosc 2008; 67: 572-4.

  14. Chau TN, Patch D, Chan YW, Nagral A, Dick R, Burroughs AK. “Salvage” transjugular intrahepatic portosystemic shunts: gastric fundal compared with esophageal variceal bleeding. Gastroenterology 1998; 114: 981-7.

  15. Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000; 31: 864-71.

  16. Boyer TD, Haskal ZJ, American Association for the Study of Liver Diseases. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: update 2009. Hepatology 2010; 51: 1-16.

  17. Sanyal AJ, Freedman AM, Shiffman ML, Purdum PP 3rd, Luketic VA, Cheatham AK. Portosystemic encephalopathy after transjugular intrahepatic portosystemic shunt: results of a prospective controlled study. Hepatology 1994; 20(1, pt. 1): 46-55.

  18. Fidelman N, Kwan SW, LaBerge JM, Gordon RL, Ring EJ, Kerlan RK Jr. The transjugular intrahepatic portosystemic shunt: an update. AJR Am J Roentgenol 2012; 199: 746-55.

  19. Qi XS, Fan DM. Hepatic venous pressure gradient measurement before TIPS for acute variceal bleeding. World J Gastroenterol 2014; 20: 7523-4.

  20. Zamora CA, Sugimoto K, Tsurusaki M, Izaki K, Fukuda T, Matsumoto S, Kuwata Y, et al. Endovascular obliteration of bleeding duodenal varices in patients with liver cirrhosis. Eur Radiol 2006; 16: 73-9.

  21. Tsurusaki M, Sugimoto K, Matsumoto S, Izaki K, Fukuda T, Akasaka Y, Fujii M, et al. Bleeding duodenal varices successfully treated with balloon-occluded retrograde transvenous obliteration (B-RTO) assisted by CT during arterial portography. Cardiovasc Intervent Radiol 2006; 29: 1148-51.

  22. Akasaka T, Shibata T, Isoda H, Taura K, Arizono S, Shimada K, Togashi K. Septic complication after balloonoccluded retrograde transvenous obliteration of duodenal variceal bleeding. Cardiovasc Intervent Radiol 2010; 33: 1257-61.

  23. Akazawa Y, Murata I, Yamao T, Yamakawa M, Kawano Y, Nomura N, Isomoto H, et al. Successful management of bleeding duodenal varices by endoscopic variceal ligation and balloon-occluded retrograde transvenous obliteration. Gastrointest Endosc 2003; 58: 794-7.

  24. Haruta I, Isobe Y, Ueno E, Toda J, Mitsunaga A, Noguchi S, Kimura T, et al. Balloon-occluded retrograde transvenous obliteration (BRTO), a promising nonsurgical therapy for ectopic varices: a case report of successful treatment of duodenal varices by BRTO. Am J Gastroenterol 1996; 91: 2594-7.

  25. Hashimoto N, Akahoshi T, Yoshida D, Kinjo N, Konishi K, Uehara H, Nagao Y, et al. The efficacy of balloon-occluded retrograde transvenous obliteration on small intestinal variceal bleeding. Surgery 2010; 148: 145-50.

  26. Hotta M, Yoshida H, Mamada Y, Taniai N, Bando K, Mizuguchi Y, Kakinuma D, et al. Successful management of duodenal varices by balloon-occluded retrograde transvenous obliteration. J Nippon Med Sch 2008; 75: 36-40.

  27. Kakizaki S, Toyoda M, Ichikawa T, Sato K, Takagi H, Arai H, Sohara N, et al. Clinical characteristics and treatment for patients presenting with bleeding duodenal varices. Dig Endosc 2010; 22: 275-81.

  28. Okahara M, Kiyosue H, Ueda S, Kashiwagi J, Tanoue S, Hongo N, Mori H. Anatomic features and retrograde transvenous obliteration of duodenal varices associated with mesocaval collateral pathway. J Vasc Interv Radiol 2012; 23: 1339-46.

  29. Soga K, Tomikashi K, Fukumoto K, Miyawaki K, Okuda K, Konishi H, Yagi N, et al. Successful endoscopic hemostasis for ruptured duodenal varices after balloon-occluded retrograde transvenous obliteration. Dig Endosc 2010; 22: 329-33.

  30. Sonomura T, Horihata K, Yamahara K, Dozaiku T, Toyonaga T, Hiroka T, Sato M. Ruptured duodenal varices successfully treated with balloon-occluded retrograde transvenous obliteration: usefulness of microcatheters. AJR Am J Roentgenol 2003; 181: 725-7.

  31. Hwang SW, Sohn JH, Kim TY, Kim JY, Yhi J, Kwak DS, Kim HS, et al. Long-term successful treatment of massive distal duodenal variceal bleeding with balloon-occluded retrograde transvenous obliteration. Korean J Gastroenterol 2014; 63: 248-52.

  32. Ohta M, Yasumori K, Saku M, Saitsu H, Muranaka T, Yoshida K. Successful treatment of bleeding duodenal varices by balloon-occluded retrograde transvenous obliteration: a transjugular venous approach. Surgery 1999; 126: 581-3.

  33. Tanaka O, Ohno K, Ohno T, Tomioka H, Shimizu S, Yamagami T, Nishimura T. Should balloon-occluded retrograde transvenous obliteration be the first-line interventional radiologic treatment for bleeding duodenal varices? A case report and review of the literature. Acta Radiol 2008; 49: 32-6.

  34. Ota K, Okazaki M, Higashihara H, Kokawa H, Shirai Z, Anan A, Kitamura Y, et al. Combination of transileocolic vein obliteration and balloon-occluded retrograde transvenous obliteration is effective for ruptured duodenal varices. J Gastroenterol 1999; 34: 694-9.

  35. Takamura K, Miyake H, Mori H, Terashima Y, Ando T, Fujii M, Tashiro S, et al. Balloon occluded retrograde transvenous obliteration and percutaneous transhepatic obliteration for ruptured duodenal varices after operation for rectal cancer with multiple liver metastasis: report of a case. J Med Invest 2005; 52: 212-7.

  36. Baran B, Soyer OM, Poyanli A, Karaca C. Angiographic embolization of large duodenal varix in a cirrhotic patient. Dig Liver Dis 2013; 45: 437.

  37. Menu Y, Gayet B, Nahum H. Bleeding duodenal varices: diagnosis and treatment by percutaneous portography and transcatheter embolization. Gastrointest Radiol 1987; 12: 111-3.

  38. Selçuk H, Boyvat F, Eren S, Korkmaz M, Gür G, Yilmaz U, Boyacioglu S. Duodenal varices as an unusual cause of gastrointestinal bleeding due to portal hypertension: a case report. Turk J Gastroenterol 2004; 15: 104-7.

  39. Verbeeck N, Stammet P, Weber J, Mertens L, Serignol J. Bleeding duodenal varices, an unusual presentation of portal hypertension: 3D MSCT of the feeding branches facilitates temporizing treatment by percutaneous transhepatic embolization. JBR-BTR 2009; 92: 289-92.

  40. Khouqeer F, Morrow C, Jordan P. Duodenal varices as a cause of massive upper gastrointestinal bleeding. Surgery 1987; 102: 548-52.

  41. Frossard JL, Seirafi M, Spahr L. Ectopic varices and collaterals development after band ligation treatment in a patient with portal hypertension. Case Rep Gastroenterol 2008; 2: 380-3.

  42. Wu WC, Wang LY, Yu FJ, Wang WM, Chen SC, Chuang WL, Chang WY. Bleeding duodenal varices after gastroesophageal varices ligation: a case report. Kaohsiung J Med Sci 2002; 18: 578-81.




2020     |     www.medigraphic.com