Balloon Occlusion Retrograde Transvenous Obliteration of Gastric Varices in Two Non-Cirrhotic Patients with Portal Vein Thrombosis
The patient was a 51-year-old woman with necrotizing pancreatitis and extensive enterocutaneous fistulas also complicated by portal vein thrombosis with cavernous transformation and splenic vein thrombosis (). She also had multiple episodes of upper GI bleeding for which she had undergone an upper GI endoscopy and ligation of the varices. She underwent splenic artery and gastroduodenal artery embolization due to recurrence of the upper GI bleeding. She was referred for a BRTO procedure due to continual upper GI bleeding even after multiple variceal ligations, splenic and gastroduodenal artery embolization, and persistence of multiple gastric varices on both upper GI endoscopy and CT imaging (). Laboratory data before the BRTO procedure was creatinine, 0.6 mg/dL; bilirubin, 4.4 mg/dL; AST, 92 units/L; ALT, 59 units/L; albumin, 2.2 g/dL; and PT/INR, 19.1 sec/1.58.\nThe same BRTO technique that was described for the first case was used. A balloon occluded retrograde venogram showed filling of the gastric varices and multiple collateral veins including the inferior phrenic vein (). Two collateral veins including the inferior phrenic vein were catheterized with a 2.7 Fr microcatheter (Progreat; Terumo Medical, Elkton, MD, USA) and embolized with multiple 6 mm and 4 mm microcoils (Nester coil; Cook Inc., Bloomington, IN, USA). A Gelfoam slurry was used to embolize multiple small collateral veins before administering the sclerosant. The sclerosant was administered with the occlusion balloon inflated, and the varices were filled under fluoroscopic guidance over 40 minutes. Six mL of 3% sodium tetradecol sulfate was used as the sclerosant (Sotradecol; AngioDynamics) mixed with 3 mL lipiodol (Ethiodol; Savage Laboratories) and 9 mL of air. A spot image after embolization showed shrunken gastric varices with lipiodol uptake (). The balloon occlusion catheter was left in place overnight through the guiding catheter. The patient was monitored in the intensive care unit to assess the therapeutic response as well as delayed complications. A complete blood count and hepatic function panel were obtained to assess the therapeutic response the following morning. The sheath and catheters were removed the following morning after checking lipiodol uptake on plain abdominal radiography.\nThe patient's upper GI bleeding cleared within a few days after the procedure, and she was discharged. Follow-up upper endoscopy 65 days post procedure showed normal gastric mucosa. Additionally, follow-up CT scans at 6 months post BRTO procedure showed complete obliteration of gastric varices (). However due to underlying necrotizing pancreatitis with multiple enterocutaneous fistulas and abdominal wounds, she expired 8 months post procedure due to complicated sepsis.