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      Comparison of Transjugular Intrahepatic Portosystemic Shunt with Covered Stent and Balloon-Occluded Retrograde Transvenous Obliteration in Managing Isolated Gastric Varices

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          Abstract

          Objective

          Although a transjugular intrahepatic portosystemic shunt (TIPS) is commonly placed to manage isolated gastric varices, balloon-occluded retrograde transvenous obliteration (BRTO) has also been used. We compare the long-term outcomes from these procedures based on our institutional experience.

          Materials and Methods

          We conducted a retrospective review of patients with isolated gastric varices who underwent either TIPS with a covered stent or BRTO between January 2000 and July 2013. We identified 52 consecutive patients, 27 who had received TIPS with a covered stent and 25 who had received BRTO. We compared procedural complications, re-bleeding rates, and clinical outcomes between the two groups.

          Results

          There were no significant differences in procedural complications between patients who underwent TIPS (7%) and those who underwent BRTO (12%) ( p = 0.57). There were also no statistically significant differences in re-bleeding rates from gastric varices between the two groups (TIPS, 7% [2/27]; BRTO, 8% [2/25]; p = 0.94) or in developing new ascites following either procedure (TIPS, 4%; BRTO, 4%; p = 0.96); significantly more patients who underwent TIPS developed hepatic encephalopathy (22%) than did those who underwent BRTO (0%, p = 0.01). There was no statistically significant difference in mean survival between the two groups (TIPS, 30 months; BRTO, 24 months; p = 0.16); median survival for the patients who received TIPS was 16.6 months, and for those who underwent BRTO, it was 26.6 months.

          Conclusion

          BRTO is an effective method of treating isolated gastric varices with similar outcomes and complication rates to those of TIPS with a covered stent but with a lower rate of hepatic encephalopathy.

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          Most cited references 24

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          Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients.

          To determine the prevalence and natural history of gastric varices, we prospectively studied 568 patients (393 bleeders and 175 nonbleeders) with portal hypertension (cirrhosis in 301 patients, noncirrhotic portal fibrosis in 115 patients, extrahepatic portal vein obstruction in 117 patients and hepatic venous outflow obstruction in 35 patients). Primary (present at initial examination) gastric varices were seen in 114 (20%) patients; more were present in bleeders than in non-bleeders (27% vs. 4%, respectively; p < 0.001). Secondary (occurring after obliteration of esophageal varices) gastric varices developed in 33 (9%) patients during follow-up of 24.6 +/- 5.3 mo. Gastric varices (compared with esophageal varices) bled in significantly fewer patients (25% vs. 64%, respectively). Gastric varices had a lower bleeding risk factor than did esophageal varices (2.0 +/- 0.5 vs. 4.3 +/- 0.4, respectively) but bled more severely (4.8 +/- 0.6 vs. 2.9 +/- 0.3 transfusion units per patient, respectively). Once a varix bled, mortality was more likely (45%) in gastric varix patients. Gastric varices were classified as gastroesophageal or isolated gastric varices. Type 1 gastroesophageal varices (lesser curve varices) were the most common (75%). After obliteration of esophageal varices, type 1 gastroesophageal varices disappeared in 59% of patients and persisted in the remainder; bleeding from persistent gastroesophageal varices was more common than it was from gastroesophageal varices that were obliterated (28% vs. 2%, respectively; p < 0.001). Type 2 gastroesophageal varices, which extend to greater curvature, bled often (55%) and were associated with high mortality. Type 1 isolated gastric varices patients had only fundal varices, with a high (78%) incidence of bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)
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            Improved clinical outcome using polytetrafluoroethylene-coated stents for TIPS: results of a randomized study.

            A 50% dysfunction rate at 1 year is one of the main drawbacks of the transjugular intrahepatic portosystemic shunt procedure. Preliminary experimental and clinical studies suggest that the use of stents covered with polytetrafluoroethylene could tremendously decrease this risk. Eighty patients with cirrhosis and uncontrolled bleeding (n = 23), recurrent bleeding (n = 25), or refractory ascites (n = 32) were randomized to be treated by transjugular intrahepatic portosystemic shunts with either a polytetrafluoroethylene-covered stent (group 1; 39 patients) or a usual uncovered prosthesis (group 2; 41 patients). Follow-up Doppler ultrasound was scheduled at day 7, at 1 month, and then every 3 months for 2 years. Angiography and portosystemic pressure gradient measurements were performed 6, 12, and 24 months after the transjugular intrahepatic portosystemic shunt procedure and whenever dysfunction was suspected. Dysfunction was defined as a >50% reduction of the lumen of the shunt at angiography or a portosystemic pressure gradient >12 mm Hg. After a median follow-up of 300 days, 5 patients (13%) in group 1 and 18 (44%) in group 2 experienced shunt dysfunction (P < 0.001). Clinical relapse occurred in 3 patients (8%) in group 1 and 12 (29%) in group 2 (P < 0.05). Actuarial rates of encephalopathy were 21% in group 1 and 41% in group 2 at 1 year (not significant). Estimated probabilities of survival were 71% and 60% at 1 year and 65% and 41% at 2 years in groups 1 and 2, respectively (not significant). The use of polytetrafluoroethylene-covered prostheses improves transjugular intrahepatic portosystemic shunt patency and decreases the number of clinical relapses and reinterventions without increasing the risk of encephalopathy.
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              Long-term results of balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy.

              To evaluate the long-term results of balloon-occluded retrograde transvenous obliteration (B-RTO) for the treatment of gastric varices (GV) and hepatic encephalopathy. A total of 43 patients who had undergone B-RTO were evaluated, 32 with GV, two with hepatic encephalopathy, and nine with both. All but one had been consecutively followed up with gastrointestinal endoscopy for more than 1 year (3-60 months; mean, 30.44 months). Collateral veins of gastric varices were graded using balloon-occluded retrograde left adrenal venography. The relation of both worsening of esophageal varices (EV) and improved Child-Pugh score after B-RTO to the grades of collateral vein development was analyzed. The relapse-free survival and the prognostic factors for survival after B-RTO were also assessed. GV disappeared or decreased markedly in size, and hepatic encephalopathy was completely cured in all patients. Improvement in Child-Pugh score was observed in 21 patient (50.0%) 6 months after B-RTO, but in only 11 patients (25.6%) 1 year after B-RTO. Worsening of EV was seen in eight patients and was related to a worsened grade of collateral veins. Cumulative relapse-free survival rate was 90.8% at 1 year and 87.4% at 3 years after B-RTO. The most significant prognostic factor was Child-Pugh classification (relative risk: 4.16) B-RTO is a safe and effective treatment for patients with GV and hepatic encephalopathy. The most important prognostic factors are the extent of Child-Pugh classification.
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                Author and article information

                Journal
                Korean J Radiol
                Korean J Radiol
                KJR
                Korean Journal of Radiology
                The Korean Society of Radiology
                1229-6929
                2005-8330
                Mar-Apr 2017
                07 February 2017
                : 18
                : 2
                : 345-354
                Affiliations
                [1 ]Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO 63110, USA.
                [2 ]Division of Gastroenterology, Department of Internal Medicine, Washington University St. Louis School of Medicine, St. Louis, MO 63110, USA.
                [3 ]Department of Radiology, Kyung Hee University College of Medicine, Seoul 02447, Korea.
                Author notes
                Corresponding author: Seung Kwon Kim, MD, Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, 510 S Kingshighway Boulevard, Campus Box 8131, St. Louis, MO 63110, USA. Tel: (1314) 362-2900, Fax: (1314) 362-2276, skim35@ 123456wustl.edu
                Article
                10.3348/kjr.2017.18.2.345
                5313522
                ea358781-a2b8-43db-907b-0100ee4f9b4c
                Copyright © 2017 The Korean Society of Radiology

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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                Intervention
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