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Histogram of the prevalence of thrombocytopenia and varying platelet counts in patients with gastric varices prior to undergoing BRTO.
Source publication
Objectives:
Gastric varices primarily occur in cirrhotic patients with portal hypertension and splenomegaly and thus are probably associated with thrombocytopenia. However, the prevalence and severity of thrombocytopenia are unknown in this clinical setting. Moreover, one-third of patients after balloon-occluded retrograde transvenous obliteration...
Citations
... In the terminal/end stage (C), HE related to both shunt and declining synthetic function, liver atrophy, thrombosis of the portal vein (due to a larger fraction of shunted blood), ascites, and jaundice is seen. Thrombocytopenia (seen in >90%) and indirect hyperbilirubinemia (due to shunt hemolysis, 10% post TIPS) are noticeable events in PSS [4,5]. Sakurabayashi and colleagues initially showed that embolization of large PSS in cirrhotics decreased HE, lowered ammonia, and improved quality of life [6]. ...
Introduction
Large spontaneous portosystemic shunts (SPSS) are seen in a subset of patients with liver disease and medically refractory recurrent/persistent hepatic encephalopathy (MRHE). Shunt occlusion has been shown to improve clinical outcomes.
Methods
We retrospectively analyzed patient characteristics, SPSS attributes, procedural features, baseline clinical and investigational parameters, neurological outcomes, adverse effects (procedure and portal hypertension related), and risk factors predicting outcomes in liver disease patients undergoing shunt occlusion procedure for MRHE.
Results
Between October 2016 and July 2017, 21 patients (Child-Pugh score, CTP 6 to 13) with mean model of end-stage liver disease (MELD) and MELD-sodium scores 15.7 and 19.3 respectively with MRHE [3-cirrhotic Parkinsonism (CP)] were diagnosed to have single or multiple large SPSSs. A total of 29 shunts were occluded (1 surgical, 20 non-surgical). Recurrent and persistent HE and CP markedly improved in the short (n=20, 1 to 3 months), intermediate (n=12, 3 to 6 months), and long (n=7, 6 to 9 months) follow up. None had spontaneous or persistent HE at a median follow up 105 (30 to 329) days (p<0.05). Motor, speech, sleep abnormalities, daily activities of living, and liver disease severity scores improved significantly on follow up. Baseline arterial ammonia showed a statistically significant reduction in all time periods of follow up after shunt occlusion (p<0.05). CTP >11 predicted mortality post shunt occlusion (p=0.04). Embolization of large SPSS in liver disease patients with MRHE and modestly preserved liver function is safe and efficacious and associated with improved quality of life and can function as a bridge to liver transplantation in accurately selected patients.
... In splenic shunts (such as splenorenal and gastrorenal shunts), there is dilation of the splenic vein and diminution of the portal vein, thus reducing the portal vein-to-splenic vein diameter ratio. 2 There is commonly splenomegaly, and thrombocytopenia is seen in more than 90% of patients with large SPSS. 9 In the late stages, there is also significant hepatic atrophy as well as splenomegaly. 8,9 In the setting of prehepatic SPSS (which are the most common type), Doppler ultrasound demonstrates sluggish (< 20 cm/s) hepatopetal portal blood flow in the main portal vein with a paucity of portal vein branches intrahepatically. ...
... 9 In the late stages, there is also significant hepatic atrophy as well as splenomegaly. 8,9 In the setting of prehepatic SPSS (which are the most common type), Doppler ultrasound demonstrates sluggish (< 20 cm/s) hepatopetal portal blood flow in the main portal vein with a paucity of portal vein branches intrahepatically. With time the flow becomes bidirectional, then reverses (hepatofugal) with a diminutive portal vein, and then finally a thrombosed or collapsed portal vein is commonly noted but is seen without cavernous transformation. ...
The term "portosystemic shunt syndrome" was coined by Kumamoto et al referring to reduction of the hepatic reserve (reflected by progression of the Child-Pugh score) over 5 years compared with portal hypertensive cirrhotics without gastrorenal shunts or with prior history of obliterated gastrorenal shunts. Saad et al elaborated on this term further by describing a complete syndrome with clinical findings (including worsening liver failure and hepatic encephalopathy [HE]) and imaging findings (including hepatic atrophy, portal vein thrombosis, and paucity of intrahepatic portal vein radicles). This article discusses the syndrome in detail. In addition, the article describes the types of HE and the endovascular management of shunt-related HE.
Background:
Balloon-occluded retrograde transvenous obliteration (BRTO) is an effective treatment for gastric varices, but predictors associated with overall survival rate (OS) and occurrence of esophagogastric varices (EGV) have not yet been clarified. In this study, we clarified these predictors by performing ultrasound elastography and blood tests at various time points.
Methods:
A total of 34 patients were enrolled. The primary endpoint was to identify predictors associated with OS and EGV occurrence by univariate and multivariate analyses. Secondary endpoints were to extract the cutoff values for OS and EGV occurrence, and to clarify chronological changes in liver stiffness (LS), spleen stiffness (SS), spleen index (SI), and portal vein flow volume (PVF). Time points were set as before BRTO (Bf), and 1 day (D1), 7 days (D7), 1 month (1M), 3 months (3M), and 6 months (6M) after BRTO.
Results:
Albumin-bilirubin score Bf, fibrin-4 index change 6M, and branched chain amino acids tyrosine molar ratio (BTR) 1M were predictors of OS on univariate analysis (p = 0.021, 0.033, and 0.019, respectively) but were not extracted by multivariate analysis. The factors of LS 6M > 19.9 kPa and SS D7 > 21.7 kPa were predictors of the occurrence of EGV on multivariate analysis (p = 0.029 and 0.025, respectively). PVF significantly increased with time after BRTO.
Conclusion:
Albumin-bilirubin score and BTR had the possibility to associated with OS, and the predictors of reduced occurrence of EGV were LS < 19.9 and SS < 21.7.
Purpose:
To evaluate changes in liver perfusion after occlusion of spontaneous portosystemic shunt and to analyze mechanisms of liver profile improvement.
Materials and methods:
Liver function changes and portal venous and hepatic arterial blood flow were evaluated using perfusion CT before and after shunt occlusion in 23 patients who underwent percutaneous occlusion of spontaneous portosystemic shunt because of gastric varices (n = 15) or hepatic encephalopathy (n = 8).
Results:
Portal venous blood flow was significantly higher at 1 week (278.7 ml/min, 92.7-636.7, p = 0.012), 1 month (290.0 ml/min, 110.1-560.1, p < 0.001) and 3 months (299.6 ml/min, 156.7-618.5, p = 0.033) after shunt occlusion than the baseline (220.9 ml/min, 49.5-566.7). Hepatic arterial liver blood flow became lower than the baseline (132.3 ml/min, 47.9-622.3) after shunt occlusion, but a significant decrease was observed only at 1 month later (107.9 ml/min, 45.8-263.6 p = 0.027). Serum albumin concentration became significantly higher than the baseline (3.4 mg/dl, 1.9-4.5) at 1 month (3.8 mg/dl, 2.3-4.3, p = 0.018) and 3 months (3.9 mg/dl, 2.6-4.3, p = 0.024) after shunt occlusion.
Conclusion:
Shunt occlusion increases portal venous blood flow and decreases hepatic arterial blood flow, thereby improving the liver profile.
Bleeding from gastric varices is a major complication of portal hypertension. Although less common than bleeding associated with esophageal varices, gastric variceal bleeding has a higher mortality. From an endovascular perspective,transjugular intrahepatic portosystemic shunts (TIPS) to decompress the portal circulation and/or balloon-occluded retrograde transvenous obliteration (BRTO) are utilized to address bleeding gastric varices. Until recently, there was a clear medical cultural divide between the strategy of decompressing the portal circulation (TIPS creation, for example) and transvenous obliteration for the management of gastric varices. However, the practice of BRTO is gaining acceptance in the United States and its practice is spreading rapidly. Recently, the American College of Radiology has identified BRTO to be a viable alternative to TIPS in particular anatomical and clinical scenarios. However, the anatomical and clinical applications of BRTO were not defined beyond the conservative approach of resorting to BRTO in non-TIPS candidates. The article discusses the outcomes of BRTO and TIPS for the management of gastric varices individually or in combination. Definitions, endovascular technical concepts and contemporary vascular classifications of gastric variceal systems are described in order to help grasp the complexity of the hemodynamic pathology and hopefully help define the pathology better for future reporting and lay the ground for more defined stratification of patients not only based on comorbidity and hepatic reserve but on anatomy and hemodynamic classifications.
Copyright © 2014 Elsevier Inc. All rights reserved.
This study was prospectively conducted to evaluate the effectiveness of the combination of transjugular retrograde obliteration and partial splenic embolization in the treatment of gastric varices with gastrorenal shunt.
Between November 2002 and December 2006, 14 patients with gastric varices and gastrorenal shunt were treated by combining transjugular retrograde obliteration and partial splenic embolization (group 1). These patients were compared with 19 patients with gastric varices and gastrorenal shunt treated by only transjugular retrograde obliteration (group 2) for the disappearance rate of gastric varices, the cumulative survival rate, and the occurrence rate of esophageal varices after transjugular retrograde obliteration. Partial splenic embolization was performed 7-14 days before transjugular retrograde obliteration. No significant differences were seen between the two groups in terms of demographic data, including age, sex, and Child-Pugh classification.
The disappearance rate of gastric varices after transjugular retrograde obliteration was 100% in both groups. The 3-year cumulative survival rate after transjugular retrograde obliteration was 92% in group 1 and 95% in group 2. The 3-year cumulative occurrence rate of esophageal varices after transjugular retrograde obliteration was 9% in group 1 and 45% in group 2, a significant difference (p < 0.05).
The findings of this study indicate that partial splenic embolization contributed to preventing portal congestion after transjugular retrograde obliteration. We conclude that the combination of transjugular retrograde obliteration and partial splenic embolization for gastric varices is more effective than transjugular retrograde obliteration only in the long-term prevention of esophageal varices after transjugular retrograde obliteration.
