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We describe the usefulness of n-butyl-cyanoacrylate (nBCA)-assisted retrograde transvenous obliteration (NARTO) for gastric varices in 3 consecutive patients. In all patients, balloon catheters were inserted into the gastrorenal shunt via the left renal vein. After injecting sclerosant into the gastric varix under balloon occlusion, nBCA was injected to the proximal side of the shunt, to completely embolize the shunt. NARTO is a simple technique to achieve stagnation of the injected sclerosant in gastric varices and to occlude a gastrorenal shunt. This procedure is also cost-effective, and may improve procedure time compared with original or modified balloon-occluded retrograde transvenous obliteration.

Background: No single effective method has yet been established for the primary prophylaxis of bleeding from gastric varices (GV). Methods: We retrospectively analyzed liver cirrhosis patients with GV who had undergone either endoscopic variceal obturation (EVO) or balloon-occluded retrograde transvenous obliteration (BRTO) as prophylactic treatments, comparing them with those who were observed without any procedural intervention. The endpoints were GV bleeding rate and complete eradication rate. Results: 72 patients in EVO, 41 patients in BRTO, and 97 patients in the clinical observation groups were enrolled. No difference was observed in baseline characteristics. As the primary endpoint, 14 (19.4%) patients in the EVO group and 3 (7.3%) in the BRTO group bled from GV after prophylactic treatment, and 34 (35.1%) patients bled in the observation group during the median follow-up of 35 months (p = 0.001). Patients who received EVO or BRTO developed less bleeding from GV than those who received observation only, with no difference between EVO and BRTO (EVO vs. observation, p = 0.038; BRTO vs. observation, p = 0.001; EVO vs. BRTO, p = 0.089). As secondary endpoints, GV disappeared completely in 33 patients (45.8%) in the EVO group and 31 patients (75.6%) in the BRTO group (p = 0.003). By multivariate analysis, complete eradication of GV was the sole determinant for predicting GV bleeding. Conclusions: EVO and BRTO are effective and safe primary prophylactic treatments for preventing bleeding from GV. In particular, BRTO is better than EVO in complete eradication of GV. [ABSTRACT FROM AUTHOR]

Introduction: Postoperative complications and worse prognosis still burden liver transplantations (LT) with complex portal vein thrombosis (CPVT). When an engorged left gastric vein (LGV) is present, the portal inflow is restorable with an anastomosis between the graft portal vein and the LGV of the recipient. We analyzed short‐ and long‐term results of this procedure in 12 LT with CPVT. Methods: Between 2005 and 2019, 55 patients with CPVT underwent LT. We applied this technique in 12 patients. In six cases, we placed a vascular graft to obtain a tension‐free structure. We evaluated patency, short‐ and long‐term results. Results: No intraoperative complication was observed. The median duration of LT, blood transfusion, deceased donor age, and MELD score of the recipients were 7 h, 1250 mL, 72 years, and 19. Seven patients were affected by hepatocellular carcinoma. No major complications or PVT recurrence were observed. One patient required a liver re‐transplantation for primary non‐functioning syndrome. The mean hospital stay was 20 days. The actuarial patient survival was 85% with a mean FU of 4 years. The two late deaths were due to hepatocellular carcinoma recurrence and sepsis for cholangitis. Conclusions: This technique in presence of both CPVT and engorged LGV is feasible and safe for patients, with good short‐ and long‐term results. [ABSTRACT FROM AUTHOR]

A 70-year-old woman with liver cirrhosis presented with gastric varices and recurrent hepatic encephalopathy. Magnetic resonance imaging (MRI) showed a splenorenal shunt, and balloon-occluded retrograde transvenous obliteration (B-RTO) was indicated but could not be performed due to iodine allergy. We then performed B-RTO using gadoteridol, an MRI contrast medium, instead of iodine contrast and successfully occluded the shunt vessel. After the procedure, hepatic encephalopathy did not recur, and the size of the gastric varices was reduced. This experience may aid in the management of iodine-allergic patients requiring interventional radiological treatment.

The use of surgical treatment for refractory isolated gastric varices has decreased owing to the development of endoscopic and radiologic procedures, although surgeries are sometimes required as the final method. A 75-year-old Japanese woman was diagnosed with solitary gastric varices. Initially, intraoperative splenic artery embolization was performed using the balloon transcatheter technique under general anesthesia. Laparoscopic splenectomy was performed safely owing to preoperative splenic artery embolization. Intraoperative indocyanine green (ICG) fluorescence angiography was performed following the injection of 5 mL of ICG; the remnant stomach was observed using laparoscopic equipment with an ICG imaging system, and blood flow from the remnant gastric artery was confirmed. The blood did not pool or wash out immediately, which confirmed successful devascularization of the stomach. The total operative time was 269 minutes, and the intraoperative blood loss was 500 mL. The patient's postoperative course was good, and at 21 days after the last operation, she was discharged from our hospital in remission. Real-time fluorescence angiography with ICG is a reliable and objective technique of assessing blood flow of the stomach. Accurate, extensive devascularization in the lower esophagus and upper stomach was performed using Hassab's procedure in combination with ICG imaging. [ABSTRACT FROM AUTHOR]

Acute pancreatitis rarely occurs in the postpartum period. Furthermore, there are very few reports of it after cesarean section delivery. A 35-year-old woman presented with dyspnea and abdominal distension on the third day after cesarean section delivery. Under a suspicion of acute pancreatitis, she was initially managed with conservative treatment. However, she developed intra-abdominal fluid collections and gastric bleeding, which were managed with percutaneous drainage, endoscopic hemostasis, and angiographic embolization. She was discharged with good clinical recovery. Postpartum pancreatitis, especially after cesarean section, is rare; however, its management is not different from that for usual pancreatitis. (Korean J Gastroenterol 2016;68:161-165)

Idiopathic portal hypertension (IPH) is often misdiagnosed as liver cirrhosis. Because it is difficult to distinguish between the two using diagnostic imaging, invasive tests, such as pathology and hepatic vein pressure gradient measurement, are necessary to make a diagnosis. Several studies have shown that the measurement of liver and spleen stiffnesses using elastography is useful in the diagnosis of IPH; however, there are few concrete reports on this subject. Herein, we report the case of a 58-year-old woman with IPH in which elastography was helpful for the diagnosis., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Yano et al.)

Objectives: To assess the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) with and without adjunctive embolisation in managing cardiofundal varices bleeding.Methods: The retrospective study comprised 82 patients (54 men; mean age 53.9 years; mean Model of End-stage Liver Disease score 9.3) with cardiofundal varices bleeding who underwent TIPS creation from 2011 to 2015. Variceal rebleeding, the outflow tracts of varices, overt hepatic encephalopathy (HE) and post-procedure varices patency were assessed.Results: Gastrorenal shunt was present in 92.7% of patients (n = 76). Embolisation was performed in 67.1% of patients (n = 55). The 1- and 2-year variceal rebleeding rates in the TIPS combined with embolisation group were significantly lower than those in the TIPS alone group (3.8% and 13.4% vs 13.0% and 28.0%, respectively; p = 0.041). No significant differences between the two groups were found in the cardiofundal varices patency, overt HE or survival (p > 0.05).Conclusions: The results suggest that TIPS combined with embolisation can reduce the risk of variceal rebleeding for patients with cardiofundal varices.Key Points: • TIPS combined with embolisation reduces the risk of rebleeding in treating cardiofundal varices. • TIPS combined with embolisation could not completely occlude cardiofundal varices. • TIPS combined with embolisation could not prevent the development of hepatic encephalopathy. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the technical feasibility and safety of vascular plug assisted retrograde transvenous obliteration (PARTO) for bleeding gastric varix performed in the emergent clinical setting and describe the mid-term clinical results. Materials and Methods: From April 2012 to January 2015, emergent PARTO was tried in total 9 patients presented with active gastric varix bleeding. After initial insufficient or failure of endoscopic approach, they underwent PARTO in the emergent clinical setting. Gelatin sponge embolization of both gastrorenal (GR) shunt and gastric varix was performed after retrograde transvenous placement of a vascular plug in GR shunt. Coil assisted RTO (CARTO) was performed in one patient who had challenging GR shunt anatomy for vascular plug placement. Additional embolic materials, such as microcoils and NBCA glue-lipiodol mixture, were required in three patients to enhance complete occlusion of GR shunt or obliteration of competitive collateral vessels. Clinical success was defined as no variceal rebleeding and disappearance of gastric varix. Results: All technical and clinical success-i.e., complete GR shunt occlusion and offending gastric varix embolization with immediate bleeding control-was achieved in all 9 patients. There was no procedure-related complication. All cases showed successful clinical outcome during mean follow up of 17 months (12-32 months), evidenced by imaging studies, endoscopy and clinical data. In 4 patients, mild worsening of esophageal varices or transient ascites was noted as portal hypertensive related change. Conclusion: Emergent PARTO is technically feasible and safe, with acceptable mid-term clinical results, in treating active gastric varix bleeding. [ABSTRACT FROM AUTHOR]

Purpose: To compare the clinical outcomes of balloon-occluded retrograde transvenous obliteration (BRTO) using ethanolamine oleate (EO), BRTO using sodium tetradecyl sulfate (STS) foam, and vascular plug-assisted retrograde transvenous obliteration (PARTO).Materials and Methods: From April 2004 to February 2015, ninety-five patients underwent retrograde transvenous obliteration for gastric varices were analyzed retrospectively. BRTO with EO was performed in 49 patients, BRTO with STS foam in 25, and PARTO in 21. Among them, we obtained follow-up data in 70 patients. Recurrence of gastric varices was evaluated by follow-up endoscopy or CT. Medical records were reviewed for the clinical efficacy. Statistical analyses were performed by Kaplan-Meier method, Chi-square, Fisher's, and Kruskal-Wallis tests.Results: Technical and clinical success was 94.7 %. As major complications, a hemoglobinuria and a death due to disseminated intravascular coagulation (DIC) were occurred in two patients with BRTO using EO. Recurrence occurred more frequently in PARTO group (P < 0.05). Recurrence occurred in three patients in BRTO using EO group and four patients in PARTO group with 3.2 and 32.8 % of each expected 1-year recurrence rates. There was no recurrence in BRTO using STS group. Abdominal pain occurred more frequently in BRTO using EO than BRTO using STS foam and PARTO (P < 0.05). Procedure time of PARTO was shorter than two conventional BRTOs (P < 0.05).Conclusions: BRTO using STS foam or PARTO is better than BRTO using EO for treatment of gastric varices in terms of complication or procedure time. However, PARTO showed frequent recurrence of gastric varices during the long-term follow-up rather than BRTO. [ABSTRACT FROM AUTHOR]

During retrograde transvenous sclerotherapy for gastric varices, sufficient opacification of the target varices on venography is essential for successful treatment. However, venography sometimes cannot identify target varices due to overlapping adjacent collateral vessels or leakage of contrast medium to other outflow veins. We report how C-arm CT images acquired using a flat-panel detector angiography system helped to identify target varices and predict the distribution of a sclerosant, which resulted in safer sclerotherapy and increased operator confidence.

During retrograde transvenous sclerotherapy for gastric varices, sufficient opacification of the target varices on venography is essential for successful treatment. However, venography sometimes cannot identify target varices due to overlapping adjacent collateral vessels or leakage of contrast medium to other outflow veins. We report how C-arm CT images acquired using a flat-panel detector angiography system helped to identify target varices and predict the distribution of a sclerosant, which resulted in safer sclerotherapy and increased operator confidence.

Purpose: Balloon-occluded retrograde transvenous obliteration (B-RTO) has shown great potential in controlling acute gastric variceal hemorrhage, although rebleeding related to the procedure may occur in a small percentage of patients. The purpose of this study was to identify risk factors of perioperative rebleeding and prognostic factors of postoperative survival in B-RTO performed for acute episodes of gastric variceal hemorrhage. Methods: We retrospectively analyzed 39 consecutive patients who underwent B-RTO for gastric variceal rupture at our hospital between June 2003 and May 2011. Uni- and multi-variate analyses were performed to assess risk factors for perioperative rebleeding and prognostic factors for postoperative survival. Results: Surgical success and complete eradication of varices were achieved in 36 cases (92.3 %) and 35 cases (89.7 %), respectively. Six patients experienced rebleeding either intraoperatively ( n = 3) or within 1 h after B-RTO ( n = 3). Child-Pugh class C was identified as a risk factor for rebleeding on univariate ( P = 0.018) and multivariate analyses (odds ratio, 6.003; P = 0.014). With a median follow-up of 23 months (range 0-106.6 months), overall survival rates at 1, 3, and 5 years were 91.7, 74.7, and 67.2 %, respectively. Multivariate analyses revealed Child-Pugh class C as a prognostic factor for survival (relative risk, 4.014; P = 0.023). Conclusion: Although B-RTO is generally effective in the treatment of acute gastric variceal rupture, patients classified as Child-Pugh class C have a higher risk of perioperative rebleeding and shorter survival. [ABSTRACT FROM AUTHOR]

Hepatic arterioportal fistulae (APF) are abnormal communications between the hepatic artery and the portal vein. In this report, we present the second case in the literature of a symptomatic APF presenting as a gastric variceal bleeding. A 55-year-old female presented to our facility with hematemesis. Upper endoscopy revealed a bleeding gastric varix. A computed tomography scan identified a large left hepatic lobe APF between the left hepatic artery and the left portal vein. Through angiography coil embolization was performed and with resultant loss of arterial flow, the APF was decompressed. On hospital day 3, the patient developed new melena. Portovenogram was performed and a TIPS stent was deployed. The patient subsequently did well. Hepatic arterioportal fistulae can result in portal hypertension secondary to arterial blood flowing directly into the portal vein bypassing the hepatic sinusoids. Iatrogenic causes (e.g. percutaneous liver biopsy) represent more than 50% of published cases of APFs. Most APFs resolve spontaneously as they are small and peripherally located. In rare instances, when APFs are centrally located, clinical symptoms develop. There have been 30 reported cases of symptomatic intrahepatic APFs following percutaneous liver biopsy. Of those, only one case presented as a gastric variceal bleed. Digital subtraction angiography is the gold standard in the diagnosis and treatment of APFs. In addition to initial embolization, we elected to treat the patient with TIPS due to the magnitude of her bleed. Although rare, intrahepatic APF should be kept on the differential of a patient presenting with isolated gastric varices. [ABSTRACT FROM AUTHOR]

Two cases of gastric varices were treated by balloon-occluded retrograde transvenous obliteration via the pericardiophrenic vein at our hospital, and both were successful. One case developed left hydrothorax. Gastric varices did not bled and esophageal varices were not aggravated in both cases for 24-30 months thereafter. These outcomes indicate the feasibility of balloon-occluded retrograde transvenous obliteration via the pericardiophrenic vein. [ABSTRACT FROM AUTHOR]

We encountered a case of gastric varix without a gastrorenal shunt that drained through the left pericardiacophrenic vein, which entered the left brachiocephalic vein. For this case we successfully performed balloon-occluded retrograde transvenous obliteration, in which sclerotic agents were infused via the left pericardiacophrenic vein approached from the left subclavian vein. [ABSTRACT FROM AUTHOR]

An 81-year-old man with previously diagnosed cancer of the pancreatic body presented with melena and anemia. Upper gastrointestinal endoscopy showed gastric varices with bleeding in the entire stomach. Contrast-enhanced computed tomography identified a splenic vein occlusion resulting from invasion by the pancreatic body cancer and dilated collateral pathways from the splenic hilum to the gastric fundus. The patient was diagnosed with gastric varices associated with left-sided portal hypertension caused by obstruction of the splenic vein and underwent percutaneous transsplenic embolization with n -butyl-2-cyanoacrylate mixed with lipiodol. Splenic subcapsular hematoma occurred and was treated conservatively. The patient died of advanced cancer 5 months after the procedure, without experiencing rebleeding. Percutaneous transsplenic embolization was effective in treating gastric variceal bleeding caused by left-sided portal hypertension., Competing Interests: None, (© 2022 Japanese Society of Interventional Radiology.)

Gastric variceal bleeding has a high mortality. Endoscopic cyanoacrylate injection is the standard therapy; however, rebleeding and unexpected adverse events, such as injection sites ulcers and distal glue embolisms, are pitfalls of this therapy. Endoscopic ultrasound (EUS)-guided endovascular therapies offer a safer and more practical alternative for the treatment of gastric varices. EUS-guided combined therapy with coiling and cyanoacrylate injection is the most promising alternative with high obliteration rates and fewer adverse events reported. The authors reviewed the latest available data for all endoscopic therapies proposed for the management of gastric varices in patients with chronic liver disease., Competing Interests: Author's contributions R. Oleas and C. Robles-Medranda contributed equally to the conception and design of the work, drafting of the article, and critical revision for important intellectual content. Both authors approved the final version of the article to be published. Conflict of interests R. Oleas has nothing to disclose. C. Robles-Medranda is a key opinion leader and consultant for Pentax Medical, Boston Scientific, Steris, Medtronic, Motus, Micro-tech, G-Tech Medical Supply, Creo Medical, and Medicons Group., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Variceal bleed is a severe complication of portal hypertension. We studied the predictors of failure to control variceal bleed and re-bleed in patients with cirrhosis. We reviewed the case records of 382 consecutive patients admitted with variceal bleed from January 2001 to December 2005. Diagnosis of cirrhosis was made on clinical, laboratory, and radiological parameters. Acute variceal bleeding, failure to control bleed, and re-bleeding were defined according to Baveno III consensus report. Failure to control bleed was observed in 39 (10.2%) patients while in hospital re-bleed occurred in 49 (12.8%) patients. Thirty-four patients died. Diabetes was present in 148 (39%) patients. On multivariate logistic regression analysis, predictors of failure to control bleed were presence of diabetes mellitus and active bleeding at the time of endoscopy; predictors of in-hospital re-bleed were diabetes mellitus and serum bilirubin >3 mg/dL. Diabetes mellitus, active bleeding at endoscopy and bilirubin >3 mg/dL are bad prognostic factors for initial control of variceal bleed, and recurrent bleed in patients with cirrhosis. [ABSTRACT FROM AUTHOR]

Gastric varices develop in patients with portal hypertension, including liver cirrhosis, idiopathic portal hypertension as well as left sided-local portal hypertension such as splenic vein thrombosis or splenic AV malformation. The inflow vein is the left gastric vein, posterior vein, or short gastric vein, while the outflow vein is the gastro-renal shunt in most of the patients with gastric varices. The form of the gastric varices is classified into three types of venous dilatation; tortuous type, notched type and tumor type according to the shape and size of the varices. The location is classified into five sites; the posterior site, anterior site, greater curvature site and lesser curvature site of the cardiac area, and the fundic area. The risk of the rupture depends on the mucosal factor of the varices as well as the location and the form. The hemostasis rate has been improved to 94–97% with the usage of the endoscopic occlusive agent such as Histoacryl. It is absolutely necessary to eradicate the gastric varices within a few weeks after rupture of the gastric varices. There are new management options such as laparoscopic Hassab's operation or balloon-occluded retrograde transvenous obliteration of the varices (B-RTO). The 5-year cumulative rate of the non-variceal bleeding is more than 90% after the B-RTO as well as after surgery. Further prospective clinical trials are to be investigated for an evidence-based medicine. [ABSTRACT FROM AUTHOR]

We encountered a patient with gastric varix draining not via the usual left suprarenal vein but via the left inferior phrenic vein joining the left hepatic vein. Transfemoral balloon-occluded retrograde transvenous obliteration (BRTO) of the varix was performed under balloon occlusion of the left inferior phrenic vein via the left hepatic vein and retrograde injection of the sclerosing agent (5% of ethanolamine oleate) into the gastric varix. Disappearance of the gastric varix was confirmed on endoscopic examination 2 months later. [ABSTRACT FROM AUTHOR]

We encountered a case with a gastric varix that drained into the gastro-renal shunt, left pericardiacophrenic vein, and several other dilated collateral veins. This patient had a circumaortic venous ring. For this case we successfully performed balloon-occluded retrograde transvenous obliteration in which sclerotic agents were infused from the balloon catheter advanced to the left pre-aortic renal vein and the tip was wedged into the end of the gastro-renal shunt. Before injection of sclerotic agents, collateral veins other than the left pericardiacophrenic vein were embolized with micro-coils. During the injection, the left pericardiacophrenic vein was occluded temporarily with a micro-balloon catheter coaxially advanced from the catheter inserted from the femoral vein to the left pericardiacophrenic vein through the left brachiocephalic vein. [ABSTRACT FROM AUTHOR]

Gastric variceal bleeding is a major complication of portal hypertension and is associated with high morbidity and mortality. While esophageal varices are more common, gastric varices are often more challenging to treat. Balloon-Occluded Retrograde Transvenous Obliteration is an interventional procedure whereby the portosystemic gastrorenal shunt is accessed via the left renal vein and the gastric varix outflow tract obliterated using direct sclerotherapy. Herein, we present a case of a 68-year-old female patient with cirrhosis who presented with bleeding gastric varices and successfully treated. This case highlights the procedural steps and the importance of detailed knowledge of the patient's portosystemic anatomy for determining suitability for balloon-occluded retrograde transvenous obliteration of gastric varices.

Purpose: To evaluate the technical feasibility and safety of vascular plug assisted retrograde transvenous obliteration (PARTO) for bleeding gastric varix performed in the emergent clinical setting and describe the mid-term clinical results., Materials and Methods: From April 2012 to January 2015, emergent PARTO was tried in total 9 patients presented with active gastric varix bleeding. After initial insufficient or failure of endoscopic approach, they underwent PARTO in the emergent clinical setting. Gelatin sponge embolization of both gastrorenal (GR) shunt and gastric varix was performed after retrograde transvenous placement of a vascular plug in GR shunt. Coil assisted RTO (CARTO) was performed in one patient who had challenging GR shunt anatomy for vascular plug placement. Additional embolic materials, such as microcoils and NBCA glue-lipiodol mixture, were required in three patients to enhance complete occlusion of GR shunt or obliteration of competitive collateral vessels. Clinical success was defined as no variceal rebleeding and disappearance of gastric varix., Results: All technical and clinical success-i.e., complete GR shunt occlusion and offending gastric varix embolization with immediate bleeding control-was achieved in all 9 patients. There was no procedure-related complication. All cases showed successful clinical outcome during mean follow up of 17 months (12-32 months), evidenced by imaging studies, endoscopy and clinical data. In 4 patients, mild worsening of esophageal varices or transient ascites was noted as portal hypertensive related change., Conclusion: Emergent PARTO is technically feasible and safe, with acceptable mid-term clinical results, in treating active gastric varix bleeding.

Introduction: Ascites is a common complication of chronic liver diseases and is related to the extent of portal hypertension. This study evaluated whether the serum ascites albumin gradient (SAAG) (the difference between the albumin level of serum and of ascitic fluid) is endowed with clinical implications., Materials and Methods: This is a prospective study involving 50 patients with cirrhosis of liver with ascites. The SAAG was measured in all patients and its relation with portal hypertensive changes was analyzed., Results: Based on SAAG values, the patients were divided into three groups: Group 1 - SAAG value 1.1 to 1.49 gm/dL (n = 15); group 2 - SAAG value 1.5 to 1.99 gm/dL (n = 9); and group 3 - SAAG value 2.0 gm/dL (n = 26). In group 1, 14 patients had esophageal varices (93.3%) and 13 had gastropathy (86.6%). In group 2, all 9 patients had esophageal varices (100%), 7 (77.7%) had gastropathy, and 1 (11.1%) had gastric varices. In group 3, all 26 patients had esophageal varices (100%), 24 patients (92.3%) had gastropathy, and 1 patients (3.8%) had gastric varices., Conclusion: Serum ascites albumin gradient value is weakly related to the extent of portal hypertension in patients with liver cirrhosis and its implication seems to be limited in clinics., How to Cite This Article: Shahed FHM, Al-Mahtab M, Rahman S. The Evaluation of Serum Ascites Albumin Gradient and Portal Hypertensive changes in Cirrhotic Patients with Ascites. Euroasian J Hepato-Gastroenterol 2016;6(1):8-9., Competing Interests: Source of support: Nil Conflict of interest: None

Aim: To evaluate the efficacy and safety of N-butyl-2-cyanoacrylate in treating acute bleeding of gastric varices in children., Methods: The retrospective study included 21 children with 47 episodes of active gastric variceal bleeding who were treated by endoscopic injection of N-butyl-2-cyanoacrylate at Asan Medical Center Children's Hospital between August 2004 and December 2011. To reduce the risk of embolism, each injection consisted of 0.1-0.5 mL of 0.5 mL N-butyl-2-cyanoacrylate diluted with 0.5 or 0.8 mL Lipiodol. The primary outcome was incidence of hemostasis after variceal obliteration and the secondary outcome was complication of the procedure., Results: The 21 patients experienced 47 episodes of active gastric variceal bleeding, including rebleeding, for which they received a total of 52 cyanoacrylate injections. Following 42 bleeding episodes, hemostasis was achieved after one injection and following five bleeding episodes it was achieved after two injections. The mean volume of each single aliquot of cyanoacrylate injected was 0.3 ± 0.1 mL (range: 0.1-0.5 mL). Injection achieved hemostasis in 45 of 47 (95.7%) episodes of acute gastric variceal bleeding. Eleven patients (52.4%) developed rebleeding events, with the mean duration of hemostasis being 11.1 ± 11.6 mo (range: 1.0-39.2 mo). No treatment-related complications such as distal embolism were noted with the exception of abdominal pain in one patient (4.8%). Among four mortalities, one patient died of variceal rebleeding., Conclusion: Endoscopic variceal obliteration using a small volume of aliquots with repeated cyanoacrylate injection was an effective and safe option for the treatment of gastric varices in children.

We experienced a case with a gastric varix that did not have a catheterizable main drainage vein and had multiple afferent veins. For this case we successfully performed percutaneous transhepatic sclerotherapy using the following procedure. After the drainage vein was embolized by metallic coils and n-butyl cyanoacrylate from a microcatheter that was advanced through the gastric varix, 5% ethanolamine oleate-iopamidol was infused into the gastric varix from one main afferent vein under balloon occlusion.

Aim: To evaluate the long-term efficacy and safety of endoscopic obliteration with Histoacryl(®) for treatment of gastric variceal bleeding and prophylaxis., Methods: Between January 1994 and March 2010 at SoonChunHyang University Hospital, a total of 127 patients with gastric varices received Histoacryl(®) injections endoscopically. One hundred patients underwent endoscopic Histoacryl(®) injections because of variceal bleeding, the other 27 patients received such injections as a prophylactic procedure., Results: According to Sarin classification, 56 patients were GOV1, 61 patients were GOV2 and 10 patients were IGV. Most of the varices were large (F2 or F3, 111 patients). The average volume of Histoacryl(®) per each session was 1.7 ± 1.3 cc and mean number of sessions was 1.3 ± 0.6. (1 session-98 patients, 2 sessions-25 patients, ≥ 3 sessions-4 patients). Twenty-seven patients with high risk of bleeding (large or fundal or RCS+ or Child C) received Histoacryl(®) injection as a primary prophylactic procedure. In these patients, hepatitis B virus was the major etiology of cirrhosis, 25 patients showed GOV1 or 2 (92.6%) and F2 or F3 accounted for 88.9% (n = 24). The rate of initial hemostasis was 98.4% and recurrent bleeding within one year occurred in 18.1% of patients. Successful hemostasis during episodes of rebleeding was achieved in 73.9% of cases. Median survival was 50 mo (95% CI 30.5-69.5). Major complications occurred in 4 patients (3.1%). The rebleeding rate in patients with hepatocellular carcinoma or GOV2 was higher than in those with other conditions. None of the 27 subjects who were treated prophylactically experienced treatment-related complications. Cumulative survival rates of the 127 patients at 6 mo, 1, 3, and 5 years were 92.1%, 84.2%, 64.2%, and 45.3%, respectively. The 6 mo cumulative survival rate of the 27 patients treated prophylactically was 75%., Conclusion: Histoacryl(®) injection therapy is an effective treatment for gastric varices and also an effective prophylactic treatment of gastric varices which carry high risk of bleeding.