SPLENIC VEIN RECANALIZATION VIA THROUGH-AND-THROUGH TRANS-HEPATIC AND TRANS-SPLENIC ACCESS, WITH CONCOMITANT TRANS-SPLENIC BRTO OF ISOLATED

GASTRIC VARICES

Fellow: Zachary J. Liner, M.D.

Resident: Eric Chang, M.D.

Attending: Anastacio Saenz Jr., M.D.

Program: Baylor Scott & White Health

CLINICAL HISTORY

V.F. is a 32 year old female who initially presented in July, 2015 as a transfer from an outside institution due to hematemesis. She has past medical history significant for hypertriglyceridemia-induced necrotizing pancreatitis with pseudocyst formation and subsequent development of splenic vein thrombosis in March, 2015. Ultimately, the splenic vein thrombosis lead to formation of isolated gastric varices, as confirmed on abdominal CT in April, 2015. The patient stated that she ate dinner on July 10th and shortly thereafter had two episodes of hematemesis prompting an ER visit. She was initially started on Nexium and an octreotide drip. She underwent upper endoscopy, which confirmed gastric variceal bleeding. However, no intervention was able to be performed endoscopically at that time. She was then transferred to Baylor Scott & White for higher level of care.

CLINICAL HISTORY

EGD Findings 07/11/2015: Esophagus: The esophagus appeared normal.

Stomach: Gastric Varices were noted in the proximal stomach and fundus. There was new spontaneous blood in the fundus. The fundus was unable to insufflate fully to visualize the exact point of bleeding. Likely source was the gastric varices. No specific spot could be seen to band. The scope was then withdrawn.

Duodenum: The duodenum appeared normal.

CLINICAL HISTORY

Upon arrival at our institution on 7/12/2015, she was admitted to the medical ICU. Vital signs were initially stable.

On the day of admission, hemoglobin was 9.2 and hematocrit was 29.7. After 24 hours, the hemoglobin was 7.5 and the hematocrit was 24.2. Blood pressure remained stable. A transfusion protocol was then started. She responded well and the H&H remained stable at approximately 8.0 and 25.0 over the next two days.

On hospital day 2, An abdominal CT scan was obtained and compared to prior scan from April. Pancreatic tail pseudocyst adjacent to splenic hilum, splenic vein thrombosis, and isolated gastric varices remained stable. There was no portal vein or superior mesenteric vein thrombosis.

General Surgery was consulted for evaluation for possible splenectomy. Emergent splenectomy was deferred due to high operative morbidity in the setting of an adjacent

pseudocyst. Plans were made to follow up in surgery clinic in three months for discussion of splenectomy to prevent further upper GI bleeding.

CT 07/13/2015

Gastric Varices Pancreatic tail pseudocyst adjacent to splenic hilum Splenic vein thrombosis

CLINICAL HISTORY

On hospital day three, the patient became hemodynamically unstable with a blood pressure of 78/36 mmHg and heart rate of 140 bpm. Hemoglobin and hematocrit dropped to 6.4 and 20.2, respectively. Gastric lavage revealed acute blood. The patient was then emergently intubated and sedated, and a central line was placed.

Gastroenterology then repeated the upper endoscopy, at which time a single bleeding gastric varix was found and subsequently sclerosed with Sodium Tetradecyl (Sotradecol) solution. Per GI, definitive treatment for the gastric varices was strongly recommended due to

the high likelihood of re-bleeding.

General surgery was re-consulted for possible splenectomy. Despite the high operative morbidity, surgery was planned for the following morning pending hemodynamic stability.

QUESTION

True or False: According to gastroenterology literature, recurrence of any variceal bleeding after successful endoscopic control of variceal hemorrhage is common and is thought to occur in 25% – 33% of patients over an 18 month period.

CORRECT!

True or False: According to gastroenterology literature, recurrence of any variceal bleeding after successful endoscopic control of variceal hemorrhage is common and is thought to occur in 25% – 33% of patients over an 18 month period. True

Re-bleeding is a common occurrence following endoscopic control of variceal hemorrhage. In the setting of bleeding esophageal varices, a recent randomized controlled trial compared the outcomes of endoscopic banding plus early TIPS with endoscopic banding alone. The study demonstrated a reduction in re-bleeding and improved survival at one year. The authors suggested that performing definitive treatment (usually TIPS) within 72 hours of endoscopy is critical in producing an improved clinical outcome.

Garcia-Pagan JC, Caca K, Bureau C, et al.: Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 362:23970-23979 2010

Return to Case

SORRY, THAT’S INCORRECT

True or False: According to gastroenterology literature, recurrence of any variceal bleeding after successful endoscopic control of variceal hemorrhage is common and is thought to occur in 25% – 33% of patients over an 18 month period. True

Re-bleeding is a common occurrence following endoscopic control of variceal hemorrhage. In the setting of bleeding esophageal varices, a recent randomized controlled trial compared the outcomes of endoscopic banding plus early TIPS with endoscopic banding alone. The study demonstrated a reduction in re-bleeding and improved survival at one year. The authors suggested that performing definitive treatment (usually TIPS) within 72 hours of endoscopy is critical in producing an improved clinical outcome.

Garcia-Pagan JC, Caca K, Bureau C, et al.: Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 362:23970-23979 2010

Return to Case

CLINICAL HISTORY

On hospital day four, Interventional Radiology was consulted for evaluation for possible splenic artery embolization to control hemorrhage prior to splenectomy.

Upon our initial evaluation, the patient was intubated and sedated in the medical ICU. Blood pressure was 103/61 mmHg and the heart rate was 76 bpm. There was no evidence of active upper GI bleeding at the mouth or rectum. Posterior tibialand dorsalis pedis pulses were 2+ bilaterally. Hemoglobin and hematocrit had risen to 7.6 and 23.4, respectively.

INTERVENTION

After evaluation, and in consultation with the ICU team, General Surgery, and Gastroenterology, we recommended Splenic vein recanalization with possible stenting, followed by balloon-occluded trans-catheter obliteration of the isolated gastric varices. If control of bleeding was unsuccessful, we would then embolizethe splenic artery in preparation for subsequent splenectomy.

INTERVENTION

We took the patient to the Angiography Suite for Transhepatic portal, superior mesenteric, and splenic venography; Splenic arteriography; and Trans-splenic venography.

Skin of the abdomen and left groin was prepped and draped in usual sterile fashion.

A portal vein branch via the right hepatic lobe was accessed under direct sonographic guidance with a Greb Set micropuncture needle, which was exchanged for a 5 French introducer sheath.

The introducer sheath was then exchanged for a 6 French x 45 cm Ansel sheath and a 5 French pigtail catheter was then advanced into the portal venous system over a guidewire. Portal, superior mesenteric, and inferior mesenteric venography was obtained.

Portal Vein Superior Mesenteric Vein Unable to visualize Splenic vein due to thrombosis

INTERVENTION

In conjunction with a 5 French Kumpe catheter, a 0.035 Angled-tip Glidewire was used to navigate bluntly through the chronically occluded lumen of the splenic vein. The proximal splenic vein was reached by the Glidewire/Kumpe catheter, however the venous hilum was unable to be cannulated.

Therefore, attention was then turned to the left groin where the left common femoral artery was accessed with a micropuncture needle, and ultimately the celiac artery was accessed with a 6 French Cobra 2 catheter.

Celiac trunk angiography was then performed and carried out to the venous phase in order to highlight the venous drainage pathways of the splenic parenchyma.

Glidewire/Kumpecatheter reached proximal splenic vein, but unable to cross into the hilum.

Celiac Trunk arteriogram demonstrates patency of the splenic artery and opacifiesveins of the splenic hilum draining into large gastric varices.

INTERVENTION

The venous drainage of the spleen was then mapped, and trans-splenic venous access was obtained under direct ultrasound guidance using a 21-gauge Greb Set needle, which was exchanged for a 5 French GrebSet sheath.

Through the sheath, splenic venography was performed. Several gastric varices were noted providing dominant outflow from the spleen. A Fogarty catheter was advanced and the balloon was inflated just proximal to the origin of the gastric varices.

Following this, two Amplatz Gooseneck snares were deployed, one in the proximal splenic vein via the transhepatic access and the other in the splenic hilum via the trans-splenic access. A 21-gauge Greb Set needle was then advanced through each snare loop via an anterior abdominal approach under direct fluoroscopic guidance (“Gun-sight” technique). A microwire was then advanced through the needle and the tip of the needle was placed in the splenic vein hilum. The needle was removed.

Both ends of the microwire were then snared. The snare originating from the transhepatic access was then retracted, which then subsequently retracted the trans-splenic snare wire/catheter across the most proximal occluded segment of the splenic vein/hilum.

The snare wire was then exchanged for an exchange length Rosen guidewire, and through-and-through access across the occluded splenic vein was successfully achieved.

Trans-splenic access was achieved using a 21 gauge needle. Limited venography through the needle confirms venous access.

Trans-splenic venography illustrates large gastric varices providing outflow drainage from the splenic parenchyma. Balloon occlusion opacifiesveins of the splenic hilum.

INTERVENTION

Balloon angioplasty of the splenic vein was then performed using a 6 mm x 10 cm Mustang balloon. This was followed by successful deployment of a 9 mm x 8 cm self-expanding bare-metal Epic stent. The stent was post-dilated using an 8mm x 10cm Mustang balloon.

Repeat venography via a trans-splenic 6 French Pinnacle sheath was then performed, which demonstrated successful recanalization of the splenic vein with brisk outflow.

Through-and-through access with a 0.035 Rosen guidewire was achieved via trans-splenic and trans-hepatic access using the “Gun-sight” technique.

Balloon angioplasty of splenic vein

Venography via trans-splenic sheath injection demonstrates restored patency of the splenic vein following balloon angioplasty and stent deployment.

INTERVENTION

Repeat celiac arteriography was performed and again carried out to the splenic venous phase. Again, the gastric varices were found to supply significant outflow from the splenic parenchyma after stent placement. Therefore, we elected to proceed with BRTO of the gastric varices.

The Fogarty balloon was re-advanced through the sheath and placed into the dominant outflow of the splenic parenchyma, and the balloon was inflated. The gastric varices were then embolized using Sodium Tetradecyl (Sotradecol) and lipiodol foam.

Following sclerosant injection, four 6mm Nester coils were deployed in the dominant venous outflow trunk to the gastric varices. Follow-up venography through the sheath demonstrated successful exclusion of the gastric varices with dominant outflow via the splenic vein stent.

The 6 French trans-splenic sheath was then removed, and the tract was embolized with Gelfoam.

Next, a celiac arteriogram was again performed and carried out through the venous phase. Near-complete exclusion of the gastric varices was noted with dominant splenic parenchymal venous outflow via the splenic vein stent.

Celiac Trunk arteriography carried out to the venous phase demonstrates persistent outflow from the splenic parenchyma through the gastric varices. There was some flow through the stent.

Balloon occlusion again illustrates the gastric varices prior to sclerosant injection.

Repeat venography through the sheath demonstrates complete exclusion of the gastric varices and patency of the stent.

Radio-opaque Lipiodol and Nester coils

Repeat Celiac Trunk arteriogram carried out to the venous phase demonstrates dominant outflow through the stent. Some residual flow remained through the gastric varices, which was felt insignificant.

QUESTION

True or False: reported technical success rates for BRTO procedures have ranged from 90% to 100%, and regression or disappearance of gastric varices on endoscopy was achieved in 80% to 100% of patients after BRTO.

CORRECT!

True or False: reported technical success rates for BRTO procedures have ranged from 90% to 100%, and regression or disappearance of gastric varices on endoscopy was achieved in 80% to 100% of patients after BRTO. True.

One study out of Japan, which included 24 consecutive patients treated with BRTO for isolated gastric varices, saw 100% clinical success (as defined by re-bleeding) after complete technical success (n=21) in which all varices were obliterated, as confirmed on follow-up CT scan.

In that study, Eradication of gastric varices was obtained in all patients (n = 19) who were examined by endoscopy 3 months after the treatment.

Kitamoto M, Imamura M, Kamada K, et al.: Balloon-occluded retrograde transvenous obliteration of gastric fundal varices with hemorrhage. AJR Am J Roentgenol. 178:1167-1174 2002

Return to Case

SORRY, THAT’S INCORRECT

True or False: reported technical success rates for BRTO procedures have ranged from 90% to 100%, and regression or disappearance of gastric varices on endoscopy was achieved in 80% to 100% of patients after BRTO. True.

One study out of Japan, which included 24 consecutive patients treated with BRTO for isolated gastric varices, saw 100% clinical success (as defined by re-bleeding) after complete technical success (n=21) in which all varices were obliterated, as confirmed on follow-up CT scan.

In that study, Eradication of gastric varices was obtained in all patients (n = 19) who were examined by endoscopy 3 months after the treatment.

Kitamoto M, Imamura M, Kamada K, et al.: Balloon-occluded retrograde transvenous obliteration of gastric fundal varices with hemorrhage. AJR Am J Roentgenol. 178:1167-1174 2002

Return to Case

CLINICAL FOLLOW-UP

The patient was placed on a Heparin drip for three days post intervention, followed by 75 mg Plavix daily for two months.

She required no further RBC transfusions and her hemoglobin and hematocrit stabilized at 8.1 and 24.2 by POD 2. She was extubated one day after the procedure.

There were no further episodes of GI bleeding.

General surgery elected to cancel planned splenectomy.

She was discharged home 07/20/2015, four days after intervention.

CLINICAL FOLLOW-UP

CT scans of the abdomen with portal venous contrast were obtained at one month and again at six months following splenic vein recanalization and BRTO. Splenic vein stent remains widely patent at six months.

There have been no recurrent GI bleeds.

Additionally, a repeat upper endoscopy was performed by GI which revealed that the previous gastric varices were “barely perceptible”.

Splenic vein stent remains patent at six months.

TEACHING POINTS

Our case highlights the difficult management of a young patient presenting with life-threatening upper GI bleeding from isolated gastric varices due to chronic splenic vein thrombosis, which itself was secondary to an adjacent pancreatic pseudocyst and/or chronic pancreatitis.

Through an interdisciplinary approach, we were able to control acute hemorrhage and nearly eliminate the gastric varices by performing recanalization of the chronically occluded splenic vein and subsequent balloon-occluded retrograde trans-splenic obliteration of gastric varices.

We were able to definitively treat the isolated gastric varices in order to prevent recurrent life-threatening bleeding, and simultaneously save this young patient from a potentially morbid splenectomy.

TEACHING POINTS

To our knowledge, not much literature exists on recanalization of the splenic vein to treat isolated gastric varices. Similarly, to our knowledge, the “Gun-sight” technique utilizing two snare wires and a 21 gauge needle to cross a difficult occlusion has yet to be described.

We do know that the majority of isolated gastric varices can be treated safely with balloon-occluded retrograde transvenous obliteration (BRTO). In our case we altered that technique slightly because we already achieved trans-splenic access.

Similarly, we know that early definitive treatment of bleeding gastroesophageal and/or isolated gastric varices after endoscopic banding is superior to endoscopic banding alone.

Thus, we felt strongly that if we could eliminate the varices and provide an alternate outflow venous drainage pathway from the spleen by recanalizing the splenic vein, we would be providing a valuable service to this patient in terms of reducing the risk of re-bleeding, and would save her from a potentially morbid splenectomy.

REFERENCES

Garcia-Pagan JC, Caca K, Bureau C, et al.: Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 362:23970-23979 2010

Kanagawa H, Mima S, Kouyama H, et al.: Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 11:51-58 1996

Hirota S, Matsumoto S, Tomita M, et al.: Retrograde transvenous obliteration of gastric varices. Radiology. 211:349-356 1999

Kiyosue H, Mori H, Matsumoto S, et al.: Transcatheter obliteration of gastric varices: Part 2. Strategy and techniques based on hemodynamic features. Radiographics. 23:921-937 2003

Kitamoto M, Imamura M, Kamada K, et al.: Balloon-occluded retrograde transvenousobliteration of gastric fundal varices with hemorrhage. AJR Am J Roentgenol. 178:1167-1174 2002