BRTO /PARTO Indications and outcomes

Transcription

1 BRTO /PARTO Indications and outcomes Saher Sabri, MD Associate Professor of Radiology and Surgery Division of Interventional Radiology University of Virginia Health System

2 Saher Sabri, M.D. Speakers Bureau: W.L.Gore & Associates, Abbott

3 Disclosures W.L. Gore- Speaker

4 RTO Indications To treat encephalopathy GV bleed with contraindication to TIPS ( ex. Encephalopathy) Continued GV bleed after TIPS optimization ( RTO vs antegrade GV sclerosis)? Isolated GV bleed. No EVs or ascites.

5 Outcomes- Technical success 568 BRTO patients-meta-analysis Technical success rate is 91% Complete obliteration rate is 93% Partial obliteration is more common in complex varices ( 3 or more afferent veins) Takaji et al (AJR 2011) Technical and clinical failures were routinely treated with endoscopic NBCA injection Saad et al CVIR 2013

6 OUTCOMES- Rebleeding The GV rebleed rate after successful BRTO procedure was % For all types of variceal rebleed rate reached % The rate of exacerbation of existing EVs 1 year is % 2 years % 3 years % EV bleeding occurred in in % Aggressive surveillance for EVs is needed

7 Rebleeding TIPS vs BRTO - Sabri et al JVIR TIPS and 22 BRTO for GVs TIPS with embolization of afferent veins (coils and AVP) Technical success 100% TIPS and 93% BRTO Complications 4% TIPS 9% BRTO Encephalopathy 15% TIPS, 0% BRTO 1 year Rebleeding from a GV source 11% TIPS, 0% BRTO (p 0.2) 2 TIPS dysfunction and one continued bleeding despite TIPS optimization

8 Outcome Author Patients (n) Technical success (%) Rebleeding rate (%) Cho et al Hiraga et al Kitamoto et al Complete obliteration rate (%) Arai et al Ninoi et al Kanagawa et al Sabri et al Updated UVA Gown et al (PARTO)

9 PARTO (Gwon et al JVIR 2015) 73 patients ( 57 GV bleeds and 16 HE) Technical success 100% AVP II ( 8-22 mm)- 70 only had one plug Rebleeding 1/73 Complete obliteration at 3 months 98.6% All HE had resolution of symptoms and decrease in Ammonia level (p<.001) ZERO complications

10 PARTO Chang et al. (Korean J Rad) 19 pts. 95% tech success Acute complications included fever (n = 2), fever and hypotension (n = 2; one diagnosed adrenal insufficiency), and transient microscopic hematuria (n = 3) Obliteration rate 84%

11 Kim at al CVIR Jan 2016 Retrospective. 95 patients ( follow up available on 70 ) BRTO with EO in 49 patients. BRTO with STS foam in 25. PARTO in 21 Technical success was 95% (94% BRTO, 100% PARTO) Procedure time of PARTO was significantly shorter than those of other two BRTO procedures (P<0.017). More complications with EO, including one mortality from DIC.

12 Kim at al CVIR Jan cases of failure to obliterate GVs in BRTO with EO group. None with STS 4 cases of failure with PARTO. (including 2 cases of rebleeding ) At 1 YEAR 81 % obliteration rate for PARTO Statistical difference of gastric varices recurrence between two BRTO procedures and PARTO (P<0.05). Conclusion: BRTO using STS foam and PARTO are better than BRTO using EO in terms of complication or procedure time. However, PARTO showed frequent recurrence of gastric varices during the long-term follow-up compared to BRTO.

13 OUTCOMES- Portal HTN Exacerbation Development of ascites (0 44 %) hepatic hydrothorax (0 8 %) Hypertensive gastropathy (5 13 %) In our experience 4/70 ( 6%) required subsequent TIPS to treat complications of portal HTN Tanihata et al showed that 58 % of patients have > 5 mmhg increase in PSG ( 58%) and were associated with EV exacerbation

14 Effect of RTO on liver function The bilirubin rises significantly (P =.007) within days after RTO The MELD score significantly improved 3-4 months post-rto (from 14.1 to 10.7, P =.0008). Effect is transient and most patients return to baseline by 6-9 months The Child Pugh score did not change significantly (from 7.6 to 6.7, P =.063). Ascites worsened in 31% of patients Saad et al Vasc Endovasc Surgery 2013

15 RTO for Encephalopathy 65 patients reported in the literature Immediate response is % Long term improvement in HE 100% Serum Ammonia levels of 127. mmol/l decreased significantly to 28 mmol/l within 1 week after the procedure (P =.002) ( Gwon et at Radiology 2013)

16 Complications Pulmonary complications. Decrease in PaO2 and A-A gradient ( Arai et al ) PE ( Sabri et al) Venous thrombosis Partial PV or SV thrombosis up to 15% ( Cho et al) Partial renal Vein thrombosis ( 7%) Balloon rupture 8.7% ( Park et al) Stroke from air embolus( R-L shunt)

17 TIPS & RTO combination TIPS may have a protective effect on portal HTN after RTO ( 5-10% of RTO pts will require TIPS at some point) TIPS placement may prevent PV thrombosis post RTO with diminutive PVs In Encephalopathic patients, can we replace a large portosystemic shunt with a small controllable shunt (TIPS)?

18 Scenarios GV with EV or ascites and no encephalopathy: TIPS +/- GV sclerosis( RTO or antegrade) GV without EVS or ascites and encephalopathy: RTO GV with EV or ascites and encephalopathy:??tips, NBCA, banding and medical management GV without EVS or ascites and no encephalopathy: I think RTO