BRTO: Updates to Techniques

Transcription

1 Session XIV: BRTO, PARTO and Portal Hypertension GEST2016 BRTO: Updates to Techniques Hiro Kiyosue Oita University Hospital, Japan

2 Hiro Kiyosue, MD Royalty: Cook, Medkit Consulting Fee: Stryker Japan, Fuji Medical Systems Speakers Bureau: Codman, Terumo, Asahi Intec, Bayer Pharma, Daiichi-Sankyo

3 Talk outline 1. Treatment results of BRTO 2. Technical development/modification in BRTO Based on literature review for the last 5 years (2011-) 3. My technique for the recent cases 1. Treatment Results of BRTO for Gastric Varices

4 1016 patients from 24 studies (ruptured GV or a large/growing GV) Coexistance of HCC 271 (31.8 %) Child-Pugh classification: A, 424 (42.8 %); B, 452 (45.6 %); C 115 (11.6 %) Sclerosing agents: EOI in 958 cases (94.3 %), STS foam in 22 cases (2.2 %), and polidocanol foam in 36 cases (3.5 %). Technical success: 96.4% Clinical success (no recurrence, no rebleeding, complete obliteration): 97.3% Major complications: 2.6% EV aggravation: 33.3%

5 2.6% 0.4% 1.1% 0.3% 0.1% 0.6% 0.2%

6 17 patents of ruptured GV within 24 hours before BRTO Temporary hemostasis spontaneously (n=9) by balloon compression (n=8) BRTO: 5% EOI 2-40ml (21.3ml) Balloon indwelling time h CECT at following day Additional injection of EOI if the GVs remain

7 Complete thrombosis of GV at the first BRTO 7/17 after the second injection 16/17(94%) Disappearance of GV: 16/17 patients No rebleeding ( days: mean 1130 days)

8 69 patients with ruptured, growing, large GV Follow-up CT at 1W Complete thrombosis of GV 58 (85%) Partial thrombosis of GV 11 (15%) Follow-up GF at 3M All cases showed regression or disappearance of GV

9 Follow-up > 6mo (median 32 mo: 7-90 mo ) No cases of GV rebleeding Regrowth of GV in 5 patients All the 5 cases successfully retreated by rebrto The cumulative risk of regrowth of GV at 6 mo and 18mo All GV: 1.6% and 4.0% Complete thrombosed GV: 0% and 0% Partial thrombosed GV: 10% and 25%

10 50 patients with GV bleeding treated by TIPS with covered stent (n=27) (VIATORR) or BRTO with foam sclerosant (n=23) 3% Sotradecol mixed with gas (air or carbon dioxide) and ethiodized oil (Ethiodol)in a 2:3:1 ratio Balloon indwelling time: 4-12 hrs

11 Encephalopathy 4/27 (15%) 0/27 (0%) Overall survival at 12 mo 74% 87%

12 Retrospective comparison of the cases treated BRTO alone (n=27) v.s. BRTO+TIPS (n=9) Ascites/hydrothorax free rate at 6M, 12M, 24M 58%, 43%, 29% 100%, 100%, 100% Rebleeding at 6M, 12M, 24M 9%, 9%, 21% 0%, 0%, 0%

13 1. 2. Technical development/modification in BRTO Sclerosing agents PARTO BRTO for GVs without GRS

14 Sclerosing agents 3% polidocanol, room air, contrast media 1:2:1 Technical success 15/16 (93.8%) patients No pain Complication: 1 pulmonary edema Clinical success: 10/11 patients (91%) Rebleeding: one patients

15 22 patients with GV bleeding 3% STS, gas, Lipiodol (2:3:1) Dose of STS (20-600mg, mean 300mg) Total amount of mixture (10-65ml, mean 34.1ml)

16 Technical success 20/22 patients (91%) Complication: 3 patients (14%) portal vein thrombosis, bacteremia PE due to central line placement Imaging follow-up: 18 patients Complete obliteration of GV: 16/18 patients (89%, 80%) No Rebleeding: days (mean 130days)

17 No rebleeding (142 days median f/u) No mortality 17 patients with GV (15 bleeding cases) 2% STS (3%STS and Contrast media, 2:1) Total amount of 2%STS (6-33ml: mean 19.9ml) Technical success: 16/17 patients (94.1%), one failed case: very large GRS Complete obliteration of GV: 15/16 (93.8%) Complication: 2 (renal vein thrombosis, transient increase of ascites

18 PARTO Radiology 2013; patients with GV All 12 cases were successful 2 patients died early after treatment unrelated to the procedure 10 patients complete thrombosis or regressed No bleeding at 442 days meanfollow-up

19 Vascular Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Varices and Hepatic Encephalopathy: A Prospective Multicenter Study. J Vasc Interv Radiol Nov;26(11): Gwon DI, Kim YH, Ko GY, Kim JW, Ko HK, Kim JH, Shin JH, Yoon HK, Sung KB. 73 consecutive patients including 57 patients with GV Complete thrombosis of GV or PSS: 72/72 patients (98.6%) No cases of variceal bleeding or HE ( for 544days mean fu)

20 95 patients with gastric varices treated by retrograde transvenous obliteration BRTO with EO: 45 patients (EO + Lipiodol 5:1) BRTO with STS foam: 25 patients (3 % STS, contrast media, and room air, 1:1:2) PARTO: 21 patients (GS)

21 Cardiovasc Interv Radiol 2016;Jan 12 [Epub ahead of print]

22 BRTO for GV without GRS 11/76 cases of GV without GRS (4 ruptured GVs) 5 Gastrocaval shunt (GCS) 2 Pericardiophrenic vein (PCV) 2 Paraesophageal vein (PEV) 1 Mediastinal vein inferior pulmonary vein 1 unknown

23 GCS GCS GCS GCS GCS PCV PCV PEV PEV Med V -pul V Unknown BRTO was performed in 9 cases Success 6/9 cases (67%) GCS 4/5 (80%) PCV 1/2 (50%) PEV 1/2 (50%) Reasons of failure 2 extravasation 1 inaccessible All success cases showed disappearance of GVs

24 4 cases of GVs draining PCV alone Treated by flexible balloon or microballoon catheter

25 78F growing GV failed BRTO at another HP

26 13:59

27 14:30

28 14:50 During injection of EOI 6F guiding catheter 4F flexible catheter microballon catheter 5% EOI 2ml

29 Before withdrawn 15:21 Total procedure time 85min 5% EOI 3.6ml

30 5days after BRTO 3M after BRTO

31

32

33 Our techniques 1. to prevent incomplete thrombosis of GV

34

35

36 Our techniques 2 To shorten the procedure time 1. Selective BRTO to avoid embolization of collateral drainages (coaxial double balloon catheter) 2. Use of NBCA & coils after BRTO (stagnation for min) 3. Use or AVP after BRTO (balloon occlusion for 40-60min)

37 Our techniques 2 To shorten the procedure time 1. Use of NBCA & coils after BRTO (stagnation for min) 2. Use or AVP after BRTO (balloon occlusion for 40-60min)

38 Ruptured GV Alcoholic cirrohosis and multiple HCCs

39 16:26

40 16:46 16:52 (26min) (20min) Another drainage from GV Microcatheter tip In the GV Splenic a balloon

41 17:08 (42min) 4ml EOI Balloon occlusion for25min

42 17:20 25% NBCA 2ml coils procedure time 54min

43 EOI 4ml, NBCA, 2ml, procedure time 54min Immediately after BRTO with EOI& NBCA

44 Before Follow-up CT at 3 rd day

45 Our techniques 2 To shorten the procedure time 1. Use of NBCA & coils after BRTO (stagnation for min) 2. Use or AVP after BRTO (balloon occlusion for 40-60min)

46 2013

47 AVP after BRTO

48 puncture 15:35 15:40 (5min)

49 16:03 (23min)

50 EOI 3ml 16:19 (39min)

51 Stagnation for 60 min 17:01 (86min) 17:04 (89min)

52 Placement of AVP 17:26 (111min)

53 17:28 (113min)

54 EOI: 3ml stagnation for 60min procedure time 113min If I use NBCA & coils instead of AVP, the time will be 70 min. 4 Weeks 3 months

55 Conclusion Various modifications in BRTO techniques have been reported. Sclerosing agents and types (Liquid and foam) shows similar treatment results: high success rate PARTO is the most impactive modification in technique

56 Conclusion BRTO can be successfully applicable for GV without GRS Faster BRTO can be done with AVP or NBCA/COILs