ARRS 2022 Abstracts

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E1836. Plug-Assisted Retrograde Transvenous Obliteration of Giant Gastrorenal Shunts: Report of Two Cases
Authors
  1. Trong Binh Le; Hue University of Medicine and Pharmacy Hospital
  2. Dac Hong An Ngo; Hue University of Medicine and Pharmacy Hospital
  3. Ton Nu Hong Hanh Huyen; Hue University of Medicine and Pharmacy Hospital
  4. Minh Tuan Le; Hue University of Medicine and Pharmacy Hospital
  5. Trong Khoan Le; Hue University of Medicine and Pharmacy Hospital
  6. Thanh Thao Nguyen; Hue University of Medicine and Pharmacy Hospital
  7. Xuan Long Truong; Hue University of Medicine and Pharmacy Hospital
Objective:
Plug-assisted retrograde transvenous obliteration (PARTO) has been recognized as a safe and effective treatment modality for patients with gastric variceal bleeding (GVB). The hallmark of this technique is to block the gastrorenal shunt (GRS) using a vascular plug followed by infusion of gelfoam slurry to completely occlude the gastric varices. Many authors advocate at least 20% oversizing of the plug to ensure shunt occlusion and to prevent device migration. However, the maximal diameter of the commercially available plug is 22 mm, making the procedure technically unfeasible for GRS > 18–20mm. We report two challenging cases of recurrent GVB due to liver cirrhosis and portal hypertension. Both patients had giant and tortuous GRS which were successfully embolized with 22-mm plugs.

Materials and Methods:
Institutional review board approval was waived for case reports. Two male patients (58 and 47 years old) presented with recurrent GVB due to liver cirrhosis and portal hypertension. Their past history was noted with chronic hepatitis B virus infection and heavy alcohol consumption. Upper gastrointestinal endoscopy failed to achieve hemostasis. Contrast-enhanced CT revealed multiple gastroesophageal varices and giant tortuous GRS. The GRS diameters were 24–30 mm and 23–32 mm for each patient. PARTO was indicated after multidisciplinary discussions. From the right femoral vein access, a 6F vascular long sheath was placed at the proximal GRS. A 5F cobra catheter was then advanced distally into the GRS followed by the introduction of an Amplatz super-stiff wire. A 10F long sheath was finally secured at the mid-portion of the GRS. Venogram demonstrated a giant, tortuous, aneurysmal GRS with multiple “waists.” A 22-mm Amplatzer vascular plug II was deployed between the two dilated segments of the GRS so that the middle mesh of the plug was anchored at the waist. After 10 minutes of waiting for thrombosis, the varices were embolized with gelfoam slurry as standard PARTO. Additional coils were used to occlude the proximal recess between the plug and the GRS wall and to stabilize the plug. The completion venogram showed total occlusion of the GRS. The two patients were discharged uneventfully.

Results:
Both patients experienced mild abdominal pain and fever several days after the procedure. Neither major complications nor recurrent bleeding were documented during the 5-month follow-up. Aggravation of esophageal varices were evident on regular endoscopy, but no intervention was necessary.

Conclusion:
PARTO can be performed safely in patients with giant tortuous GRS. Careful review and tailoring of the anatomical characteristics of the GRS are essential for a successful procedure.