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Gastric varices: is there a role for endoscopic cyanoacrylates, or are we entering the BRTO era?

Abstract
Bleeding from portal hypertension-related gastric varices arising in the cardiofundal region of the stomach presents a challenge due to the unique underlying vascular anatomy which is sometimes underappreciated in endoscopic classification schemes. They often have dominant tributaries from the splenic vein or splenic hilum and terminate in the left renal vein (spontaneous splenorenal or gastrorenal shunts). This may limit the applicability of a transjugular intrahepatic portosystemic shunt (TIPS), because of the shunt's distance from the hilum of the liver. Endoscopically, the presence of a large systemic outflow track also may influence the performance of different cyanoacrylates. However, this anatomy allows an alternative approach, balloon-occluded retrograde transvenous obliteration (BRTO), which accesses the varix via the outflow pathway. Definitive comparisons between TIPS, endoscopic cyanoacrylate, and BRTO will be challenging because the incidence of this type of varix is insufficient for large trials. Here, I provide a perspective based on existing literature, 15 years of experience with various cyanoacrylates, and 4 years of experience with BRTO.
AuthorsStephen Caldwell
JournalThe American journal of gastroenterology (Am J Gastroenterol) Vol. 107 Issue 12 Pg. 1784-90 (Dec 2012) ISSN: 1572-0241 [Electronic] United States
PMID23211846 (Publication Type: Journal Article)
Chemical References
  • Cyanoacrylates
  • Tissue Adhesives
Topics
  • Adult
  • Aged
  • Angiography
  • Balloon Occlusion (methods)
  • Chemoembolization, Therapeutic (methods)
  • Cyanoacrylates (therapeutic use)
  • Embolization, Therapeutic (methods)
  • Endoscopy, Gastrointestinal
  • Esophageal and Gastric Varices (classification, complications, diagnostic imaging, epidemiology, etiology, pathology)
  • Female
  • Gastrointestinal Hemorrhage (etiology)
  • Humans
  • Hypertension, Portal (complications)
  • Male
  • Middle Aged
  • Polymerization
  • Portasystemic Shunt, Transjugular Intrahepatic
  • Recurrence
  • Retrospective Studies
  • Splenic Vein
  • Time Factors
  • Tissue Adhesives (therapeutic use)
  • Treatment Outcome
  • United States (epidemiology)

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