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Balloon-Occluded Retrograde Transvenous Obliteration(BRTO) Along with TIPS for Variceal Bleeding
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A5183 - Balloon-Occluded Retrograde Transvenous Obliteration(BRTO) Along with TIPS for Variceal Bleeding
Author Block: A. Bhardwaj1, D. Gorman1, F. N. Hussain1, T. Clark2, M. E. Mikkelsen3; 1Medicine, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, PA, United States, 2Radiology, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, PA, United States, 3University of Pennsylvania, Penn Presbyterian Medical Center, Wynnewood, PA, United States.
Introduction: Balloon-occluded retrograde transvenous obliteration (BRTO) is a procedure that has been used for bleeding varices. While commonly performed in Japan, this procedure is not widely practiced in the United States. We present a case of a 67-year-old male admitted with hemorrhagic shock from bleeding varices and was successfully managed with BRTO.
Description: 67-year-old male with a history of alcohol and hepatitis C -induced cirrhosis, complicated by esophageal varices and hepatic encephalopathy (HE) status post TIPS presented to the ED with 8 episodes of hematemesis. On arrival, he endorsed lightheadedness without syncope, chest pain, or shortness of breath.
ED Vitals: HR 66, BP 130/60. Initial hemoglobin(Hb): 9.4 (baseline 12) and platelets 45. He was given 1L NS as well as a unit of platelets. He was started on protonix and octreotide infusions, and ceftriaxone and vitamin K was administered.
Upon arrival to the MICU, his Hb was 6.7 and the BP was 90/40. He had an emergent EGD that demonstrated 3 columns of large esophageal varices without active bleeding or stigmata of recent bleeding, mild portal gastropathy, large cluster of fundal gastric varices, antral gastritis, and multiple duodenal erosions. He had 4 bands placed to the esophageal varices. Despite the intervention, he continued to bleed requiring multiple transfusions.
Interventional Radiology (IR) was consulted for venogram of TIPS, which was found to be occluded. Multiple attempts were made to open TIPS without success. Decision was made to attempt BRTO. Patient was electively intubated for BRTO, which partially treated the varices. He was continued on octreotide, PPI daily and was restarted on home HE regimen. Over the course of his MICU stay, he received 7U PRBCs and 5U platelets in total. He was extubated without incident and was discharged home in a stable condition.
Discussion:Management of variceal bleeding includes initial resuscitation with fluids and blood products, octreotide infusion to decrease portal blood flow and endoscopic ligation of the varices. In the event of failure of endoscopic intervention, TIPS or surgical shunt are considered the next steps. More recently, BRTO has emerged as an effective treatment for control of bleeding gastric varices. We recommend early involvement of IR, and consideration of BRTO, in cases where TIPS fails to successfully control the bleeding. To our knowledge, this is the first reported case of TIPS with BRTO for management of variceal bleeding in the United States. Comparative effectiveness studies between TIPS and BRTO are needed.
Author Block: A. Bhardwaj1, D. Gorman1, F. N. Hussain1, T. Clark2, M. E. Mikkelsen3; 1Medicine, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, PA, United States, 2Radiology, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, PA, United States, 3University of Pennsylvania, Penn Presbyterian Medical Center, Wynnewood, PA, United States.
Introduction: Balloon-occluded retrograde transvenous obliteration (BRTO) is a procedure that has been used for bleeding varices. While commonly performed in Japan, this procedure is not widely practiced in the United States. We present a case of a 67-year-old male admitted with hemorrhagic shock from bleeding varices and was successfully managed with BRTO.
Description: 67-year-old male with a history of alcohol and hepatitis C -induced cirrhosis, complicated by esophageal varices and hepatic encephalopathy (HE) status post TIPS presented to the ED with 8 episodes of hematemesis. On arrival, he endorsed lightheadedness without syncope, chest pain, or shortness of breath.
ED Vitals: HR 66, BP 130/60. Initial hemoglobin(Hb): 9.4 (baseline 12) and platelets 45. He was given 1L NS as well as a unit of platelets. He was started on protonix and octreotide infusions, and ceftriaxone and vitamin K was administered.
Upon arrival to the MICU, his Hb was 6.7 and the BP was 90/40. He had an emergent EGD that demonstrated 3 columns of large esophageal varices without active bleeding or stigmata of recent bleeding, mild portal gastropathy, large cluster of fundal gastric varices, antral gastritis, and multiple duodenal erosions. He had 4 bands placed to the esophageal varices. Despite the intervention, he continued to bleed requiring multiple transfusions.
Interventional Radiology (IR) was consulted for venogram of TIPS, which was found to be occluded. Multiple attempts were made to open TIPS without success. Decision was made to attempt BRTO. Patient was electively intubated for BRTO, which partially treated the varices. He was continued on octreotide, PPI daily and was restarted on home HE regimen. Over the course of his MICU stay, he received 7U PRBCs and 5U platelets in total. He was extubated without incident and was discharged home in a stable condition.
Discussion:Management of variceal bleeding includes initial resuscitation with fluids and blood products, octreotide infusion to decrease portal blood flow and endoscopic ligation of the varices. In the event of failure of endoscopic intervention, TIPS or surgical shunt are considered the next steps. More recently, BRTO has emerged as an effective treatment for control of bleeding gastric varices. We recommend early involvement of IR, and consideration of BRTO, in cases where TIPS fails to successfully control the bleeding. To our knowledge, this is the first reported case of TIPS with BRTO for management of variceal bleeding in the United States. Comparative effectiveness studies between TIPS and BRTO are needed.
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