OGH Reports 2018; 7(1): 46-48Peer Reviewed Journal in Oncology, Gastroenterology and Hepatologywww.oghreports.org | www.journalonweb.com/ogh

OGH Reports, Vol 7, Issue 1, Jan-Jun, 2018 46

Case Report

Lijesh Kumar1 Cyriac Abby Philips2, Philip Augustine3

1Interventional Radiology, PVS Institute of Digestive Diseases, PVS Memorial Hospital, Cochin, Kerala, INDIA.2Hepatology and Transplant Medicine, PVS Institute of Digestive Diseases, PVS Memorial Hospital, Cochin, Kerala, INDIA.3Gastroenterology, PVS Institute of Digestive Diseases, PVS Memorial Hospital, Cochin, Kerala, INDIA.

Correspondence

Cyriac Abby PhilipsPhilip Augustine Associates, PVS Memorial Hospital Campus, Kaloor, Cochin 682017, Kerala, INDIA.

Phone: +91 9207745776, +91 7356677776

Email: abbyphilips@gmail.com

History• Submission Date: 17-04-2017; • Review completed: 30-06-2017; • Accepted Date: 28-07-2017.

DOI : 10.5530/ogh.2018.7.1.10

Article Available online http://www.oghreports.org

Copyright© 2018 Phcog.Net. This is an open- access article distributed under the terms of the Creative Commons Attribution 4.0 International license.

Cite this article: Kumar L, Philips CA, Augustine P. First Report of Balloon-Occluded Antegrade Cyanoacrylate Glue Embolization (BAGE) for Bleeding Rectal Varices from India. OGH Reports. 2018;7(1):46-8.

ABSTRACTRectal variceal bleeding occurs in 38% of patients with portal hypertension leading to an overall mortality in 5%. Conventional management involves endoscopic measures utilizing sclerotherapy/glue injection/banding ligation or surgical management. Some patients, mostly Child A or B cirrhotics, pose difficulty for traditional management and have been shown to benefit from transjugular intrahepatic portosystemic shunting (TIPSS) or interventional balloon occluded shunt embolization procedures, balloon occluded transvenous obliteration being the most common used modality, however, seldom reported in literature. In this report, we present the case, through striking images and real time step by step procedural video; of a difficult to control rectal variceal bleeding in a Child C cirrhotic in whom, balloon occluded antegrade glue embolization of multiple shunts was performed with beneficial outcomes.

Key words: Interventional radiology, Embolization, Glue therapy, Sclerotherapy, Portal vein, Ectopic varices.

Lijesh Kumar1, Cyriac Abby Philips2, Philip Augustine3

INTRODUCTIONRectal variceal bleeding, can at times be difficult to manage through conventional methods and prove fatal if not emergently salvaged. There have been several reports of bleeding rectal varices treated with endoscopic variceal ligation, endoscopic sclerotherapy, transjugular intrahepatic portosystemic shunt and surgery. Even though various strategies have been described in literature, consensus guidelines for management of bleeding rectal varices are lacking due to heterogeneity of associated portosystemic collateral anatomy, due to which, no single effective method has yet been established.[1] In 1997, Kimura et al reported the successful treatment of bleeding rectal varices with a new interventional radiological procedure utilizing double balloon-occlusion assisted embolotherapy.[2] Thereafter reports on modification of this technique for bleeding rectal varices, mostly through balloon-occluded retrograde route and use of sclerosant has been described. Here we report the case of a difficult to manage rectal variceal bleeding, utilizing balloon occluded antegrade technique and cyanoacrylate glue therapy followed by coil emboli-zation for immediate hemostasis achievement trans-lating to beneficial outcome in a Child C cirrhotic.

CASE REPORTA 42-year-old male patient, known case of decom-pensated alcoholic cirrhosis (Child C) with prior endoscopic band ligation sessions for bleeding esophageal varices in the last 3 years, currently listed for living donor liver transplantation, presented to

First Report of Balloon-Occluded Antegrade Cyanoacrylate Glue Embolization (BAGE) for Bleeding Rectal Varices from India

the emergency department with torrential rectal bleeding associated with postural symptoms for one day. Physical examination revealed an alert patient, oriented to place, but not time with scleral icterus, pallor, tachycardia, diaphoresis and blood pressure was 88/60 mm Hg with grade 3 ascites and flapping tremors. Laboratory evaluation revealed hemoglobin 7.6 g/dL with serum bilirubin 12.8 mg/dL and inter-national normalized ratio 2.1. One unit of packed red cells was transfused and intravenous terlipressin started. An urgent sigmoidoscopy was noncontribu-tory in view of poor visualization due to fresh blood and clots. Transjugular intrahepatic portosystemic shunt was not ideal in view of advanced liver disease. A review of prior contrast imaging of the abdomen revealed large portosystemic shunt with afferent supply by inferior mesenteric vein through a shunt to the superior rectal vein (Figure 1A) forming large rectal varices; the efferent supply being internal iliac vein (Figure 1B). The large portosystemic shunt supplied the rectal variceal complex (Figure 1C, black arrow) through anterior, anterolateral and posterior tributaries (Figure 1C, arrows). In view of advanced liver disease status, failure to control bleed with traditional modality and complex shunt anatomy, interventional radiological approach was called for. A 7 Fr drainage catheter (Cook Medical, Bloomington) was inserted in right sub-diaphragmatic region to drain the ascites slowly and continuously. The left common femoral vein was punctured under ultra-sound guidance and a 7 Fr sheath inserted. Using 5

Lijesh et al.: BAGE for bleeding rectal varices

OGH Reports, Vol 7, Issue 1, Jan-Jun, 2018 47

Figure 1: A - Computed venography of abdomen showing a large portosystemic shunt with afferent supply by inferior mesenteric vein through a shunt to the superior rectal vein forming large rectal varices; B - internal iliac vein serves as the efferent; C – the rectal variceal complex (black arrow) is supplied by 3 tribu-taries of the shunt (arrows); D - A plain computed tomography done 24 hours later showing complete obliteration of rectal varices with glue cast formation (arrow). SMV – superior mesenteric vein, IMV – inferior mesenteric vein, PV – portal vein; EIV – external iliac vein, IIV – internal iliac vein

Figure 2: A - Venogram taken from the inferior mesenteric vein showing large shunt in pelvic region (arrow); and B - associated rectal varices (arrows); C - keeping the balloon inflated (white arrow), tributaries of the shunt were sequentially cannulated embolized with N-butyl -2-Cyanoacrylate (black arrow); D - post embolization venogram showed absent filling of the varices (arrows).

Table 1: The reported interventional radiology approaches to management of rectal variceal bleeds (4 – 10)

Author (year) Cases Child status Procedure Treatment

Kimura et al (1997) 1 A Double balloon occluded embolization Ethanolamine oleate+iopamodol

Hidajat et al (2002) 1 A TIPSS followed by variceal embolization Ethanolamine oleate

Okazaki et al (2006) 1 B Balloon-occluded anterograde transhepatic obliteration EthanolamineOleate+iopamidol

Ibukuro et al (2009) 1 C Embolization through paraumbilical vein Gelfoam, lipiodol, ethanol, micro-coils

Watanabe et al (2011) 1 A Balloon occluded retrograde transvenous obliteration Ethanolamine oleate+lipiodol

Arai et al (2013) 1 A Trans-ileocolonic vein obliteration Ethanolamine oleate+lipiodol

Minamiguchi et al (2013) 2 B Balloon-occluded anterograde shunt obliteration Ethanolamine oleate+iopamidol

Ono et al (2015) 2 A Balloon-Occluded Antegrade Transvenous through greater sciatic foramen

Ethanolamine oleate+iopamidol

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48 OGH Reports, Vol 7, Issue 1, Jan-Jun, 2018

Fr Internal Mammary (IM) catheter (Cordis, Fremont) right common iliac vein was cannulated and a 0.035” hydrophilic guidewire (Terumo, Tokyo) was passed into the right internal iliac vein. 5F IM catheter was exchanged for a 7 Fr pulmonary artery (PA) catheter (Edwards Life-sciences, California), which was placed in the right internal iliac vein. Venogram taken after inflating the PA catheter bulb showed good collat-eral flow between right and left internal iliac veins. Segment 5 branch of portal vein was then punctured using micro-puncture set (Cook Medi-cal, Bloomington) and a 5 Fr sheath inserted and a 4 Fr Multipurpose catheter (Cook Medical, Bloomington) was advanced into the main por-tal vein. Venogram showed hepatofugal flow with predominant filling of inferior mesenteric vein. Venogram taken from the inferior mesenteric vein showed large shunt in pelvic region and associated rectal varices (Figure 2A, arrow; 2B, arrows respectively) draining predominantly into right internal iliac vein with reduction in shunt flow velocity on infla-tion of the right internal iliac balloon catheter. Keeping the balloon in-flated (Figure 2C, white arrow), tributaries of the shunt (3 in number) were sequentially cannulated using 2.7 Fr Progreat microcatheter (Terumo, Tokyo) and embolized with N-butyl -2-Cyanoacrylate (Endocryl™, En-dotech, Mumbai; Figure 2C, black arrow) keeping the balloon inflated. Post embolization venogram showed no residual filling of the varices (Figure 2D, arrows) and absence of systemic embolization. Post pro-cedure portogram revealed hepatopetal flow with evidence of a partial chronic thrombus in main portal vein causing ~ 50% narrowing. Balloon was deflated and taken out. The hepatic tract was embolized using mi-cro fiber coils (Boston Scientific, Massachussets) under fluoroscopy and ultrasound guidance. A plain computed tomography done 24 hr later revealed complete obliteration of rectal varices with glue cast formation (Figure 1D). Video 1 shows the real time procedural steps encompassing salient features of the interventional treatment.

DISCUSSIONRectal variceal bleeding has been classically managed using band ligation, endoscopic sclerotherapy, surgery, TIPSS or interventional embolization. Norton et al suggested that in the event that the rectal entire varix cannot be banded, there would be risk of a wide defect in the varix after sloughing of the band leading to unsafe banding technique in case of large rectal varices.[3] Common interventional modalities include double balloon occlusion, percutaneous transhepatic obliteration or balloon occluded transvenous obliteration (BRTO) using sclerosant. Based on shunt com-plexity, most of the conventional interventional option pose difficulty. Table 1 shows reported interventional approaches to management of rectal variceal bleeds in portal hypertension.[4-10] Endoscopic sclerotherapy and banding based occlusion of blood supply or main drainage routes is difficult, requiring multiple sessions for variceal eradication and TIPSS is effective in only select group of patients. The BRTO, is ineffective and difficult to perform when multiple drainage routes are involved and complete shunt tributary flow cannot be stopped with additional waiting time for sclerosant to obliterate the shunt. Use of coil-assisted (CARTO) shunt occlusion would have been technically difficult due to complex

shunt anatomy, large number of coils and associated cost; plug-assisted (PARTO) shunt occlusion would have also been complicated in view of complex shunt anatomy. The use of cyanoacrylate glue proved much cheaper, shunt occlusion much faster and in the process, more beneficial. Before we commit to endoscopic management as the standard of care in bleeding rectal varices, the determination hemodynamics/shunt anatomy of rectal varices in each patient is important for selecting the most appropriate treatment modality.[11] Our report is unique in many ways – one, we performed a demanding interventional procedure in a Child C cirrhotic, seldom reported in literature and two – we utilized balloon occlusion through retrograde transfemoral approach and used cyano-acrylate glue based embolization through the transhepatic anterograde route; all the while draining tense ascites – a complexity which is cur-rently not described in literature.

CONCLUSIONWith development in interventional procedures for portal hypertension and improved technical ease, newer studies/trials in management of ectopic variceal bleeding must consider interventional radiology proce-dures as possible first line of management in patients deemed as ‘difficult to control bleed’ or ‘difficult portal hemodynamic anatomy’.

REFERENCES1. Sato T. Treatment of ectopic varices with portal hypertension. World J Hepatol.

2015;28(7):1601-5.2. Kimura T, Haruta I, Isobe Y, et al. A novel therapeutic approach for rectal varices:

a case report of rectal varices treated with double balloon occluded embolo-therapy. Am J Gastroenterol. 1997;92(5):883-6.

3. Norton ID, Andrews JC, Kamath PS. Management of ectopic varices. Hepatology. 1998;28(4):1154-8.

4. Hidajat N, Stobbe H, Hosten N, et al. Transjugular intrahepatic portosystemic shunt and transjugular embolization of bleeding rectal varices in portal hyper-tension. Am J Radiol. 2002;178(2):362-3.

5. Okazaki H, Higuchi K, Shiba M, et al. Successful treatment of giant rectal varices by modified percutaneous transhepatic obliteration with sclerosant: report of a case. World J Gastroenterol. 2006;12:5408-11.

6. Ibukuro K, Kojima K, Kigawa I, et al. Embolization of rectal varices via a paraum-bilical vein with an abdominal wall approach in a patient with massive ascites. J Vasc Interv Radiol. 2009;20(9):1259-61.

7. Watanabe K, Imai Y, Takayama H, et al. A case of liver cirrhosis due to hepatitis C virus infection complicating giant anorectal varices treated with balloon-occluded retrograde transvenous obliteration. Clin J Gastroenterol. 2011;4(1):19-23.

8. Arai H, Kobayashi T, Takizawa D, Toyoda M, Takayama H, Abe T. Transileocolic Vein Obliteration for Bleeding Rectal Varices with Portal Thrombus. Case Rep Gastroenterol. 2013;7(1):75-81.

9. Minamiguchi H, Kawai N, Sato M, Ikoma A, Sanda H, Nakata K, et al. Successful treatment of endoscopically unmanageable rectal varices by balloon-occluded antegrade transvenous sclerotherapy followed by microcoil embolization. J Vasc Interv Radiol. 2013;24(9):1399-403

10. Ono Y, Kariya S, Nakatani M, Yoshida R, Kono Y, Kan N et al. Balloon-Occluded Antegrade Transvenous Sclerotherapy to Treat Rectal Varices: A Direct Puncture Approach to the Superior Rectal Vein Through the Greater Sciatic Foramen Under CT Fluoroscopy Guidance. Cardiovasc Intervent Radiol. 2015;38(5):1320-4.

11. Saad WE, Lippert A, Saad NE, Caldwell S. Ectopic varices: anatomical classifica-tion, hemodynamic classification, and hemodynamic-based management. Tech Vasc Interv Radiol. 2013;16(2):158-75.

Cite this article: Kumar L, Philips CA, Augustine P. First Report of Balloon-Occluded Antegrade Cyanoacrylate Glue Embolization (BAGE) for Bleeding Rectal Varices from India. OGH Reports. 2018;7(1):46-8.