Portal hypertension with esophagogastric variceal bleeding is a common emergency in gastroenterology, with a mortality rate of 48-62% for initial bleeding and a 60-70% risk of rebleeding within 2 years in surviving patients. How to control ruptured esophagogastric variceal bleeding and prevent rebleeding has become the key to save the lives of patients with cirrhosis. It is also an urgent clinical problem to be solved. Now, the advantages and disadvantages of various therapeutic techniques from anatomical structure are combined with recent interventional techniques carried out by the Department of Gastroenterology of Shandong Provincial Hospital in this field at home and abroad. 1.Esophageal varices applied anatomy esophageal veins are located in the submucosa and muscle layer of esophagus or in the wall of the subplasma membrane, esophageal varices usually refer to varices in the lower part of esophagus, especially varices located in the submucosa of esophagus are easy to rupture and bleed, which are better observed on CT axial and MPR, TSMIP two-dimensional images, showing nodular, striated, earthworm-like, clustered vascular cross-sectional images in the thickened esophageal wall , uneven jagged esophageal lining, mild varices are not easily revealed by CT and are less sensitive than endoscopy [ 10]. Figure-1: Fractionation of esophagogastric varices blood supply The paraoesophageal vein is located in the posterior mediastinum outside the esophageal wall, its patency can play a shunting role to reduce the degree of esophageal varices, CT shows variceal vascular shadow outside the esophageal wall, which is easily distinguished from variceal esophageal vein on CT 2D images, but the two are not easily distinguished on 3D images, especially when the vascular varices are significant. Both varices and paraoesophageal veins merge directly or indirectly into the dilated odd and/or semi-oval veins and finally into the superior vena cava. According to Shinichi Nakamura et al [12], there are four types of connections between esophageal veins, paraesophageal veins and coronary veins: type I, where the coronary vein ends in a branch that enters the cardia and connects to the esophageal vein, and no paraesophageal vein exists outside the esophageal wall; type II, where the coronary vein is divided into two branches, the anterior branch enters the cardia and connects to the esophageal vein, and the posterior branch connects to the paraesophageal vein outside the esophageal wall In type II, the coronary vein is divided into two branches, the anterior branch enters the cardia and connects with the esophageal vein, the posterior branch connects with the paraoesophageal vein outside the esophageal wall, and the latter branch connects with the paraoesophageal vein outside the esophageal wall. In type Ⅳ, the coronary vein is also divided into two branches at the end, which are connected with esophageal vein and paraoesophageal vein respectively, and there is a penetrating vein traffic between them. For type II without intervening veins, the paraoesophageal veins should be preserved during surgery or intervention to play the role of shunt, but it is difficult to distinguish the intervening veins by CT, which is the limitation of CT, while ultrasound endoscopy can clearly show the distribution and course of the intervening veins; in conclusion, in portal hypertension, the esophageal veins mainly receive the retrograde blood from the coronary veins, but also partly from the fundic veins [13], and occasionally the left branch of the portal vein is coexisting The ectopic high esophageal branches that develop, when the above-mentioned vessels are dilated, can be clearly shown on CT images. 2, Advantages and limitations of endoscopic ligature and sclerotherapy Endoscopic ligature and sclerotherapy is the conventional treatment for esophagogastric varices, and it is the first-line treatment technique for ruptured esophageal varices and bleeding. It is widely used clinically because of the advantages of easy operation, small trauma and reliable effect of emergency hemostasis. Reproducible and easy to promote, it is the current standardized treatment plan for esophagogastric varices and plays a great role in the control of portal hypertension esophageal variceal bleeding and prevention of rebleeding. Although endoscopic ligation (EVL) and sclerotherapy (ESI) can result in scarring of the esophageal mucosa and submucosa and temporary disappearance of esophageal veins, because endoscopic treatment, especially EVL – this mechanical ligation – cannot adequately obstruct the penetrating veins connecting the paraesophageal and submucosa, the blood flow around the high pressure esophagogastric fundus can flow through the penetrating veins to the submucosa The blood flow around the high pressure esophagogastric fundus can flow through the periportal veins to the submucosal veins, so that varices of the esophagogastric fundus can be re-formed in a short time (Figure-2). Therefore, endoscopic treatment is currently considered to be an effective method of stopping bleeding in emergencies, preventing rebleeding that requires repeated treatments and still has a high rate of recurrent bleeding, increasing the operational invasiveness, and economic burden. Endoscopic treatment is not infallible. 3, transjugular intrahepatic portal stent shunt (TIPS) In 1989, German radiologist richer et al. introduced an interventional radiology technique for the treatment of ruptured variceal bleeding caused by portal hypertension in hepatic sclerosis into clinical practice. This interventional technique has been carried out in our hospital since 1993. TIPSS mainly emphasizes that all interventional operations are performed in the liver, and its method is the classic transjugular approach, which establishes a partial portal shunt in the liver, thus reducing portal pressure, and simultaneously embolizing the collateral circulation of the variceal bleeding, It also allows simultaneous embolization of the collateral circulation of the variceal bleeding, achieving the dual treatment goal of shunting and disconnecting the flow. TIPSS has important advantages: (1) it is less invasive and can be performed under local anesthesia in patients with acute illnesses, child C patients can tolerate the procedure, and the effect of lowering the pressure is definite and effective; (2) due to the adjustable shunt channel (using balloon-expanded stents), individualized shunts are realized according to individual needs, which can minimize the adverse factors of hepatic encephalopathy caused by transitional shunts. (iii) Simultaneous small-bore shunt and portal dissection in TIPSS operation is conducive to greater utilization of their respective therapeutic advantages and reduction of side effects. Figure-2: Transjugular intrahepatic portosystemic shunt with peritoneal stenting While TIPSS is currently “quiet” in China, the basic and clinical applications in Europe and the United States continue to develop steadily. The results of the clinical application of TIPSS in foreign countries show that compared with medical methods, TIPSS is more effective in acute gastrointestinal hemorrhage caused by portal hypertension; especially hemorrhage caused by fundic varices, and the combination of embolization of esophageal and fundic varices is beneficial to the prevention of reissue of blood; compared with surgical shunts, TIPSS is less invasive, safe, relatively easy to perform, and the shunt effect is similar to that of surgical shunts. Compared with surgical bypass, TIPSS is less invasive, safer, and relatively simple to perform, and the bypass effect is the same as that of surgical bypass. Therefore, TIPSS should be included as a treatment option in acute gastrointestinal hemorrhage when medical treatment is not effective. It can be concluded that TIPSS is still a valuable and practical technique among the existing treatments for portal hypertension in cirrhosis, and has advantages that are not available with medical and surgical approaches. On the contrary, in the domestic situation, some scholars have changed from the initial excitement to the current “cold” situation for various reasons, the gap between expectations and actual results being the main problem. Indeed, the relatively wide grasp of indications for some patients at the early stage of TIPSS application has caused some blindness; the occurrence of stenosis or even occlusion of the internal stent in some patients after surgery, especially the expensive cost does not bring satisfactory long-term results, is also one of the reasons for the current relative stagnation. The problem of postoperative shunt stenosis and restenosis is also a hot spot and a difficult problem. The clinical application of peritoneal stents in recent years has reduced stent restenosis due to excessive proliferation of liver tissue, and has played an active role in improving the long-term patency rate of stents and improving the long-term efficacy of TIPS. The application of dedicated peritoneal stents is expected to make the clinical status of TIPS be re-recognized and promoted. 4, percutaneous transhepatic tissue glue interventional dissection Because of the limitations of endoscopic treatment and the re-occlusion of the TIPS long-term stent, the development of interventional dissection provides an opportunity. This technique is aimed at the anatomical characteristics of varicose veins and blood supply veins, and embolization is thorough and reasonable. TH glue is a domestic tissue adhesive, which is an a-cyanoenolate glue, its structural formula a-carbon atom combines CN and COOR groups, so that the carbon atom in β position has strong electric absorption, in the presence of trace anions, can produce instant polymerization reaction and solidification, The purpose of permanent occlusion of the lumen is achieved. TH gel is a liquid embolic agent, after injected through the coronary vein of stomach, TH gel enters into the lower esophagus and submucosal varices of gastric fundus along the esophageal and gastric branches through the perforating veins between the muscular layer, and at the same time blocks the abnormal blood flow inside and outside the esophageal wall, so that the traffic branches between the portal veins are completely and permanently embolized to ensure the long-term efficacy after interventional embolization. 5.Several factors affect the long-term efficacy of TH gel embolization. (1) Focus on embolization of the lower esophagus, gastric fundus and the varices around the cardia at 5cm above and below the cardia When injecting TH glue, the catheter should be inserted to the distal end of the gastric coronary vein, so that TH glue is infused into all the vascular branches of the lower esophagus and the cardia area of the gastric fundus, making the vascular shape there and completely blocking the paradoxical blood flow in the bleeding area of the gastric fundus and lower esophagus. The lower esophageal varices in the upper 3-5 cm of the cardia and the fundic varices in the lower 5 cm of the cardia are suitable sites for portal hypertension combined with variceal rupture and bleeding, and only permanent embolization of this site can achieve the desired long-term effect. As early as 1979, Bengmark et al. reported the use of octyl cyanoacrylate for embolization of the gastric coronary vein, but the amount of adhesive used at that time was only 0.5-2 ml, which mainly embolized the main trunk of the gastric coronary vein, and the varicose vein was rarely filled with embolic agent. In our group, the amount of TH gel used was 4-22 ml, with an average of 7.5 ml, and TH gel was required to embolize not only the main trunk of the coronary vein but also all branches around the cardia of the fundus. According to the results of our 146 patients, the embolization results can be divided into three types according to the range of TH glue filling in the vessels: 1) esophagogastric-fundus type, where the embolization is more complete, with TH glue filling in the anterior and posterior branches of the coronary vein, the vessels around the cardia of the fundus, and the varices of the lower esophagus of at least 5 cm or more (Figure); 2) fundus-cardia type3, where TH glue embolizes the coronary vein and the cardia of the fundus but not the varices of the cardia. 3) Trunk type 3, TH gel embolized in the trunk of the coronary vein but did not reach the lower esophagus; 3) Trunk type 3, TH gel embolized in the trunk of the coronary vein but did not reach the fundus of the stomach around the cardia (Figure). The results of our application in the past 4 years show that the rebleeding rate is less than 10% in the case of TH gel embolization reaching the peripancreatic vessels of the fundus or the varices of the lower esophagus, while the rebleeding rate is as high as 67% in the case of embolization of the trunk of the coronary vein only. This suggests that complete embolization of the varices in the lower esophagus and gastric fundus is the key factor to ensure the long-term efficacy. Figure-2. 3 types of embolization of TH glue: a. esophagus-fundus type; b. fundus type; c. trunk type 2) Combined partial splenic embolization In portal hypertension, 60-70% of the blood flow in the portal vein comes from the spleen, and splenic artery embolization can reduce the splenic blood flow and portal blood flow, and subsequently Embolization of the splenic artery can reduce splenic blood flow and portal venous blood flow, which in turn can reduce portal venous pressure and block portal venous hyperdynamic circulation. In our study, we found that the basal portal pressure increased by 8.6% after gastric coronary vein embolization, and decreased by 19.5% after splenic embolization. This indicates that the combined intervention can significantly reduce the portal pressure. Gao Huan et al. reported a group of intraoperative TH gastrointestinal coronary vein embolization cases [8], in which 38.3% rebleeding was observed in embolization alone and 8.9% in combined splenectomy, suggesting that the high blood flow status of the spleen affects the long-term outcome of coronary vein embolization. We advocate splenic embolization at 50-80% to minimize portal vein pressure and reduce postoperative neovascularization and variceal recurrent bleeding. However, the abdominal pain, fever and ascites aggravation after splenic embolization should be taken seriously and actively prevented. 3) Reasonable application of endoscopic ligation and sclerotherapy In esophagogastric fundic type with more complete variceal embolization, TH glue has been filled in the peripancreatic vessels of the fundus and at least 5 cm above the varices of the lower esophagus, so endoscopic treatment is not necessary. However, in the case of fundic-cardia embolism or coronary trunk embolism where TH glue does not reach the lower esophagus, endoscopic ligation or sclerotherapy can be considered as an extension and supplement to the scope of interventional embolization, which will also reduce the risk of endoscopic treatment because the main source of blood supply to the varices of the esophagus is blocked by the embolization of the varices at the base of the stomach. The efficacy of combined treatment: 1+1〉2. Figure-3 Simulation of combined treatment 4) Prevention of ectopic embolism The curing time of TH gel after encountering blood flow is 6-10 seconds, because the varices are twisted and the blood flow is slow, TH gel has enough time to coagulate and embolize in the varices, and it usually collects in the varices of the lower esophagus and the cardia of the gastric fundus and does not flow to distant areas. Pulmonary embolism occurs. However, in patients with abnormally large varices, excessive blood flow rate or abnormally large traffic branches, ectopic embolism should be prevented. In such patients, we advocate that after the catheter is superselected into the gastric coronary vein, an appropriate amount of anhydrous alcohol is injected or a ciliated steel ring is placed at the beginning of the gastric coronary vein to partially block the blood flow in the gastric coronary vein, and then the catheter is injected with TH gel across the ring to prevent ectopic embolism caused by the rapid “downward flow” of TH gel. In addition, during TH gel injection, if coronary venous flow is blocked, the injection should be stopped in time to avoid portal vein embolism caused by reflux. In our group, only one case of minor pulmonary embolism occurred at the beginning of the study, but the injection was stopped in time after the intraoperative discovery of ectopic TH glue migration, and no significant adverse consequences occurred. 6.Technical advantages and postoperative regression of TH glue infusion embolization TH glue is an a-cyanoacrylate octyl ester containing contrast agent, which solidifies and forms thrombus within 6 seconds after encountering blood, and then mosaic with tissues to achieve the purpose of permanent occlusion of the official cavity. As early as 1983, Liu Xiaogong and other scholars in China proposed TH glue embolization of the gastric coronary vein under direct vision in the open abdomen, during which TH glue was injected into the lower esophagus and the venous plexus at the base of the stomach by a gastric coronary vein cannula. The TH gel was shown to be a permanent mucoadhesive agent, which is not easily recanalized after embolization, and its long-term efficacy is equivalent to that of traditional surgical dissection or bypass. However, the intravascular distribution of TH glue cannot be shown dynamically during surgery, and the possible ectopic traffic branches cannot be detected in time, and fatal pulmonary embolism may occur [10], which limits the clinical application. This technique is operated under X-ray surveillance, and TH gel is injected along the esophageal and gastric branches of the gastric coronary vein and flows towards the end, eventually filling the varices in the lower esophagus, cardia and fundus, solidifying the lumen and completely eliminating the anomalous blood flow forming the varices in the esophagogastric fundus. Compared with intraoperative TH glue embolization, the X-ray operation can accurately understand all the portal branches, including high or ectopic side branches, and avoid ectopic embolization caused by blind injection; it can observe the flow range of TH glue in the blood vessel in real time, and by adjusting the injection speed and dosage, it is possible to completely eliminate the ectopic flow of varices. By adjusting the injection speed and volume, the TH gel can be used to achieve a satisfactory embolization site. In conclusion, endoscopic sclerotherapy with sclerotherapy and ligation is a standardized treatment for esophagogastric varices because of its simplicity, recent hemostasis and accuracy. For patients who fail endoscopic treatment or recurrence, transjugular intrahepatic portal shunt and percutaneous transhepatic esophagogastric varices embolization are reasonable treatment options.