Percutaneous percutaneous hepatic gastroesophageal vein embolization is performed by puncturing a branch of the intrahepatic portal vein and delivering a catheter to the varices of the gastroesophagus for embolization. We use PTVE combined with partial splenic embolization (PSE) to treat portal hypertensive gastroesophageal variceal hemorrhage with miraculous results.
I. Indications.
(1) Patients with cirrhosis combined with ruptured esophagogastric variceal bleeding who are unwilling to undergo surgery, especially those who have recurred after repeated gastroscopic ligation and rebleeding.
(2) Patients with cirrhosis combined with ruptured esophagogastric varices and bleeding without surgical evaluation, such as liver function Child grade C, large amount of ascites.
(3) Patients who have undergone surgical splenectomy and flow dissection and have recurrent ruptured esophagogastric variceal bleeding.
II. Contraindications.
(1) Absolute contraindication: patients with severe coagulation disorders
(2) Relative contraindications: Patients with unstable vital signs
III. Methods.
1. PTVE procedure: preoperative intramuscular injection of lumefantrine and dexamethasone. The patient is placed in supine position, and the appropriate position in the right axillary midline is taken as the entry point under fluoroscopy. After local disinfection, the portal vein is successfully punctured with a kilobar needle after local anesthesia, and a guidewire is inserted.
The 5F Pigtail catheter was inserted through the catheter sheath, and the catheter tip was placed in the splenic vein near the splenic hilum and the main trunk of the superior mesenteric vein respectively. The 5F RH catheter is then hyper-selected to the coronary vein of the stomach.
After “smoking”, the gastric ductus venosus is embolized with TH gel, and then the image is reviewed. The varicose short gastric vein is treated in this way. After the PSE is completed, the 5F Pigtail catheter is used again for pressure measurement and portal venography review. The catheter and sheath are withdrawn and the puncture site is compressed for ten minutes and fixed with gauze coverage.
2, PSE procedure: percutaneous puncture of the femoral artery by the Seldinger method, feeding the 5F Cobra or RH catheter to superselect the splenic artery, observing the distribution of the splenic artery and the position of the catheter tip so that it is as deep as possible below the splenic artery to the lower branches of the spleen, injecting a thin strip of autoclaved gelatin sponge and saline containing antibiotics, stopping the embolization when the blood flow in the splenic artery slows down significantly, and imaging Review. The embolization should be limited to 50%-60% of the splenic volume. Postoperative extubation, groin pressure bandage.
IV. Postoperative management.
The lower extremity on the puncture side should be kept straight and braked for 12 hours, and the vital signs such as heart rate, respiration, blood pressure and abdominal condition should be monitored for 24 h. Intravenous rehydration should be applied, and hemostasis, anti-inflammatory, hepatoprotective and symptomatic treatment should be given. The follow-up was every 3 to 6 months, and the routine blood count and fecal occult blood were repeated every 3 months after the procedure.
Gastric coronary vein embolization combined with partial splenic artery embolization for portal hypertension Q&A
How does percutaneous transhepatic puncture with TH gel localization embolization treat ruptured varicose vein bleeding?
This technique uses a percutaneous transhepatic portal vein puncture cannula, and after portal venography, the catheter is superselected to the gastric coronary vein and injected with TH gel under X-ray surveillance to reach the varices in the lower esophagus, fundus and cardia, and to occlude the main trunk of the gastric coronary vein at the same time. The purpose of embolization of the lumen.
As the varicose vein, its blood supply vessels and its traffic branches are completely and comprehensively perfused and embolized, ruptured varicose vein bleeding is controlled and prevented. The method also involves partial embolization of the splenic artery to treat hypersplenism and to reduce portal venous blood flow, lower portal venous pressure, and prevent neovascularization to further enhance and maintain the hemostatic effect.
Why does the TH glue localization embolization technique achieve definite long-term results?
The fundus region within 3-5 cm of the lower esophagus and 5 cm below the cardia is a vulnerable site for variceal rupture and bleeding. Our TH gel localization embolization technique is designed to target the varices in this area by injecting TH gel into the varices in the lower esophagus and fundus, and simultaneously occluding the main trunk of the gastric coronary vein and the possible short or posterior gastric veins.
The TH gel is a permanent embolic agent that gradually solidifies the lumen after embolization, thus preventing variceal recurrence and rebleeding. In contrast, the embolic materials used in conventional gastric coronary embolization (anhydrous ethanol, gelatin sponge, hypertonic sugar, or spiral steel rings) do not allow complete and permanent embolization of the source vessel of the varicose vein and its branches, allowing short-term recanalization of the target vessel.
Is percutaneous transhepatic TH gel localization embolization + partial splenic embolization very invasive?
This is a minimally invasive interventional technique that requires only local anesthesia at the puncture site, and the largest puncture sheath used is only 5F, with a skin incision of only about 2 mm. Permanent embolization of the varicose vein TH glue and partial splenic embolization similar to surgical splenectomy + flow dissection can be accomplished through 2 puncture sites in the right axillary midline intercostal and right inguinal regions. This technique is minimally invasive and tolerated by patients in Child C class.
Does TH gel embolization of varices in the esophagogastric fundus aggravate portal hypertension?
Intraoperative direct portal venous manometry studies have shown that portal venous pressure increases by approximately 10% after TH glue esophagogastric fundic variceal embolization alone, but after combined splenic artery embolization (dual interventional embolization), portal venous pressure decreases by 15-30% compared to preoperative levels. After dual interventional embolization, the absolute value of free portal pressure can mostly be reduced to about 30 cm water column. Therefore, after treatment, the portal pressure not only does not increase, but also can be significantly reduced. Some splenic embolization is performed with gelatin sponge particles, and the range of splenic embolism is generally controlled at 50-80%, and the treatment mechanism is similar to the current surgical splenectomy with flow dissection.
How to improve the long-term outcome of TH gelatin esophagogastric fundic variceal embolization?
(1) Do not perform embolization of the main trunk of the gastric coronary vein only, but inject TH glue into the lower esophageal varices within 5 cm above the cardia and the fundic varices within 5 cm below the cardia as much as possible during surgery. This area is not only the common access of varices, but also the site of rupture and bleeding, only permanent embolization of this area can ensure the long-term efficacy
(2) Simultaneous embolization of the possible short and posterior gastric veins.
(3) Splenic embolization should be more than 50% in order to minimize portal blood flow, reduce portal vein pressure and avoid neovascularization. We control the splenic embolus at 50-80%, and the portal vein pressure can be decreased by 20-30%. With proper postoperative measures of hepatoprotection, anti-infection, anticoagulation, hormonal and supportive therapy, significant complications rarely occur.
What are the common postoperative complications and how to deal with them?
Epigastric discomfort may occur after esophagogastric fundic variceal embolization and last for about 1 week, which can be relieved by antacid drip. After splenic embolization, left upper abdominal pain and fever may occur, and some patients may develop post-embolization syndrome such as chest and ascites. Postoperative dexamethasone drip and 2-3 antibiotics for 1-2 weeks In a few cases, abdominal pain may last up to 4 weeks, and a small amount of prednisone and antibiotics may be taken. Mixing gelatin sponge granules with antibiotics when performing partial splenic artery embolization can reduce postoperative complications.