Introduction

For more than 20 years, the placement of transjugular intrahepatic portosystemic shunts (TIPS) has been a widely accepted procedure for the treatment of portal hypertension. Resulting from a variety of conditions, the most common of which is liver cirrhosis, portal hypertension can lead to the formation of esophageal or gastric varices, which are often accompanied by a strong tendency to develop bleeding. In conditions of uncontrollable bleeding, procedures such as gastric banding or coil embolization can be used to suppress or alleviate symptoms.

The following cases describe coil embolization of gastric varices after TIPS, using the Interlock™– 35 Fibered IDC Occlusion System.

CASE 1

Overview

A 77-year-old man presented with a history of endstage liver disease, intractable ascites, and multiple episodes of esophageal variceal hemorrhage. He was referred to Interventional Radiology from the Gastroenterology department for a TIPS procedure. The patient had no history of encephalopathy and a bilirubin of 1.8.

Procedure Description

The TIPS procedure was performed using a Gore® Viatorr® TIPS Endoprosthesis with a 2-cm exposed segment and a 7-cm covered segment. After implantation, a wide, short gastric varix was noted exiting the splenic vein, coursing toward the fundus of the stomach and distal esophagus (Figure 1).

The varix was engaged with a 5-F, 0.038- inch, H1H-shaped catheter, and venography was performed. Venography demonstrated that the caliber of the varix varied between 9 mm and 12 mm.

After venography, which was performed at 4:09 PM, two Interlock™ – 35 Fibered IDC Coils were placed within the varix. Each of these coils was 10 mm in diameter and 40 cm in length, and the completion of coil deployment occurred at 4:22 PM, only 13 minutes after embolization began.

Placement of the coils resulted in total occlusion of flow toward the varices (Figure 2). Thirty days after the procedure, the patient had improvement in his ascites. No hepatic encephalopathy was noted, and stable hepatic and renal functions have been observed.

Case 2

Overview

A 44-year-old man presented with a history of end-stage liver disease and recurrent, life-threatening variceal hemorrhage. He was referred from two outside hospitals where a TIPS procedure was attempted unsuccessfully due to the presence of a small right portal vein.

Procedure Description

Under general anesthesia, an Accustick® Needle was used to engage the small right portal system, with percutaneous portography documenting a right portal vein of 6 mm in diameter. A percutaneous portal venogram allowed for the visualization of a target, facilitating conventional TIPS placement. Incidental note was made that multiple coils were present adjacent to the splenic vein, located in the hepatic artery secondary to previous splenic artery embolization for hypersplenism (Figure 3).

After placing a 9-mm Gore&ref; Viatorr&ref; TIPS Endoprosthesis, the venogram confirmed persistent hepatofugal flow through a large varix with a diameter of at least 20 mm. The varix was engaged with a 5-F, 0.038- inch, H1H-shaped catheter to a depth where the variceal diameter approached 15 mm (Figure 4).

Once proper catheter positioning was obtained, embolization of the varix with the Interlock™ – 35 Fibered IDC Occlusion System began. Over the course of the next 21 minutes, eleven (11) 15-mm X 40-cm sized coils were packed into the varix. Figure 5 depicts the midpoint of the embolization, as six coils can be seen tightly packed into the varix.

The eleventh coil was placed at 2:03 AM, and complete stasis was observed at 2:24 AM (Figure 6).

Thirty days after performing this TIPS procedure and variceal embolization, the patient had stable hepatic and renal function and no further esophageal bleeding.

Discussion

These cases presented demonstrate two different extremes of variceal embolization. Case 1 illustrated a moderate-sized varix that required only two coils, each 40 cm long. The coils used in the case were placed rapidly and effectively, resulting in a tight coil nest and complete embolization. Case 2 illustrated the embolization of a much larger varix that required 11 coils to attain complete stasis. Although case 2 required a greater number of coils, the total time needed for embolization was only 21 minutes. The placement of Interlock™ – 35 Coils was efficient and effective, which reduced procedure times and radiation exposure in these cases.

Andrew Marsala, MD, is Chief of Radiology at Willis Knighton Medical Center in Shreveport, Louisiana.