CLINICAL HISTORY: Reason: Pt with cirrhosis and bleeding gastric
varix. Plan for CARTO
COMPARISON: Correlation of prior imaging studies including most
recent CT study
PROCEDURE:
1. Ultrasound-guided access to right common femoral vein.
2. Selective catheterization of left renal vein and venogram.
3. Selective catheterization of left adrenal phrenic trunk and venogram.
4. Superselective catheterization gastrorenal shunt and venogram.
5. Fluoroscopic guided embolization of gastrorenal shunt with detachable microcoils and Gelfoam slurry.
Operator: Dr. ______, interventional radiology attending.
Anesthesia: Local anesthesia with 1% lidocaine solution.
Analgesia: 50 mcg of fentanyl IV.
Fluoroscopic time: 25.9 minutes.
Contrast: 80 mL Omnipaque 300.
Complication: No intraprocedural complication.
Procedure in detail:
After the risks, benefits, and alternatives of procedure explained to the patient, written informed consent was obtained. A procedure timeout was performed as per department protocol. Patient was placed supine on the procedure table and the right groin was prepped and draped in usual sterile fashion.
Real-time physiologic monitoring was provided by qualified radiology nurse for approximately 20 minutes. 1% lidocaine solution was administered subcutaneously. Fentanyl was measured intravenously for analgesia.
With real-time ultrasound guidance access to the right common femoral vein was obtained after multiple exchanges a 9 French Nagare steerable sheath was advanced to the IVC under fluoroscopic guidance advanced into the left renal vein. Left renal venogram demonstrates
normal flow as well as a mildly prominent gastrorenal shunt.
Based upon the above findings a 4 French Navicross catheter and 035 Glidewire were used to selectively catheterize a gastrorenal shunt. This was exchanged for a balloon occlusion catheter and a retrograde venogram was performed outlining the venous anatomy including a
parallel ingress vessel adjacent to the each egress vessel communicating with the portal vein.
Based upon the above findings a 4 French Navicross catheter was advanced further into the shunt near the gastric cardia and the second Navicross catheter was advanced approximately 4cm proximal to the first metacarpal as catheter. Both catheters were confirmed to be
in satisfactory position with selective venograms.
The proximal catheter was utilized to embolize the gastrorenal shunt using a CX Azur coils including 13 mm x 24 cm, 10 mm x 19 cm, and 8 mm x 24 cm. This is followed by Azur Hydrocoil measuring 4 mm x 10 cm.
Subsequently Gelfoam slurry mix of contrast was injected through the more distal catheter into the gastric varices fluoroscopic guidance. Once stasis was obtained and there was good coverage throughout the gastric varices, both catheters were removed under fluoroscopic
guidance. The sheath was also subsequently removed under fluoroscopic guidance.
Hemostasis was achieved with manual compression. Sterile dressing was applied.
Patient was transferred to recovery in stable condition.
Impression:
Fluoroscopically guided retrograde transvenous obliteration of gastric varices using CARTO technique as described above.
PLAN: Patient to follow-up with abdominal CT to verify durable thrombosis of gastric varices. This will be followed with endoscopic surveillance.