New Data Supports Use of Vascular Plug-Assisted Retrograde Transvenous Obliteration (PARTO) for the Treatment of Gastric Varices and Hepatic Encephalopathy

A new prospective, multicenter study from investigators in Korea supports the use of PARTO in the treatment of GVs and HE. 73 consecutive patients were included from two institutions. 57 of the 73 patients had GVs with 28 in danger of rupture, 23 with recent bleeding, and 6 with active bleeding. 16 of the 73 were done for HE recalcitrant to medical therapy. The study reported a 100% technical success rate with no procedure-related complications. A 1 week follow-up CT was obtained and showed complete thrombosis in 72 of 73 patients (98.6%). 60 patients had follow-up to at least 3 months and all 60 showed complete obliteration. Of this group of 60 patients, there was no development of rebleeding or HE at end of follow-up. The authors concluded that PARTO can be “rapidly performed with high technical success and durable clinical efficacy for the treatment of GVs and HE in the presence of a portosystemic shunt.”

Comment:

This is the first, prospective multicenter trial evaluating PARTO in the treatment of GVs and HE in patients with a portosystemic shunt. Previous work by Gwon et al. discussed the use of PARTO in a limited number of patients and in a retrospective fashion. While BRTO has been considered a first-line treatment in the appropriate patients, the present manuscript makes a strong argument to consider PARTO in more patients. Clear advantages include logistical issues related to prolonged balloon inflation as well as the relative safety of PARTO when compared with BRTO. However, there are anatomical and clinical considerations that should be made. There are instances when it is not anatomically feasible to get an appropriately sized sheath into the shunt deep enough to deploy the Amplatzer. Further, while the data of the present study indicate that the nidus of the varix was appropriately embolized, it would seem intuitive that the foam sclerosant of BRTO would more effectively and efficiently treat the varix when compared with a gelfoam slurry given its ability to travel into smaller vessels in a more effective manner. Lastly, the patient population presented in the current manuscript is likely different than the population treated in North America and Europe and this will likely impact results as well. Regardless, the results are compelling and warrant careful consideration and further research.




Images from a 55-year-old man with GVs. (a) Contrast-enhanced CT obtained before PARTO shows GVs (asterisk). Note the hypertrophied left gastric vein (arrowhead). (b) After placement of the vascular plug (white arrow) within the narrowest portion of the portosystemic shunt via the left adrenal vein, additional embolization of the gastrorenal shunt, GVs (asterisk), and left gastric vein (arrowhead) was performed by using gelatin sponge particles through the 4-F catheter (black arrow). (c) Contrast-enhanced CT scan obtained 3 months after PARTO shows complete obliteration of the GVs.

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Gwon, et al. Vascular Plug–Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Varices and Hepatic Encephalopathy: A Prospective Multicenter Study. Journal of Vascular and Interventional Radiology 2015. DOI: 10.1016/j.jvir.2015.07.011

Post Author:
Luke R. Wilkins, MD