1. Memorial Sloan Kettering Cancer Center
Balloon-occluded Antegrade Transvenous Obliteration for Treatment of Stomal Varices
Peter Schaefer
F. Edward Boas, MD PhD
Memorial Sloan Kettering Cancer Center
New York, NY

2. Patient Presentation
56-year-old woman with stage IV colorectal carcinoma s/p abdominoperineal resection and partial hepatectomy presents with daily focal bleeding from stomal varices, necessitating transfusion
Referred for management of recurrent variceal bleeding, refractory to medical therapy

3. Patient Pre-intervention Imaging
Figure 1. Axial slice of contrast-enhanced CT showing stomal varices (white arrows). These varices were supplied by a branch of the splenic vein and drained into the right common femoral vein via a superficial subcutaneous vein of the abdominal wall inferior to the stoma.

4. About Stomal Varices Presentation Causes Supply Venous drainage
Stomal varices occur in 50% of patients with concurrent portal hypertension, 27% present with bleeding, mortality rate of 3-4%
Focal bleeding responsive to manual compression
Diffuse oozing generally unresponsive to manual compression
Causes
Portal hypertension
Post-surgical changes (constrictive effect)
Mesenteric/portal venous thrombosis (least common)
Supply
Branches of portal venous system, often via superior mesenteric vein
Venous drainage
Systemic draining veins in subcutaneous abdominal wall, typically empty into iliofemoral veins

5. About Stomal Varices Management
Currently no data-driven clinical consensus on treatment for persistent bleeding, however strategies commonly used in treating gastric varices have been utilized with success
While portal hypertension is the most frequent cause, stomal varices may bleed when transsinusoidal pressure is <12 mm Hg

6. What are potential strategies for intervention?
Direct obliteration of varices
Percutaneous or endovascular approach for accessing varices, followed by direct treatment (embolization/sclerosis)
Typical approach employed in the East (Japan and South Korea)
Decrease portal venous pressure
Alleviating portal hypertension and thereby decreasing the potential for bleeding from existing varices or formation of new varices
Typical approach employed in the West (US and Europe)

7. What potential techniques could be employed?
Direct obliteration of varices
Transvenous obliteration alone
Balloon-occluded retrograde transvenous obliteration (BRTO) - approach via systemic venous system
Balloon-occluded antegrade transvenous obliteration (BATO) - approach percutaneous/transhepatic or trans-TIPS
Direct percutaneous embolization/sclerosis
Decrease portal venous pressure
Transjugular intrahepatic portosystemic shunt (TIPS) +/- obliteration

8. What are some benefits and drawbacks for each technique?
Direct obliteration of varices
Benefits: (1) direct therapy of problem area, (2) less invasive, (3) preservation of liver function
Drawbacks: (1) failure to alleviate etiology (portal HTN), if it exists, (2) post-procedure increase in portal venous pressure may result in ascites or development of new varices, (3) stomal damage
Decrease portal venous pressure
Benefits: (1) alleviate etiology (portal HTN), (2) concurrently treat varices in several locations (if present), (3) decrease likelihood for formation of new varices, (4) alleviate ascites
Drawbacks: (1) potential for worsening encephalopathy, (2) high risk in patients with poor hepatic reserve

9. Suggested Pre-intervention Evaluation
History
History of ascites, encephalopathy, HCC, right heart failure, pulmonary HTN, prognosis of illness/co-morbidities
Imaging
Endoscopy
Cross-sectional: triple phase contrast-enhanced CT or MR to evaluate venous supply/drainage of known varix/ces, as well as the presence of additional varices, in addition to possible portal/mesenteric/splenic vein thrombosis
Labs
CBC, CMP, Coags
Liver function panel and MELD/Child-Pugh scoring to gauge hepatic reserve, if considering TIPS

10. Management Decision BRTO/BATO TIPS
BRTO requires systemic draining veins of large enough caliber for sufficient access
Felt to be appropriate intervention in our patient given isolated varices, patient preference, and preservation of liver function in the setting of liver metastasis and hepatic arterial infusion pump
TIPS
Recurrent variceal bleeding refractory to medical/endoscopic management is one indication
TIPS is also a possible treatment option for our patient

11. Management Decision Data in TIPS vs. BRTO
Limited data given low incidence of stomal varices
Anecdotal evidence of focal bleeding better treated via direct obliteration versus diffuse oozing better treated via TIPS
Head-to-head data in treatment of gastric varices suggests equal to more favorable outcomes in BRTO vs. TIPS
Largest study of BRTO vs. TIPS in treatment of gastric varices in patients with portal HTN showed:
1-year rebleeding rate of 2% (BRTO) vs. 20% (TIPS) – p<0.018
Improved 1, 3, and 5-year-survival in BRTO vs. TIPS (only in Child-Pugh class A) - p=0.018

12. Case Intervention
BRTO was attempted via the subcutaneous vein that drained into the femoral vein. However, the stomal varices could not be safely sclerosed from this approach, due to filling of numerous systemic draining veins.
As such, BATO was pursued as therapeutic alternative. A B
Figure 3. (A) Early phase angiography of splenic vein branch supplying stomal varices. (B) Late phase showing superficial systemic draining veins.
Figure 2. Portal venogram following percutaneous/transhepatic access of portal venous branch.

13. Case Intervention
Figure 5. Coils were placed through the occlusion balloon before deflating the balloon. Completion venogram shows no filling of varices.
Figure 4. Sclerosis performed by injecting STS foam (1 mL lipiodol, 2 mL 1% STS, and 3 mL air) through a 6F occlusion balloon, with external compression of superficial systemic draining veins for 15 min. Hepatic arterial infusion pump present in image.

14. Follow-up
The patient experienced decreased bleeding with no further need for transfusions post-procedure
1 month post-procedure CT scan shows retention of dense lipiodol and sclerosant in the stomal varices

15. Question #1
What is a possible intervention for treating bleeding stomal varices?
A) BATO
B) BRTO
C) TIPS
D) Direct Percutaneous Embolization
E) All of the above

16. Question #1
What is a possible intervention for treating bleeding stomal varices?
A) BATO
B) BRTO
C) TIPS
D) Direct Percutaneous Embolization
E) All of the above

17. Question #2
Which of the following is an absolute contraindication to performing TIPS?
A) Portal vein thrombosis
B) Thrombocytopenia (Plts<20K)
C) Congestive heart failure
D) Central hepatoma

18. Question #2
Which of the following is an absolute contraindication to performing TIPS?
A) Portal vein thrombosis
B) Thrombocytopenia (Plts<20K)
C) Congestive heart failure
D) Central hepatoma

19. References
Mauro MA, et. al. Image-Guided Interventions, Kiyosue H, Mori H. Chapter 113: Retrograde Balloon Occlusion Variceal Ablation, p
Saad WE, Saad NE, Koizumi J. Stomal varices: management with decompression tips and transvenous obliteration or sclerosis. Techniques in vascular and interventional radiology. 2013;16(2):
Thouveny F, Aube C, Konate A, Lebigot J, Bouvier A, Oberti F. Direct percutaneous approach for endoluminal glue embolization of stomal varices. JVIR. 2008;19(5):774-7.
Saad WEA, Darcy MD, Transjugular Intrahepatic Portosystemic Shunt (TIPS) versus Balloon-occluded Retrograde Transvenous Obliteration (BRTO) for the Management of Gastric Varices. Semin Intervent Radiol 2011;28:339–349
Kirby JM, Cho KJ, Midia M. Image-guided intervention in management of complications of portal hypertension: more than TIPS for success. Radiographics. 2013;33(5):
Spier BJ, Fayyad AA, Lucey MR, Johnson EA, Wojtowycz M, Rikkers L, et al. Bleeding stomal varices: case series and systematic review of the literature. Clinical Gastroenterology and Hepatology. 2008;6(3):
Kitamoto M, Imamura M, Kamada K, Aikata H, Kawakami Y, Matsumoto A, et al. Balloon-occluded retrograde transvenous obliteration of gastric fundal varices with hemorrhage. AJR 2002;178(5):
Ninoi T, Nakamura K, Kaminou T, Nishida N, Sakai Y, Kitayama T, et al. TIPS versus transcatheter sclerotherapy for gastric varices. AJR. 2004;183(2):369-76