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1123

Transhepatic Esophageal the Stainless

Anthony

H. Funaro1

Ernest J. Ring David B. Freiman Juan A. Oleaga Roy

L. Gordon

Obliteration Varices Using Steel Coil

of

Coronary veins in seven of eight patients with bleeding esophageal varices were successfully catheterized and embolized with Gelfoam followed by multiple steel coils. Bleeding immediately ceased in all seven, but recurred within 1 month in six. One had not rebled on 3 month follow-up. Therefore, steel coils do not prevent recurrent bleeding any more effectively than other embolic materials used for this purpose.

Transhepatic coronary

catheterization

vein

have

been

of the used

as

portal

an

vein

and

adjuvant

selective

in the

obliteration

management

of the

of patients

bleeding from esophageal vanices [1 ]. Various embolic and sclenosing have been used to obstruct flow in the coronary vein and esophageal These include modified autologous clot, Gelfoam, sclerosing agents, occlusion, and tissue adhesives [2, provide the most permanent occlusions, gational permanent

purposes. embolic

Subjects

and

3].

The tissue adhesives are but as yet are only available

We describe our experience material for coronary vein

using stainless embolization.

agents vanices. balloon

believed to for investi-

steel

coils

as a

Methods

Eight patients with endoscopically demonstrated esophageal variceal bleeding underwenttranshepatic catheterization ofthe portal vein and attempted obliteration of esophageal varices with stainless steel coils. Preliminary celiac and superior mesenteric arteriography was performed in each case to exclude an arterial source for the bleeding and demonstrate patency of the portal venous system. Percutaneous transhepatic portal vein catheterization Received revision

July

February

1 3, 1 979;

accepted

after

1 7, 1979.

was

then

described This work

was supported in part by U.S. Public Health Service grant NIH1RO1AM2O6O4 from the National Institute of Arthritis and Metabolic Disease. 1 All authors: Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St. , Philadelphia, PA 1 91 04. Address reprint nequests to E. J. Ring. AJR133:1123-1125, o361-8o3x/79/1336-1 © American Roentgen

December 1979 123 $00.00 Ray Society

portray

successfully by

the venous

1 A). Whenever

performed

Lunderquist more

et al.

anatomy than

and one

in [4].

seven Splenic

localize

major

blood

of

the

eight

and

coronary

all venous

supplies

supply

was

patients

using

venograms to the

the were

esophageal

demonstrated,

each

technique obtained varices

was

to (fig.

selectively

catheterized and embolized with Gelfoam particles to occlude the smaller intraesophageal veins. The initial sheath catheter was then replaced with the 7 French Teflon embolization catheter designed for use with the coils (Cook, Inc., Bloomington, Ind.). (Smaller coils are now available which can be introduced through a 5 French catheter.) Introduction of the embolization catheter was greatly helped by exchanging over a special

heavy

duty

transhepatic

wire

(Surgimed,

Inc.,

constructed of solid stainless steel with a welded flexible to exert sufficient force on the catheter to overcome

Summerville,

tip. It offers resistance

S.C.).

This

wire

is

the firmness required from the liver. The

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1124

FUNARO

ET

AL.

AJR:133,

December

1979

Fig. 1 -53 year old man with Laennec’s cirrhosis and bleeding esophageal vanices. A, Catheter placed transhepatically into portal vein. Hepatofugal flow into splenic vein and inferior mesenteric veins. Large coronary vein filling multiple esophageal vanices. B, Catheter selectively placed into coronary vein. C, After embolization with combination of Gelfoam followed by five stainless steel coils (arrow), flow in coronary vein ceased. Repeat portal venognam demonstrates total occlusion of cononary vein with no flow into esophageal vanices. Improved flow toward liven.

embolization catheter was then placed selectively into each of the major branches supplying the varices and multiple stainless steel coil emboli were introduced (fig. 1 B). Repeat splenic venograms in each patient after embolization showed no evidence of collateral reconstitution to the varices and no flow towards the esophagus (fig.

1 C). A final

coil

was

positioned

catheter was removed in order from the puncture site.

in the

liver

to seal the tract

parenchyma

and prevent

as the

bleeding

Results Successful catheterization achieved in seven of eight

of the coronary vein was patients. In one patient with an

excessively hand liver and massive ascites, a catheter could not be introduced into the portal venous system. Immediate cessation of bleeding occurred in all seven patients. However,

six of the

seven

patients

rebled

within

1 month.

Two

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AJR:133,

December

OBLITERATION

1979

OF

ESOPHAGEAL

1125

VARICES

of these patients died during second bleeding episodes and the other four underwent surgery for the recurrent bleeding. The seventh patient had no further bleeding with only a 3 month follow-up.

the feasibility of introducing stainless steel coils into the coronary vein for vaniceal obliteration, this technique seems to offer no more permanency than simpler embolic materials such as Gelfoam.

Discussion

REFERENCES

Of the vein, the tunately, use [5]. autologous to have

few

materials available for obliteration of the coronary tissue adhesives seem the most effective. Unforthese materials are not yet approved for general Gelfoam and other embolic materials (such as clot), while readily available, have been shown limited value since recanalization occurs within a

weeks

[6].

The

stainless

steel

coil

is a

permanent

occluding device that is readily available [7]. Its only potential disadvantage is the necessity of introducing a 7 French catheter through the liver. This limitation did not prevent successful catheter positioning in seven patients without complications. The procedure can now be performed more readily using the new smaller coils. Despite the initial cessation of flow in the vanices and immediate control of bleeding, recurrent hemorrhage developed in all but one of our patients. Although repeat portogmaphy was not performed in any of these cases, it seems likely that bleeding recurred after resorption of the Gelfoam and establishment of collateral circulation around the occlusive coils. Therefore, while our experience demonstrated

1 . Viamonte M Jr, Pereiras Transhepatic obliteration

A, Aussel E, LePage J, Hutson of esophageal varices: results

0: in

acute and nonacute bleeders. AJR 1 29 : 237-241 , 1977 2. Pereiras A, Viamonte M Jr, Aussel E, LePage J, White P, Hutson 0: New techniques for interruption of esophageal varices. Radiology 124:313-323, 1977 3. Lunderquist A, Verlang J: Transhepatic catheterization and obliteration of the coronary vein in patients with portal hypertension and bleeding esophageal varices. N EngI J Med 291: 646-649,

4.

1974

Lunderquist

A, Borjesson B, Owman T, Bengmark 5: lsobutyl(Bucrylate) in obliteration of gastric coronary vein and esophageal varices. AJR 1 30 : 1 -6, 1978 5. Lunderquist A, Simert G, Tylen U, Vang J: Followup of patients 2-cyanoacrylate

with portal hypertension percutaneous obliteration 59-63, 1977 6. Viamonte M Jr, LePage

E, Viamonte

M, Camacho

and esophageal of the portal J, Lunderquist

M: Selective

varices vein.

treated

Radiology

A, Pereiras

catheterization

with 122:

A, Russel

of the

portal vein and its tributaries. Radiology 1 1 4 : 457-460, 1975 7. Gianturco C, Anderson JH, Wallace 5: Mechanical devices for arterial occlusion. AJR 1 24 : 428-435, 1975