Safety and efficacy of angiographic occlusion of duodenal varices as an alternative to TIPS: review of 32 cases

Backgroud/rationale of study. Analyze safety and efficacy of angiographic-occlusion-with-sclerotherapy/embolotherapy-without-transjugular-intrahepatic-portosystemic-shunt (TIPS) for duodenal varices. Although TIPS is considered the best intermediate-to-long term therapy after failed endoscopic therapy for bleeding varices, the options are not well-defined when TIPS is relatively contraindicated, with scant data on alternative therapies due to relative rarity of duodenal varices. Prior cases were identified by computerized literature search, supplemented by one illustrative case. Favorable clinical outcome after angiography defined as no rebleeding during follow-up, without major procedural complications. Results. Thirty-two cases of duodenal varices treated by angiographic-occlusion-with-sclerotherapy/embolotherapy-without-TIPS were analyzed. Patients averaged 59.5 +/- 12.2 years old (female = 59%). Patients presented with melena-16, hematemesis Et melena-5, large varices-5, growing varices-2, ruptured varices-1, and other-3. Twenty-nine patients had cirrhosis; etiologies included: alcoholism-11, hepatitis C-11, primary biliary cirrhosis-3, hepatitis B-2, Budd-Chiari-1, and idiopathic-1. Three patients did not have cirrhosis, including hepatic metastases from rectal cancer-1, Wilson's disease-1, and chronic liver dysfunction-1. Thirty-one patients underwent esophagogastroduodenoscopy before therapeutic angiography, including fifteen undergoing endoscopic variceal therapy. Therapeutic angiographic techniques included balloon-occluded-retrograde-transvenous-obliteration (BRTO) with sclerotherapy and/or embolization-21, DBOE (double-balloon-occluded-embolotherapy)-5, and other-6. Twenty-eight patients (87.5%; 95%-confidence interval: 69-100%) had favorable clinical outcomes after therapeutic angiography. Three patients were therapeutic failures: rebleeding at 0, 5, or 10 days after therapy. One major complication (Enterobacter sepsis) and one minor complication occurred. Conclusions. This work suggests that angiographic-occlusion-withsclerotherapy/embolotherapy-without-TIPS is relatively effective (similar to 90% hemostasis-rate), and relatively safe (3% major-complication-rate). This therapy may be a useful treatment option for duodenal varices when endoscopic therapy fails and TIPS is relatively contraindicated.