Short Term Sclerotherapy on BRTO Using Sodium Tetradecyl Sulfate (STS) Foam
in Patient with Gastrorenal and Gastrocaval Shunt
Authors: Young Hwan Kim
A 57-year-old male presented with gastric varix bleeding. BRTO was performed using STS foam. Sclerosing time was one and half hour. The postoperative course was uneventful. Gastric varix bleeding was successfully controlled after BRTO.
CT scan shows large gastric varices
Venography after balloon occlusion of gastrorenal shunt shows contrast agent flows into gastrocaval shunt. The gastric varices are not opacified.
Balloon occluded venogram after coil embolization of gastrocaval shunt reveals full opacification of gastric varices, afferent left gastric vein and posterior gastric vein. STS foam was made using a combination of agent with a 1:1:2 ratio of STS:Contrast(optiray):air. 40ml of sclerosant mixture was injected in gastric varices using microcatheter. The occlusion balloon remained inflated in place for one and half hour.
CT scan obtained 1 week after procedure to evaluate therapeutic efficacy shows complete thrombosis of gastric varices, which means clinical success.
CT scan obtained 3 months after procedure shows complete disapperance of gastric varices
- For treatment of gastric varices which are contiguous with both the gastrorenal and gastrocaval shunt, occlusion of both draining veins is essential to avoid reflux of the agent into systemic circulation, which might result in insufficient thrombosis of gastric varices or serious complication. Either coil embolization or double-balloon catheterization is required for occlusion of shunt. Embolization is preferable to balloon occlusion in case of small diameter shunt (<5mm) as in our case.
- STS has been widely used for sclerotherapy of superficial lower extremity varicosities. The STS foam provides the potential advantage of better contact with the variceal wall when compared with liquid agent. In-vivo study revealed formation of microthrombi within 30 minutes after STS foam injection. Short term sclerotherapy (1hr 30min) on BRTO using STS foam as an alternative sclerosing agent is safe and effective for treatment of large gastric varices with gastrorenal and gastrocaval shunt, furthermore more comfortable for patient and cost effective compared with long-term sclerotherapy.