Transjugular intrahepatic portosystemic shunt versus balloon-occluded transvenous obliteration for the management of ectopic varices

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Conference Proceeding

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Background: Bleeding ectopic or non-gastroesophageal varices occur uncommonly in the setting of portal hypertension. Both transjugular intrahepatic portosystemic shunt (TIPS) and balloon-occluded antegrade or retrograde transvenous obliteration (BA-RTO) are potential treatment options. Our study is the first to assess and compare TIPS vs. BA-RTO for the management of ectopic varices. Methods: This is a retrospective cohort study at a tertiary liver center. All interventional radiology procedures performed for bleeding varices between 2006 and 2020 were identified. Only patients undergoing TIPS and BA-RTO for bleeding ectopic varices were included. Demographics, pre-procedural data and outcome data was collected and compared between BA-RTO and TIPS groups. Results: Eleven patients undergoing BARTO were compared to seven patients undergoing TIPS. In 6 of the BA-RTO patients, TIPS was deemed unfeasible. Mean age at procedure was 55.6 ± 10.0. 55.6% were men and 83.3% were white. There were 8 rectal varices, 7 peristomal, one duodenal, one cecal and one superior mesenteric. The mean MELD-Na prior to procedures was 20.8 ± 10.4 in the BA-RTO group vs. 19.0 ± 6.4 in the TIPS groups (p=0.69). In the BA-RTO vs. TIPS groups, respectively, the mean MELDNa at 30 days after procedure was 18.8 ± 9.9 vs 21.7 ± 5.5 (p=0.67) and at 90 days after procedure was 18.0 ± 4.2 vs 24.0 ± 7.5 (p=0.39). Rebleeding rates during admission were 9.1% for BA-RTO vs. 14.3% for TIPS (p=1.00). The mean length of stay for BA-RTO vs. TIPS was 10.6 ± 8.9 vs. 7.9 ± 8.1 days (p=0.41), mean paracenteses 90 days prior and after procedure were 1.9 ± 3.6 vs. 0.0 ± 0.0 (p=0.12) and 2.0 ± 3.9 vs. 0.0 ± 0.0 (p=0.082), in the BA-RTO vs TIPS groups, respectively. The rates of hepatic encephalopathy in the BA-RTO vs TIPS groups at 90 days before and after the procedure were 45.4% vs. 57.1% (p=1.00) and 28.6% vs 33.3% (p=1.00), respectively. The mortality rates were 27.3% vs 28.6% (p=1.00) in the BA-RTO vs TIPS groups. Conclusion: Our results demonstrate that both TIPS and BARTO are effective treatment modalities for bleeding ectopic varices, with comparable post-procedure outcomes. Patients undergoing BA-RTO had a higher MELD at procedure but lower MELD at 30 and 90 day post-procedure and less HE though no differences were significant. BA-RTO is an excellent option for bleeding ectopic varices, primarily rectal and peristomal, and especially in patients not candidates for TIPS.

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