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BRTO的适应症

时间:2017-11-22 22:42来源:未知 作者:Mr.Editor 点击:
BRTO: indications and treatment Authors: K. Kobayashi, S. Hirota, S. Yamamoto, S. Achiwa, M. Yamazaki, H. Maeda Abstract Content 1. Introduction: B- RTO (balloon- occluded retrograde transvenous obliteration) has developed in Japan since 1
BRTO: indications and treatment
 
 
1. Introduction: B- RTO (balloon- occluded retrograde transvenous obliteration) has developed in Japan since 1996 as a transcatheter treatment for large gastric varices.
1996年后,在日本BRTO(逆行经静脉球囊阻塞栓塞术)作为经导管治疗胃静脉曲张已经成熟。
 
 A number of patients have been treated worldwide as well as in Japan, and beneficial therapeutic effect has been proven over the last 15 years.
在日本和世界各地,已经有许多病人接受了治疗,过去15年中已经证明了有益的治疗效果。
 
 We discuss the treatment rationale, therapeutic technique, indication and results of B- RTO.
我们讨论的治疗原理、治疗技术、B RTO指示和结果。
 
2. Indications

A. 主要适应症(main indications)

(1) Emergency cases of gastric varices with rupture and cases of gastric varices with a history of rupture or in danger of rupture that have a GR shunt.

胃静脉曲张破裂出血的紧急情况和胃静脉曲张破裂历史或胃肾分流有破裂的风险

(2) Cases with hepatic encephalopathy due to a GR shunt.

由于胃肾分流导致的肝性脑病的情况

B. 相对适应症 (Relative indications:)

(1) Hepatic encephalopathy due to portosystemic shunt- attributable to mesocaval shunt, etc.

由于门腔静脉分流,如肠系膜-腔静脉分流等导致肝性脑病

(2) Bleeding:venous shunt attributable to portal hypertension such as duodenal varices and mesenteric varices.

由于门静脉高压如十二指肠静脉曲张和肠系膜静脉曲张出血

C. 相对禁忌症(Relative contraindication: )

造影剂流很容易从分流进入门静脉

cases in which contrast agent flows easily from the shunt into the portal vein.

Hemodynamics of gastric varices and B- RTO:

The supply routes for gastroesophageal varices are the left gastric vein and short/ posterior gastric vein. The former is the major route for esophageal varices, and the latter is the major route for gastric varices. The blood that pours into the gastric varices on the posterior wall of the gastric fornix descends to flow from the inferior phrenic vein into the renal vein via the adrenal vein. This is called the gastro- renal shunt (GR shunt). In the ascending route, on the other hand, the blood joins the flow in the pericardial vein to pour into the inferior vena cava just above the left hepatic vein.

3. Procedure:

1) Sclerosing agents and haptoglobin 5% EOI (ethanolamine oleate with iodide contrast agent), which were mixed with the same dose of contrast media, are used as a major
sclerosant for gastric varices. Absolute ethanol is used concomitantly to occlude the small collateral veins or when the amount of EOI exceeding the maximum single dose is used for large varices. Haptoglobin (4,000 units; Mitsubishi Pharma Corporation) is intravenously injected both preoperatively and perioperatively to prevent renal failure due to hemolysis attributable to the red cell membrane destroyed by EOI. Recently, foam style of sotoradecol was reported for B- RTO in USA.

2) Occlusion of GV:

(1) A 6F occlusion balloon catheter with a balloon diameter of 20 mm and balloon length of 20 mm is frequently used through an 8F preshaped guiding sheath. A balloon diameter of 10 mm or over is required. A wedge catheter facilitates the procedure and requires less EOI (downgrading technique).

(2) Checking the development of collateral veins/ angiography under balloon occlusion of the GR shunt reveals many collateral veins. The inferior phrenic vein is the largest in number, and the pericardial vein is frequently dilated in the angiographic images. Sclerosant injected under these circumstances does not flow into the gastric varices but drains into the inferior vena cava and the azygos venous system from the collateral veins. Therefore, it is necessary to occlude the collateral veins carefully. We grade the collateral veins and occlude the collateral veins accordingly 1). Contrast X- ray examination of the shunt is performed under balloon occlusion to grade the development of collateral veins and the gastric varices. The grade 1 and 2 collateral veins rarely need occlusion, but grade 3 and higher veins require occlusion. For large collateral veins, coils were used. For grade 2 to 4, the downgrading technique is performed once, and if this is successful, less or no occlusion of the collateral veins is required.

(3) EOI injection can surely be performed without excessive venous occlusion if a microcatheter is superselectively inserted from inside the balloon catheter into the gastric varices to inject or fill EOI. We have set the maximum injection volume of EOI at 20 ml. The gastric varices are opacified by the imaging ability of EOI. After EOI injection, the catheter is placed for technique is performed once, and if this is successful, less or no occlusion of the collateral veins is required. (3) EOI injection can surely be performed without excessive venous occlusion if a microcatheter is superselectively inserted from inside the balloon catheter into the gastric varices to inject or fill EOI. We have set the maximum injection volume of EOI at 20 ml. The gastric varices are opacified by the imaging ability of EOI. After EOI injection, the catheter is placed for 5 hours or longer under balloon occlusion. After that, we confirmed obstruction of GR shunt injecting small amount of contrast media. Then the balloon is deflated and removed. 4. Results: The items summarized below were analyzed in 279 patients who underwent B- RTO for GV since 1992.(编辑:Mr.Editor)
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