AASLD Practice Guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage

Abstract

PURPOSE AND SCOPE OF THE GUIDANCE This is a comprehensive guidance on the use of interventional radiology endovascular techniques in the management of variceal hemorrhage from the American Association for the Study of Liver Diseases (AASLD). This guidance document is complementary to the AASLD “Risk Stratification and Management of Portal Hypertension and Varices in Cirrhosis” guidance1 and addresses the recent advancements in these invasive procedures. Although the use of TIPS dates back to the 1980s, several new technical refinements in TIPS stents have occurred in the last few years. The other major addition to the management of gastric variceal hemorrhage in North America has been the introduction of retrograde transvenous obliteration (RTO) in its different forms. The present document aims to equip care providers with an in-depth understanding of the use of TIPS and/or variceal embolization/obliteration in the management of variceal hemorrhage. The goal is to facilitate multidisciplinary discussions between hepatologists, gastroenterologists, interventional radiologists, and surgeons in the selection of endovascular treatments for patients with variceal hemorrhage. This document reviews first the anatomy of portosystemic collaterals, which is essential to understand the rationale for the use of these endovascular procedures. A second section describes the technical details of TIPS, RTO, and anterograde transvenous obliteration (ATO). The final section deals with the clinical use of endovascular treatments in the management of hemorrhage from esophageal, gastrofundal, and ectopic varices. Therefore, this AASLD Guidance provides a data-supported approach to the use of endovascular therapies for the management of variceal hemorrhage. It differs from the AASLD Guidelines, which are supported by systematic reviews of the literature, formal rating of the quality of the evidence, and strength of the recommendations. In contrast, this Guidance was developed by consensus of an expert panel and provides guidance statements based on comprehensive review and analysis of the literature on the topics, with oversight provided by the AASLD Practice Guidelines Committee. The AASLD Practice Guidelines Committee chose to perform a Guidance on this topic because, in most instances, a sufficient number of randomized controlled trials (RCTs) were not available to support meaningful systematic reviews and meta-analyses on this topic. ANATOMY OF PORTOSYSTEMIC COLLATERALS IN PORTAL HYPERTENSION Portosystemic collaterals develop between the portal and the systemic circulation as a consequence of portal hypertension. They represent an unsuccessful attempt by the body to decompress the portal circulation through the systemic circulation. Collaterals in the gastrointestinal lumen are referred to as varices. Varices develop commonly at the distal esophagus and proximal stomach i.e., the gastroesophageal region. Varices outside the gastroesophageal area such as the rectum, duodenum, and surgically created sites (e.g., stomal) are uncommon (≤5% of all variceal bleeding) and are referred to as ectopic varices.2–4Table 1 shows the location, supply, and drainage of common varices. TABLE 1 - Location, supply, and drainage of gastrointestinal varices (see also Fig. 1) Location Supply (afferent) Drainage (efferent) Gastroesophageal varices Esophageal varices Mid- and distal esophagus Left gastric vein Through azygos and hemiazygos vein into SVC Gastroesophageal varices (GOV): contiguous with esophageal varices GOV1 Lesser curvature of stomach Left gastric vein Through azygos and hemiazygos veins into SVC GOV2 Greater curvature of stomach/fundus Left gastric vein and posterior gastric vein Through azygos vein and hemiazygos veins into SVC and inferior phrenic vein into left renal vein (GRS) or IVC (gastrocaval shunt) Isolated gastric varices (IGV) IGV1 Fundus Short gastric veins, posterior gastric vein Through inferior phrenic vein into left renal vein (GRS) or into IVC (gastrocaval shunt) IGV2 Any location in stomach other than the fundus Short gastric veins, posterior gastric vein Left and right gastric vein Ectopic varices Rectal varices Rectum Superior rectal vein Through middle and inferior rectal vein into internal iliac vein Duodenal varices Duodenum Superior or inferior pancreaticoduodenal veins5,6 Through gonadal or renal capsular vein into IVC Stomal varices Surgically created ostomies Mesenteric branches from the superior mesenteric vein7 Through systemic venous collaterals in abdominal wall into iliofemoral vein Abbreviations: GRS, Gastrorenal shunt; SVC, superior vena cava. Esophageal varices are located in the mucosa and submucosa of the mid- and distal esophagus. They are supplied by the left gastric vein and drain into the azygos and hemiazygos veins through periesophageal veins (gastroesophageal venous system) (Fig. 1). Esophageal varices are most likely to bleed at the gastroesophageal junction because they are more superficial in this location and are unable to decompress through the azygos vein because of lack of communication with the periesophageal veins. Based on subjective endoscopic appearance, esophageal varices can be classified into (1) small: straight varices that collapse on insufflation, (2) medium: enlarged, tortuous varices that occupy less than one third of the lumen, or (3) large: coil-shaped varices that occupy more than one third of the lumen.8 In practice, medium and large varices are as varices because they to variceal to superficial location, esophageal varices are to endoscopic variceal i.e., of for variceal or Supply and drainage of varices. Esophageal varices and GOV1 are supplied by the left gastric vein and drain through the vein into the superior vena varices are supplied by the in the posterior gastric vein and/or gastric vein varices can drain into the left renal vein through a Rectal varices are supplied by the superior rectal vein and drain into the middle rectal vein and inferior rectal veins Duodenal varices are supplied by the superior or inferior pancreaticoduodenal veins and drain into the IVC through the gonadal or the renal capsular varices can be based on endoscopic location as (1) gastroesophageal varices 1 (2) gastroesophageal varices (3) gastric varices gastric fundus and gastric varices location in the stomach other than the gastric fundus varices are supplied by the left gastric vein or gastric veins, and posterior gastric vein (Fig. 1). esophageal GOV1 and GOV2 drain into the gastroesophageal venous (Fig. 1). GOV2 and also as drain through the venous which is through the inferior phrenic vein into the left renal vein or the IVC (gastrocaval shunt) (Fig. 1). can be in patients with portal and/or vein The large an for transvenous varices to be and not be to an interventional radiology several of gastric varices have been based on for interventional radiology such as the of varices and of the anatomy of the and drainage and the of the of the are most in the of TABLE - of gastric varices of location Gastroesophageal varices curvature Gastroesophageal varices curvature Isolated gastric varices fundus Isolated gastric varices in the stomach other than fundus of varices and and of Supply through left gastric vein Drainage through portosystemic collaterals Drainage through Supply through gastric veins Drainage through portosystemic collaterals Drainage through Supply (afferent) through left gastric and gastric veins Drainage through portosystemic collaterals Drainage through with with of (afferent) and (efferent) veins Supply gastric vein gastric veins or gastric veins with gastric veins that are contiguous with a not to the varices Drainage and veins and A which be of veins, gastric varices are veins, in gastric varices for medium to large veins, of gastric in gastric varices veins, gastric varices are not with left vein be with of the veins with of communication between gastric veins and can in or portal from a vein or to an such as in in which represent portosystemic collaterals, in portal are collaterals that are supplied by the and posterior gastric veins drain back into the portal vein through the left and right gastric veins. It is to portal from systemic portal because the and management of the Rectal varices at the junction of the superior rectal vein with middle and inferior rectal veins and from because they not to the from rectal varices and other ectopic varices is and management be on a based on TIPS TIPS is a in which a created portosystemic is to the of portal such as variceal and its in the the TIPS has in and (e.g., of TIPS A TIPS is an endovascular guidance the portal with the systemic circulation and to the portal venous Portal is to the systemic in an of in right and and in to systemic and also several and TIPS through renal TIPS TIPS is by interventional and It is created a venous approach or A vein is from that the portal vein is a the portal vein is portal and are by and of the an is to the from portal vein to the vein (Fig. A can be created between the IVC and portal vein as the portosystemic is the veins are or as can with stents are in TIPS because of of and with the use of which has also been to with and The the vein to its into the IVC to The of the the and the the of the is located in the portal to have an of the portal vein and veins. In be an be to for the and of and and hypertension. AASLD guidance provides for of The goal of portosystemic is to the between in renal and the of and the to is that an TIPS be sufficient to variceal and the of the of with In the use of the to a with of the the use of the has been to be superior to in the of from esophageal from available which a a more TIPS a of to be created with a between and and The to the in between the portal vein and the TIPS portal are and to the portosystemic by recent consensus be by the IVC from portal to with clinical the IVC be because of technical the right is in of IVC this to an of the because is than IVC portal and systemic or which are in not the is of because are with of such as and are with of the with in an approach by and In patients with esophageal variceal the is or a from the for the management of gastric variceal is not The for of gastroesophageal variceal is In a recent patients with a TIPS a of of portal at as with in with a A at was with in the of of portal and/or In patients not a of the to a of the addition of be because they portal by an of or are not a to TIPS, the of and technical techniques such as and have in venous and The of TIPS in is with TIPS and portal vein the of major is TIPS and in the of are by the of portal vein and superior mesenteric vein and the of Portal vein and TIPS also a for by to the portal for and of esophageal, or ectopic varices be TIPS (see also the section on on The for varices or variceal In of portosystemic or be to in patients with of varices in patients with TIPS for the of have been Ectopic and varices of because portosystemic through the be at for esophageal statements TIPS stents be of the for TIPS is variceal hemorrhage of hemorrhage or of TIPS be at of to the to a In patients not of TIPS be to portal not of a to be In patients with large portal systemic collaterals, at the of TIPS be because the of for TIPS or or a of and systemic or and are a TIPS be in patients with or portal vein and TIPS has been in these Although for is with can be to trials the use of TIPS for variceal patients with a have been also from and TIPS in patients has been A recent of TIPS in patients TABLE - of endovascular therapies in the management of variceal hemorrhage obliteration techniques TIPS created portosystemic portal vein with can be with of a and retrograde of with gastric variceal to for The is with a and is to the gastric varices. The is with and is to the gastric varices. or of veins esophageal, gastric or ectopic varices can be with TIPS or in patients with and for to with this not be in patients with than available not be in patients with than available not be in such as a tortuous from IVC to renal vein to not be in patients with than available not be to veins in from invasive than because through the or or through TIPS in in in in portosystemic of through portosystemic collaterals to the with in and in with the of new of portal or esophageal variceal of use hemorrhage because of esophageal and varices or ectopic TIPS variceal hemorrhage with a retrograde of hemorrhage of of ectopic varices with anatomy and shunt) hemorrhage because of Esophageal varices or with and/or portal vein sufficient for esophageal variceal hemorrhage or are not a and with and/or portal vein to these or to to systemic and/or portal vein to to systemic and/or portal circulation vein or into renal vein and to to systemic and/or portal circulation vein to an in portal systemic or to to the in or esophageal or ectopic or and/or or to of gastric and esophageal varices in and endoscopic to guidance Abbreviations: endoscopic gastroesophageal varices GRS, shunt; portal vein It is to that are different TIPS is a last (e.g., variceal treatments (e.g., of variceal hemorrhage or for TIPS in the of variceal hemorrhage are in this TIPS are in capsular TIPS and in The most are to in and to The of at one of between and and that of is for are and a TIPS stents are with are with of with that of TIPS stents variceal and TIPS In can be with and in the of In a recent TIPS the of In of the patients in the TIPS was to and the of was in of the This the of these to patients with a for TIPS and with of other than is to endovascular techniques can be to TIPS the TIPS is than the be with or with endoscopic of varices as Portosystemic to a in the of this is to in the of the of the TIPS a in and a for A recent a of of of the patients a to was 1 which the of In a TIPS was with a new of in of the TIPS TIPS as the of portal venous in can be to TIPS or TIPS with of portal variceal or The of TIPS and is more likely with the most common of of and portal the the for to the vein The of stents are at 1 and at In patients TIPS for or of variceal a with of the TIPS is to TIPS This to a because TIPS with is not a is and TIPS and The use of at the portal vein and of portal TIPS with and the for TIPS in The for TIPS from this is or is and of The of for TIPS can be clinical of are into with the and are TIPS or the other the of a in the of portal or not by statements In patients TIPS for of variceal TIPS and for the of and can be In patients with of and endovascular of TIPS be In TIPS for variceal a of at 1 and to TIPS A at the portal vein is or is and to TIPS of these not TIPS in patients with or of portal hypertension. AND variceal obliteration or or are or complementary to TIPS for variceal on varices and not portal In large collaterals can portal and obliteration can be in with TIPS varices are TIPS or as a endovascular for patients with variceal are not for TIPS such as with or controlled is for gastric or ectopic varices in which the varices are from the systemic veins, as in the of a or can be to esophageal in with and ectopic varices and through a or approach or through Although the first was in by in the was and developed in and and the first was in by In the and the first in the literature was by in the and were and in by and in by as the and to a of as a for gastric variceal and of The of all is to varices that have or are RTO, of variceal hemorrhage from varices in with a of to have a technical of with major a for is the of portal venous through a portal vein or through collaterals because obliteration of the variceal veins, and to of through the portal vein into the because not have on portal venous the of to the portal and which can to the of new to the esophageal varices in to of and also in to the which TIPS a patients with esophageal and/or with TIPS the other the portal to and to RTO, comprehensive or with and is to understand and the veins, gastric collaterals, renal and The can be care or be in patients are more In a (Fig. a is in the as a of to systemic and a a in the or in is into the and varices through the The for an of to to varices and to the renal and portal this the is to be in the care because the has the to which can to treatments be to all the and of retrograde transvenous obliteration (RTO) procedures. with a in the and a retrograde into the varices and with a is to the and is the variceal with and the and is to the variceal the of with interventional radiology and as the of the the has been developed and has been to the of such The with or to the from at the use which are and for of the and with The is an to the or that the use of the and the a the and are to the gastric The use of of the for of which is an essential of to of The is by the with a which is to a large to the the most of the of the gastric variceal is are several technical in the that such as and a with a large not be a for because is large to the The is an to the and of the and in or the in the a of endovascular and to varices. of a the shunt) is with The first or distal is into or to the and the second or proximal is the the renal vein to to the of the by the proximal the distal is to perform of the gastric variceal the also aims to the gastric varices in a the use of or of the is or on the of or with Therefore, is with and a can be because the can be to of or portal vein and esophageal variceal or are not for in to The of is a that can with and can be by TIPS In several be be an (e.g., to and can be because of the anatomy of a from which of the (Fig. the can also the and because the or be to the of the renal vein and of such as or these into the systemic or portal they can portal and/or renal vein and and such as and renal are have been with these of are to portal and by new or esophageal or ectopic varices with variceal in to as as of and/or care obliteration of the variceal gastric and is because obliteration or because the available is the varices are Therefore, a of the be of the to obliteration of the variceal endoscopic can also be for this obliteration is not the such as TIPS, or endoscopic on an be by other clinical and a RTO, the of endoscopic to for new or of esophageal varices is of esophageal varices because has the to portal with with be in patients with esophageal varices statements be as an to TIPS for gastric or ectopic varices with anatomy (e.g., and RTO, by the through the portal venous to the and the portal systemic of of portal and such as TIPS, or endoscopic of esophageal varices is or have with of or and be the at RTO, a of the or endoscopic be to obliteration of the gastric or ectopic varices. be to for the or of esophageal varices. varices are be to The first of gastroesophageal varices was by and in The is to venous and to the varices through has been to esophageal, and ectopic in the of a large vein or or with varices. is present in patients with be and be is in with TIPS because TIPS provides to the of varices. to RTO, to the portal and which and and a of other of portal such as variceal and The of the in portal on the of the and be into in can be a or be by TIPS to portal of is as the obliteration of the varices and of of the and between and This of is because, or collaterals can and of the collaterals be the The can be or or the anatomy of the and the veins. can be through a or or a A is through the portal or by a to the portal venous anatomy to the branches the and is a of such as or is the also be for shows the as is for gastric varices. can be through the TIPS as in (see section for the obliteration of gastric varices. is through into portal venous or through a The branches of the portal vein or vein that gastric varices are left gastric vein posterior or gastric veins. In the in the the of the variceal is the left gastric The branches are and of the veins and gastric varices is with RTO, obliteration of varices is also with because obliteration has been with a because of of varices with Therefore, the goal of the be of the veins as as obliteration of the varices into systemic or portal circulation. is less invasive is to can be as an to RTO, or is not with can the of variceal obliteration and can the of of into the portal is a is through a because hemorrhage. to the AASLD Guidelines for the and management of In patients with and/or portal vein not be to the collaterals the varices. is an The are and abdominal which are and to portal such as esophageal varices and new or and/or less from and renal vein A approach as with to obliteration of varices and be a of the and endoscopic to for new gastroesophageal statements or or be as a in esophageal, or ectopic variceal hemorrhage with a large vein or or with varices. with of variceal is to The of or be by and or endoscopic be to obliteration of the varices. be to the or of esophageal varices. varices are be to OF IN THE OF The of TIPS in the management of esophageal varices and gastroesophageal varices 1 This section on the of TIPS in the of esophageal and gastroesophageal varices 1 in which the management is to the management of esophageal varices. of the anatomy of these are not the on the of of esophageal variceal TIPS has in the of variceal hemorrhage. not be created to first variceal of the variceal or This is in patients with in TIPS to and by from the Management of variceal of TIPS as of care for patients with variceal of a of and endoscopic variceal to of patients of care and at for can be for TIPS TIPS is be is controlled of the TIPS has also been most of these patients also have TIPS can to with from to Therefore, the of TIPS to be and the is the selection of patients at from The of TIPS was first in a controlled by patients with an were at for and randomized to TIPS of care In these TIPS of to and with of The of this have not been because the of care of variceal at most not of A second of patients by a patients at based on clinical on with were and with at of with of patients were were with gastric renal or portal and than In this TIPS of as with of endoscopic with were in a of an and of patients TIPS and patients from and patients from and of the approach to the that patients with with of and patients with with a of variceal at the of were patients at likely from TIPS endoscopic and for variceal a more recent of patients the in between the of care and the TIPS and an of this not with TIPS, the was with the recent and consensus of stents in patients from and GOV2 the in the or with at of the of trials on TIPS available because the from the were by from that the of and/or at the of on in patients with and not TIPS, as the because patients were in these likely these from and randomized trials of TIPS to have patients with of the most of and these can be to patients with to be statements TIPS not be for the of variceal In patients with esophageal variceal TIPS with stents of be in patients of the or with at with of TIPS as or for variceal TIPS has been for for the management of variceal hemorrhage or in patients the TIPS are and most TIPS were as are of more recent that TIPS be for and of these patients a TIPS The are these with of in to of was from to with patients from and/or renal TABLE - in which TIPS be for the of variceal TIPS TIPS of the in patients with hemorrhage controlled with at of TIPS TIPS in patients with and endoscopic TIPS TIPS for of variceal hemorrhage TIPS for of variceal hemorrhage TIPS in patients have from variceal hemorrhage than the the for TIPS be with a are renal for a a and a are available patients with The for this approach that TIPS in these patients be A recent large that and/or were with a than at In a in patients with with variceal TIPS was with an of is and to be The of is likely and to be for a of is of the of TIPS be with the for these the is for a that TIPS be a to in patients with statements TIPS be as in patients in variceal be controlled with and endoscopic of of TIPS be as in patients with variceal and endoscopic of of In patients with a or TIPS not be TIPS is a to in the The of TIPS in the management from variceal AASLD and Association for the Study of the Liver the for the of variceal hemorrhage is the of or and esophageal variceal with TIPS the of in patients TIPS is in the of variceal This is based on of TIPS in have also an of in of patients in TIPS be are from variceal and have In a recent patients with of of the portal vein in of the TIPS with was more than the of in variceal the of and an on TIPS was also with a or portal vein as with TIPS be in patients with is AASLD Guidelines on portal vein by TIPS in patients with and of Therefore, to patients TIPS be as in these In patients have from an esophageal variceal hemorrhage and not have TIPS TIPS be as with and endoscopic of TIPS and in the management of varices and of varices is than esophageal varices in patients with In the of from varices is than for esophageal In patients for in a recent the was from varices to be more than from esophageal and in was as as with available is not different from from esophageal variceal at This be into invasive treatments with of gastric of TIPS and The of TIPS or for of gastric variceal hemorrhage has not been in randomized from trials of a of and a for a in patients randomized to Therefore, TIPS is not for of gastric variceal In patients with for a of variceal obliteration and of on as with TIPS be to first hemorrhage in patients with varices. from varices and management of from varices is the as that for esophageal variceal as in the AASLD guidance on portal In of or with gastric as a to other is for of the of In with