University of California, Los Angeles
A number of treatment modalities are currently in use for gastric variceal bleeding (GVB). Balloon-occluded, plug-assisted, and coil-assisted retrograde transvenous obliteration (RTO) procedures are described in the literature as treatments for GVB after a bleeding episode occurs. Preliminary data suggests that prophylactic treatment of gastric varices may improve patient outcomes compared to conservative management. This study aims to compare pre-emptive treatment of gastric varices with current recommended medical management in a randomized prospective study design. Eligible patients will be randomized to receive RTO or to continue conservative management. Patients will be followed for up to 2 years for comparison of clinical outcomes, including episodes of gastric variceal bleeding, overall survival and transplant-free survival, complications, and secondary interventions.
Gastroesophageal varices occur in approximately 50% of patients with liver cirrhosis. Specifically, gastric varices (GV) are responsible for roughly 10-30% of all variceal hemorrhage which is less than their counterpart esophageal varices. Despite their lower recurrence rates, gastric variceal bleeds (GVB) are associated with higher mortality, with an estimated 35-90% of patients developing rebleeding after achieving hemostasis. Currently, there are several treatments for GVB that include endoscopic injection therapies, percutaneous antegrade transhepatic obliteration (ATO), transjugular port…
Inclusion Criteria: 1. Age \> 18 years 2. Patients with compensated cirrhosis with a higher risk of decompensation based on AASLD 2023 Practice Guidance (Kaplan et al) - no ascites with endoscopic visualization of varices 3. Confirmed diagnosis of gastric varices either through CT, MRI, or Endoscopy. 4. No imaging (LIRAD4 or 5) or tumor marker (AFP) evidence of HCC or other malignancy 5. MELD \< 20 6. First de novo RTO procedure 7. Taking NSBB 8. Patent internal jugular or right common femoral vein 9. Willing to provide the hepatology service information for F/U 10. No known diagnosis of hype…
Non-selective beta blockers are used in patients who have not had a previous variceal bleed to prevent bleeding by reducing blood pressure in the liver. These drugs also work by blocking beta receptors that reduce cardiac output and by causing vessel constriction in the abdominal organs, which lowers blood flow to the liver and the existing varices.
Pre-emptive retrograde transvenous obliteration will be performed in patients randomized to this arm to evaluate the effectiveness in decreasing gastric variceal bleeding. Either CARTO or PARTO (coil or plug-assisted retrograde transvenous obliteration) will be performed using EMBOLIZATION COILS or VASCULAR PLUGS of different sizes based on the size of the shunt. Additionally, Gelfoam (collagen sponges) slurry will be injected into the shunt and varices to completely obliterate them.
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