Vascular Anatomy and the Morphologic and Hemodynamic Classifications of Gastric Varices and Spontaneous Portosystemic Shunts Relevant to the BRTO Procedure

doi:10.1053/j.tvir.2013.02.002

Techniques in Vascular and Interventional Radiology

Volume 16, Issue 2, June 2013, Pages 60-100

https://doi.org/10.1053/j.tvir.2013.02.002 Get rights and content

The pathologic anatomy and hemodynamics of the left-sided portal circulation that is associated with gastric varices (GVs) are complex and highly variable. Understanding the pathologic anatomy and hemodynamics associated with GVs is important for clinical management decisions and for the technical descriptive details of the balloon-occluded retrograde transvenous obliteration (BRTO) and balloon-occluded antegrade transvenous obliteration procedures. A reflection of the considerable variability in anatomy, pathology, and hemodynamics is the numerous descriptive and categorical classifications that have been described in the past 2 decades. This article reviews the detailed descriptive gross anatomy, radiographic anatomy, and portosystemic venous hemodynamics that are associated with GVs and that can be encountered during the BRTO or balloon-occluded antegrade transvenous obliteration procedure(s) or both. Definitions are also set to clarify this detailed anatomy that received limited description in the prior literature. Moreover, all the classifications that have been described (to the best of the author's knowledge) that are relevant to the BRTO procedure are detailed in the article.

Section snippets

Anatomical and Hemodynamic Definitions

The commonly used acronyms related to gastric variceal anatomy and the BRTO procedure are listed in Table 1. The definitions associated with the pathoanatomy associated with GVs are discussed in the ensuing sections.

Descriptive Anatomy

The anatomy of the GVS that is sclerosed by the BRTO procedure is summarized in Table 4 (Figs. 3A and 5). This section is the detailed descriptive anatomy and radiographic anatomy of the GVS relevant to GVs and the BRTO procedure. The GVS can be divided into: (1) an afferent (portal venous inflow) part, (2) a central variceal part, and (3) an efferent (systemic venous outflow) part (Figs. 3A and 5).

Efferent Systemic Venous Drainage

This can vary in complexity from the very simple (only a GRS) to multiple additional draining systemic veins (commonly the inferior phrenic vein (IPV) or pericardiophrenic vein) that vary in significance. (Please see the Kiyosue and Hirota classifications given later.)5, 6, 7 For the purpose of this section, the detailed anatomical description is focused on the GRS and the percardiophrenic or IPV.

Classifications

The following are classifications that have been described in the past 2 decades. In addition, there are new classifications of GVs and duodenal and mesenteric varices. The new classifications (Saad gastroduodenal and mesenteric variceal classification and the Saad classifications for GVs [inflow and outflow]) are placed for management purposes for the management of small bowel (duodenal and mesenteric) varices and for the management of GVs, respectively. These 2 new classifications have a

Conclusion

There is considerable anatomical variations and details in the GVS that comprises the afferent portal venous feeders, the GVs, and the GRS. The GRS is part of the greater GVS which from a hemodynamic standpoint is a SRS (splenogastrorenal shunt). The morphologic SRS is not associated with varices. Numerous anatomical and hemodynamic classifications have been described. They commonly have particular management and/or outcome applications and/or implications, respectively.

References (15)

B.M. Ryan et al.
A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices
Gastroenetrology
(2004)
T. Fukuda et al.
“Downgrading” of gastric varices with multiple collateral veins in balloon-occluded retrograde transvenous obliteration
J Vasc Interv Radiol
(2005)
A. Matsumoto et al.
Balloon-occluded retrograde transvenous obliteration of high risk gastric fundal varices
Am J Gastroenterol
(1999)
W.E.A. Saad et al.
Transjugular intrahepatic portosystemic shunt (TIPS) versus balloon-occluded retrograde transvenous obliteration (BRTO) for the management of gastric varices
Semin Interv Radiol
(2011)
A.M.S. Al-Osaimi et al.
Medical and endoscopic management of gastric varices
Semin Interv Radiol
(2011)
W.E.A. Saad
The history and evolution of balloon-occluded retrograde transvenous obliteration (BRTO): From the United States to Japan and back
Semin Interv Radiol
(2011)
H. Kiyosue et al.
Transcatheter oliteration of gastric varices: Part-1: Anatomic classification
Radiographics
(2003)

There are more references available in the full text version of this article.

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Citation Excerpt :
IGV1 are located exclusively in the fundus and IGV2 are varices that are present in other parts of the stomach. Another classification of GV that has therapeutic implications, particularly for interventional radiologic procedures, is the Saad-Caldwell classification,27 which is based on afferent/inflow hemodynamics and vascular dominance. According to this system, GV are categorized as: type 1—lesser curve GV (left gastric or coronary vein dominant); type 2—cardiofundal GV (left gastric and posterior gastric vein dominant); type 3—both lesser curve and cardiofundal GV (equal dominance for both systems); and type 4—GV occurring in the setting of splenic vein thrombosis and entails the formation of multiple afferent veins.
Endoscopic therapy is a key component in the management algorithm for variceal and nonvariceal hemorrhage related to portal hypertension. Band ligation is the endoscopic treatment of choice for acute esophageal variceal bleeding, and for preventing a first episode of bleeding (primary prophylaxis) and rebleeding (secondary prophylaxis). In contrast, endoscopic cyanoacrylate injection is the preferred modality for cardio-fundal variceal bleeding. Thrombin injection and endoscopic ultrasound-guided angiotherapy are alternative treatment options for gastric variceal obliteration. The management of ectopic varices requires a multidisciplinary approach, and the choice of therapy is dictated, in part, by location of varices, vascular anatomy, and available expertise. Endoscopic therapy is of limited value for the control of chronic blood loss from portal hypertensive gastropathy but is at the forefront in the management of gastric antral vascular ectasia associated with portal hypertension, which includes argon plasma coagulation, band ligation, and radiofrequency ablation.

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Vascular Anatomy and the Morphologic and Hemodynamic Classifications of Gastric Varices and Spontaneous Portosystemic Shunts Relevant to the BRTO Procedure

Section snippets

Anatomical and Hemodynamic Definitions

Descriptive Anatomy

Efferent Systemic Venous Drainage

Classifications

Conclusion

Gastroenetrology

J Vasc Interv Radiol

Am J Gastroenterol

Transjugular intrahepatic portosystemic shunt (TIPS) versus balloon-occluded retrograde transvenous obliteration (BRTO) for the management of gastric varices

Semin Interv Radiol

Medical and endoscopic management of gastric varices

Semin Interv Radiol

The history and evolution of balloon-occluded retrograde transvenous obliteration (BRTO): From the United States to Japan and back

Semin Interv Radiol

Transcatheter oliteration of gastric varices: Part-1: Anatomic classification

Radiographics