Comparison Of Percutaneous Transhepatic Variceal Embolization And Endoscopic Cyanoacrylate Injection For Gastric Variceal Bleeding In The Long Term

Background and Objective:Although the incidence of gastric variceal bleeding from liver cirrhosis and portal hypertension is relatively low, but when it occurs it tends to be more severe, to require more transfusion, and to have a higher rate of rebleeding and mortality than esophageal variceal bleeding.Therefore, we must take effective treatment to control gastric variceal hemorrhage in clinical.Endoscopic gastric variceal obturation (GVO) with an injection of 2-OCA is the first-line therapy for gastric variceal rebleeding at present.Although it has been widely used, its rebleeding rate in long term is very high.In addition,patients with gastric renal shunt exist the risk of ectopic embolism.Percutaneous transhepatic variceal embolization (PTVE) with 2-octyl-cyanoacrylate (2-OCA) can eliminate varices thoroughly because of embolisming varices and blood supply vein, which is considered to be a safe and effective method,but it has not been widely used, and its long-term clinical efficacy also needs further research.Some studies have shown that gastric variceal bleeding may be related to variceal type,size of the varices,presence of red sign and advanced Child’s stage. But now precisely what trigger gastric variceal rebleeding and death are not known.Thus,the study is aimed to compare the safety and long-term efficacy of percutaneous transhepatic variceal embolization (PTVE) with 2-octyl-cyanoacrylate (2-OCA) and endoscopic gastric variceal obturation (GVO) with an injection of 2-OCA for gastric variceal rebleeding, and to provide clinical evidence for treatment method of gastric variceal rebleeding.At the same time we discuss risk factors for rebleeding and mortality in gastric varices, and provide predictive information for rebleeding and mortality in gastric varices.Methods:PTVE or GVO was performed in a total of 118 cirrhotic patients with a history of gastric variceal bleeding in Shandong Provincial Hospital from April 2010 to August 2015 in our study. Endoscopy, abdominal computed tomography and portal vein angiography were performed for the two groups after the procedures. We followed up of all patients by outpatient service and telephone,and recorded results of physical examination,laboratory examination imaging;the time of bleeding and hemorrhage causes;the time of death and cause of death and complications. We analyzed the cumulative rebleeding-free rate and survival rates in 1,2, and 3 years respectively for two groups by using the Kaplan-Meier estimation and predicted independent factors for rebleeding and death by taking Cox analysis.Results:In total,118 patients were recruited in the study,51 patients received PTVE and 67 patients received GVO.The average follow-up time was (25.86±17.67) month in the PTVE group and (19.85±13.12) month in the GVO group.1.Rebleeding occurred in 8 patients in the PTVE group and 25 patients in the GVO group;The rebleeding rates of two groups were 15.7% and 37.3%,respectively,which had significant difference(x2=6.723, P=0.013).The Kaplan-Meier estimation suggested that the cumulative rebleeding-free rate was 91%,81.3%, and 76.7% in 1,2, and 3 years respectively for PTVE, and 68.6%,49.5%, and 42.4% for GVO,which had significant difference(Long-rank test, P=0.004).Cox analysis was used to identify independent factors that predicted rebleeding after treatment.lt was revealed that choice of treatment(P=0.006), Child-Pugh classification(P=0.022), HVPG>16mmHg(P=0.039), partial splenic embolization or splenectomy(P<O.OOO), and red sign(P=0.003) were the independent factors for predicting rebleeding.2.Six patients died in the PTVE group and nine patients died in the GVO group. The mortality rates of two groups were 11.8% and 13.4%,respectively,which had no significant difference(x2=0.073, P=0.788).The Kaplan-Meier estimation suggested that the cumulative survival rates at 1,2, and 3 years were 93.4%,89.6%,and 73.6% respectively in the PTVE group, and 91.3%,84.9%, and 68.9% respectively in the GVO group. The survival rates were not significantly different between the two groups (P=0.46). Cox analysis showed that the Child-Pugh classification was the most significant prognostic factor of survival (P=0.001).3.Thirty-two patients experienced complications in the PTVE group, compared to thirty-nine patients in the GVO group (x2=0.249, P=0.705). There was no significant difference between the groups.Conclusions:1.In the long-term, PTVE with 2-OCA is superior to endoscopic 2-OCA injection for preventing gastric variceal rebleeding, and it is considered to be safe and effective method for the treatment of gastric varices.2.It is revealed that choice of treatment, Child-Pugh classification, HVPG>16mmHg, partial splenic embolization or splenectomy and red sign were the independent factors for predicting rebleeding in patients with gastric varices.3.Child-Pugh classification is the only prognostic factor of survival in patients with gastric varices.