A self-expanding metal stent for complicated variceal hemorrhage: experience at a single center

doi:10.1016/j.gie.2009.07.028

Gastrointestinal Endoscopy

Volume 71, Issue 1, January 2010, Pages 71-78

https://doi.org/10.1016/j.gie.2009.07.028 Get rights and content

Background

Refractory variceal bleeding is associated with a high mortality. Existing salvage techniques such as transjugular intrahepatic portosystemic shunt (TIPS) and balloon tamponade (BT) have important limitations and may not be appropriate for all patients.

Objective

To evaluate the safety and efficacy of a novel removable self-expanding metal stent in the management of refractory variceal bleeding.

Design

Case series.

Setting

Tertiary referral liver center.

Patients

Ten patients with variceal hemorrhage with contraindications to TIPS insertion or BT.

Interventions

Insertion of a self-expanding metal stent (SX-Ella DANIS stent).

Main Outcome Measures

Survival, failure to control bleeding, and complications.

Results

Stent insertion was successful in 9 of 10 patients. Failure to control bleeding was observed in 3 patients (2 with gastric varices), with control of bleeding in the remainder. Overall survival at 42 days was 50%. Six patients survived the acute bleeding episode and had stents removed endoscopically at a median of 9 days after insertion. One patient had a minor ulceration of the esophagus caused by stent insertion.

Conclusions

Insertion of the SX-Ella DANIS stent in patients with refractory variceal bleeding or complications of previous therapy is effective for the control of bleeding. Stent insertion can be achieved in the majority of patients without fluoroscopic control and without major complications. In selected patients, SX-Ella DANIS stent insertion offers an alternative to other methods of salvage such as BT and TIPS and could be considered a substitute for BT after a prospective trial.

Section snippets

Patients and methods

Ten patients underwent stent insertion between March 2007 and July 2008. All had cirrhosis, proven either by biopsy or a combination of typical biochemical and radiographic abnormalities. Causes of cirrhosis were alcohol (n = 6), alcohol and hepatitis C virus infection (n = 2), and cryptogenic and primary biliary cirrhosis (both n =1). Two patients had coexistent hepatocellular carcinoma.

Six patients were transferred from other hospitals to our unit for management of variceal hemorrhage and

Results

Stent deployment was successful in 9 of 10 cases. The failed deployment was the first in the series and was caused by failure of the gastric balloon to inflate. In the remaining cases, stent deployment was without complication, apart from 1 patient in whom the initial stent deployment failed because of gastric balloon rupture. A second stent was then placed successfully. The intensive care unit was the most common setting for stent insertion (n = 8), but placement of stents was also performed

Discussion

Esophageal variceal bleeding remains a management challenge for endoscopists and emergency physicians. Despite improvements in endoscopic and pharmacological therapy, a significant proportion of patients experience bleeding that cannot be controlled, and emergency salvage procedures such as TIPS placement and BT are needed.13, 14, 15 Consensus guidelines indicate that patients in whom bleeding fails to be controlled at the initial endoscopy should undergo another attempt at endoscopy or proceed

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Cited by (111)

Management of Refractory Variceal Bleed in Cirrhosis
2022, Journal of Clinical and Experimental Hepatology
Acute variceal bleeding is the major cause of mortality in patients with cirrhosis. The standard medical and endoscopic treatment has reduced the mortality of variceal bleeding from 50% to 10–20%. The refractory variceal bleed is either because of failure to control the bleed or failure of secondary prophylaxis. The patients refractory to standard medical therapy need further interventions. The rescue therapies include balloon tamponade, self-expanding metal stents (SEMS) placement, shunt procedures, including transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), and endoscopic ultrasound (EUS) guided coiling.
In cases where endoscopic variceal ligation (EVL) has failed and the variceal bleeding continues, temporary measures like balloon tamponade can be used to achieve hemostasis and as a bridge to definitive measures. SEMS being in use for refractory bleed is preferred over balloon tamponade due to the reduced complication rate. The shunting procedures are highly effective in reducing portal pressure and represent the gold standard for uncontrolled variceal bleeding. The surgical shunts, as well as nonshunt surgeries such as devascularization have become less popular with the increasing use of minimally invasive techniques like TIPS. TIPS have high success rates in controlling refractory variceal bleeding. The mortality rate is greater in high-risk patients undergoing salvage TIPS, and hence, pre-emptive TIPS should be considered in these patients. BRTO is an interventional radiologic procedure used in the management of bleeding gastric and ectopic varices. The availability of gastrorenal or splenorenal shunts is required for the BRTO procedure, which helps to reach and obliterate the cardiofundal varices through the femoral or jugular vein approach. The EUS guided coiling and glue injection have shown promising results, and further randomized controlled trials are required to establish their efficacy for refractory variceal bleeding.
ACR Appropriateness Criteria® Radiologic Management of Portal Hypertension
2021, Journal of the American College of Radiology
Citation Excerpt :
Esophageal-coated self-expanding metal stents provide rapid control of bleeding by tamponade of varices in the distal esophagus, however, there is no risk of treatment-related liver dysfunction as can be seen in patients with advanced liver disease post-TIPS. Following successful preclinical animal studies, five small case series [80-84] reported excellent control of bleeding (85% to 100%) with low risk of stent migration in patients with uncontrolled esophageal variceal hemorrhage and contraindication to TIPS placement (advanced liver disease, hepatocellular carcinoma, multisystem organ failure). However, mortality was quite high across studies with rates of 26.5% to 56% at 30 days and 50% to 77% at 42 to 60 days.
Cirrhosis is a heterogeneous disease that cannot be studied as a single entity and is classified in two main prognostic stages: compensated and decompensated cirrhosis. Portal hypertension, characterized by a pathological increase of the portal pressure and by the formation of portal-systemic collaterals that bypass the liver, is the initial and main consequence of cirrhosis and is responsible for the majority of its complications. A myriad of treatment options exists for appropriately managing the most common complications of portal hypertension, including acute variceal bleeding and refractory ascites.
The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
The role of stenting in patients with variceal bleeding
2020, Techniques and Innovations in Gastrointestinal Endoscopy
Citation Excerpt :
Considering the poor prognostic implications of uncontrolled variceal bleeding, the clinical outcome that is of perhaps the most imminent relevance is the ability of the stent to provide early and effective control of bleeding. Current literature suggests remarkable success in terms of initial hemostasis with SEMS with several small studies [7,25–27] reporting a 100% immediate bleeding control rate and many others reporting success rates higher than 80% [21–24,28–30]. Studies comparing SEMS with balloon tamponade for control of variceal bleeding suggest the much greater success of SEMS [31,32].
Uncontrolled acute variceal hemorrhage due to failure of standard endoscopic therapy increases the risk of decompensation of liver disease and multiorgan failure leading to death. In this article, we aim to provide a structured and comprehensive review of the management of variceal bleeding by the use of self-expanding metal stent(s) (SEMS). The intricacies of the appropriate patient and stent selection, technicality of stent placement, deployment, and follow-up will be discussed. Furthermore, certain stent models with unique delivery system that eliminates the need of endoscopic or radiographic guidance will be reviewed. While patients with uncontrolled acute variceal hemorrhage are at a very high risk of adverse events, SEMS complications and the steps to prevent them will also discussed. As a vast majority of these cases represent advanced liver disease, liver transplant is ultimately required, thus, making SEMS an effective bridge to definitive therapy.
Nonendoscopic management of acute esophageal variceal bleeding
2017, Techniques in Gastrointestinal Endoscopy
Acute esophageal variceal bleeding is a life-threatening complication of portal hypertension in patients with liver cirrhosis. Its management has improved over the past several years, leading to a significant reduction in rebleeding episodes and in bleeding-related deaths. Although endoscopic therapy is an integral part in the management of the acute variceal bleeder, pharmacologic and radiologic therapies are important interventions, in addition to optimal supportive care. Herein, we highlight the nonendoscopic management of acute esophageal variceal bleeding.
Endoscopic management of acute esophageal variceal bleeding
2017, Techniques in Gastrointestinal Endoscopy
Esophageal varices develop in the setting of portal hypertension, most commonly caused by cirrhosis. Esophagogastroduodenoscopy is considered the gold standard for both diagnosis and treatment of acute variceal bleeding. In this review, we highlight the management of both acute and refractory bleeding from esophageal varices, with an emphasis on endoscopic therapies, including injection sclerotherapy, band ligation, and esophageal stent placement.
An update on the management of acute esophageal variceal bleeding
2017, Gastroenterologia y Hepatologia
The mortality rate in acute variceal haemorrhage remains high (around 15%). Treatment is based on the combined use of vasoactive drugs, endoscopic band ligation, and prophylactic antibiotics. Effective resuscitation (haemostasis, volume management) is essential to prevent complications. Treatment failure is best managed by transjugular intrahepatic portosystemic shunt (TIPS). Balloon tamponade or specifically designed covered oesophageal stents can be used as a bridge to definitive therapy in unstable patients. Early, pre-emptive TIPS should be the first choice in patients at high risk of treatment failure (Child-Pugh B with active bleeding or Child-Pugh C < 14). This article reviews the most recent advances in the management of variceal bleeding and discusses the recent recommendations of the Baveno VI consensus conference.
La hemorragia aguda por varices continúa presentando una alta tasa de mortalidad (alrededor de un 15%). Su tratamiento se basa en el uso combinado de fármacos vasoactivos y tratamiento endoscópico mediante ligadura, junto a profilaxis antibiótica. El uso de medidas de reanimacion efectivas (hemostasia, corrección de volumen) resulta esencial con objeto de prevenir las complicaciones. En caso de fallos del tratamiento, se debe realizar una derivación portosistémica percutánea intrahepática (DPPI o TIPS). En pacientes inestables, el taponamiento esofágico con balón o el empleo de prótesis (stent) esofágicas recubiertas pueden utilizarse como una medida transitoria hasta la realización del tratamiento definitivo. La utilización precoz de TIPS debe ser de primera elección en pacientes de alto riesgo de fallos del tratamiento (Child-Pugh B con sangrado activo o Child-Pugh C < 14 puntos). En este artículo se revisan los avances más recientes en el manejo del sangrado por varices y se discute las últimas recomendaciones de la VI conferencia de consenso de Baveno.

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: DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

: If you would like to chat with an author of this article, you may contact Dr. O'Beirne at [email protected].

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Original articleClinical endoscopyA self-expanding metal stent for complicated variceal hemorrhage: experience at a single center

Background

Objective

Design

Setting

Patients

Interventions

Main Outcome Measures

Results

Conclusions

Section snippets

Patients and methods

Results

Discussion

Lancet

J Hepatol

J Hepatol

Gastrointest Endosc

J Hepatol

Gastroenterology

Improved survival after variceal bleeding in patients with cirrhosis over the past two decades

Hepatology

Terlipressin for acute esophageal variceal hemorrhage

Cochrane Database Syst Rev

Antibiotic prophylaxis after endoscopic therapy prevents rebleeding in acute variceal hemorrhage: a randomized trial

Hepatology

Predictors of early rebleeding and mortality after acute variceal hemorrhage in patients with cirrhosis

Nat Clin Pract Gastroenterol Hepatol

Emergency transjugular intrahepatic portasystemic stent shunting as salvage treatment for uncontrolled variceal bleeding

Br J Surg

Original article
Clinical endoscopy
A self-expanding metal stent for complicated variceal hemorrhage: experience at a single center