title: Management of Bleeding Duodenal Varices with Combined TIPS Decompression and Trans-TIPS Transvenous Obliteration Utilizing 3% Sodium Tetradecyl Sulfate Foam Sclerosis.
abstract: OBJECTIVE
  Endoscopic experience in the management of duodenal varices (DVs) is limited and challenging given the anatomic constraints and limited experience. The endovascular management of DVs is not yet established and the controversy of whether to manage them by decompression with a transjugular intrahepatic portosystemic shunt (TIPS) or by transvenous obliteration is unresolved. In the literature, the 6-12 month rebleeding rate of DVs after TIPS is 21-37% and after transvenous obliteration is 13%. The purpose of the study is to evaluate the clinical outcome of combined TIPS decompression and transvenous obliteration/sclerosis.
  
  
  METHODS
  This is a retrospective study (case series) of two institutions, evaluating patients who underwent TIPS and/or transvenous obliteration/sclerosis for bleeding DVs (from January 2009 to June 2013). TIPS was performed according to a standard procedure using covered stents. Transvenous obliteration (variceal sclerosis) from the systemic and/or portal venous circulation was performed utilizing 3% sodium tetradecyl sulfate foam. Transvenous obliteration was commonly augmented with coils and/or vascular plugs. Technical (technical success of establishing TIPS and completely obliterating the DVs) and clinical outcomes (rebleeding rate and survival) were evaluated.
  
  
  RESULTS
  Five patients with liver cirrhosis presenting with bleeding DVs were included in the study with all eventually (and coincidentally) receiving TIPS and transvenous obliteration. Two of the five patients underwent concomitant TIPS and transvenous obliteration in the same procedural setting. However, three patients underwent transvenous obliteration due to bleeding despite a patent TIPS that had been previously placed. The average time from TIPS placement to transvenous obliteration was 125 days (range: 3-324 days). After having both procedures, there was no rebleeding in the patients during a mean follow-up period of 22 months (6-50 months). Coils and/or metallic vascular plugs were used to augment the sclerosant obliteration in four of five patients.
  
  
  CONCLUSIONS
  The combination of TIPS decompression and foam sclerosant transvenous obliteration appears to be effective in preventing rebleeding in this limited case series and compares favorably with the existing evidence for either approach [TIPS or balloon-occluded retrograde transvenous obliteration (BRTO)] alone.
authors.affiliation: Department of Radiology, Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, United States.
authors.forename: Wael E
authors.initials: WE
authors.lastname: Saad
authors.affiliation: Department of Radiology, University of Virginia, Charlottesville, Virginia, United States.
authors.forename: Allison
authors.initials: A
authors.lastname: Lippert
authors.affiliation: Department of Radiology, University of Virginia, Charlottesville, Virginia, United States.
authors.forename: Sandra
authors.initials: S
authors.lastname: Schwaner
authors.affiliation: Department of Medicine, Temple University Health System, Philadelphia, Pennsylvania, United States.
authors.forename: Abdullah
authors.initials: A
authors.lastname: Al-Osaimi
authors.affiliation: Department of Radiology, University of Virginia, Charlottesville, Virginia, United States.
authors.forename: Saher
authors.initials: S
authors.lastname: Sabri
authors.affiliation: Department of Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri, United States.
authors.forename: Nael
authors.initials: N
authors.lastname: Saad
keywords: Balloon-occluded retrograde transvenous obliteration; bleeding; duodenal varices; vascular plugs