Plug or coil assisted retrograde Transvenous obliteration for gastric varices

Plug or coil-assisted retrograde transvenous obliteration (PARTO/ CARTO) is a minimally invasive procedure used to treat gastric varices, which are enlarged veins in the stomach that can cause significant bleeding. 

Indications for PARTO

1. Gastric Varices: Patients with gastric varices, particularly those at high risk of bleeding or with a history of variceal haemorrhage.
2. Failed Medical Management: When conservative treatments (such as medication or endoscopic therapy) fail to control variceal bleeding effectively.
3. Unsuitable for Surgery: Patients who are not suitable candidates for surgical interventions due to medical comorbidities or other factors.

Pre-procedure Preparation

1. Patient Assessment:
   • Comprehensive evaluation of the patient’s medical history, symptoms, severity of gastric varices, and history of variceal bleeding.
   • Imaging studies (such as CT angiography, MRI, or endoscopic ultrasound) to assess the anatomy, location, and extent of the varices.
2. Coagulation Status:
   • Evaluation of the patient’s coagulation profile to ensure it is within acceptable limits for the procedure.
3. Informed Consent:
   • Explanation of the PARTO procedure, its purpose, potential risks (such as bleeding, infection, or embolization-related complications), benefits, and alternatives. Informed consent is obtained.

Procedure Steps

1. Access and Catheterization:
   • The procedure is typically performed under local anaesthesia and conscious sedation.
   • A catheter is inserted into a vein in the groin area (femoral vein) and guided under fluoroscopic or ultrasound guidance to access the target veins supplying the gastric varices.
2. Venography:
   • Contrast dye is injected through the catheter to visualise the gastric varices, identify the feeding veins, and assess the vascular anatomy.
3. Catheter Placement and Embolization:
   • Once the feeding veins are identified, a catheter with a plug or coil delivery system is advanced through the veins to reach the varices.
   • Embolic agents, such as vascular plugs, coils, or sclerosing agents, are deployed through the catheter into the varices to induce thrombosis (clotting) and obliterate the varices.
   • The choice of embolic agent (plug or coil) depends on the size, location, and characteristics of the varices and the preferences of the interventional radiologist.
4. Post-Embolization Assessment:
   • Imaging (such as fluoroscopy or contrast-enhanced CT) is performed post-procedure to confirm successful embolization, assess for any residual flow in the varices, and evaluate for complications.

Benefits of PARTO

• Effective Variceal Obliteration: Induces thrombosis and sclerosis of the varices, reducing the risk of bleeding and recurrent variceal haemorrhage.
• Minimally Invasive: Compared to surgical interventions, PARTO is minimally invasive, with lower risks, shorter recovery times, and fewer complications.
• Preservation of Portal Hemodynamics: Targets the varices while preserving portal venous flow and hepatic function.
• Suitable for High-Risk Patients: Provides a treatment option for patients who are not surgical candidates or have contraindications to other therapies.

Risks and Considerations

• Embolization-related Complications: Potential risks include embolization to unintended vessels, thrombosis in non-target areas, or migration of embolic agents.
• Bleeding: In rare cases, PARTO may result in bleeding complications requiring additional interventions or transfusions.
• Post-Embolization Syndrome: Some patients may experience mild to moderate post-procedure symptoms such as fever, abdominal pain, or nausea, which typically resolve with conservative management.

Follow-up and Post-procedure Care

1. Monitoring:
   • Close monitoring of the patient’s vital signs, abdominal symptoms, and laboratory parameters (such as liver function tests, coagulation profile) post-procedure.
   • Observation for any signs of bleeding, infection, or embolization-related complications.
2. Nutritional Support:
   • Nutritional assessment and support, as needed, to optimize the patient’s nutritional status and liver function post-procedure.
3. Follow-up Imaging:
   • Follow-up imaging studies (such as CT or ultrasound) may be scheduled to assess the status of variceal obliteration and monitor for any recanalization or new varices.
4. Medication:
   • Patients may be prescribed medications (such as proton pump inhibitors or anticoagulants) based on their individual needs and risk factors.

Conclusion

Plug or coil-assisted retrograde transvenous obliteration (PARTO) is an effective and minimally invasive procedure for treating gastric varices and reducing the risk of variceal haemorrhage. It offers several advantages, including targeted variceal obliteration, preservation of portal hemodynamics, and suitability for high-risk patients. Close monitoring, follow-up care, and patient education are essential to ensure optimal outcomes and minimise potential complications.