1123

Transhepatic Obliteration of
Esophageal Varices Using
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the Stainless Steel Coil

Anthony H. Funaro1 Coronary veins in seven of eight patients with bleeding esophageal varices were
Ernest J. Ring successfully catheterized and embolized with Gelfoam followed by multiple steel coils.
David B. Freiman Bleeding immediately ceased in all seven, but recurred within 1 month in six. One had
not rebled on 3 month follow-up. Therefore, steel coils do not prevent recurrent
Juan A. Oleaga
bleeding any more effectively than other embolic materials used for this purpose.
Roy L. Gordon

Transhepatic catheterization of the portal vein and selective obliteration of the

coronary vein have been used as an adjuvant in the management of patients
bleeding from esophageal vanices [1 ]. Various embolic and sclenosing agents
have been used to obstruct flow in the coronary vein and esophageal vanices.
These include modified autologous clot, Gelfoam, sclerosing agents, balloon
occlusion, and tissue adhesives [2, 3]. The tissue adhesives are believed to
provide the most permanent occlusions, but as yet are only available for investi-
gational purposes. We describe our experience using stainless steel coils as a
permanent embolic material for coronary vein embolization.

Subjects and Methods

Eight patients with endoscopically demonstrated esophageal variceal bleeding under-

wenttranshepatic catheterization ofthe portal vein and attempted obliteration of esophageal
varices with stainless steel coils. Preliminary celiac and superior mesenteric arteriography
was performed in each case to exclude an arterial source for the bleeding and demonstrate
patency of the portal venous system. Percutaneous transhepatic portal vein catheterization
Received February 1 3, 1 979; accepted after
was then successfully performed in seven of the eight patients using the technique
revision July 1 7, 1979.
described by Lunderquist et al. [4]. Splenic and coronary venograms were obtained to
This work was supported in part by U.S. Public
portray the venous anatomy and localize all venous supplies to the esophageal varices (fig.
Health Service grant NIH1RO1AM2O6O4 from the
National Institute of Arthritis and Metabolic Dis- 1 A). Whenever more than one major blood supply was demonstrated, each was selectively
ease. catheterized and embolized with Gelfoam particles to occlude the smaller intraesophageal
1 All authors: Department of Radiology, Hospi- veins. The initial sheath catheter was then replaced with the 7 French Teflon embolization
tal of the University of Pennsylvania, 3400 Spruce catheter designed for use with the coils (Cook, Inc., Bloomington, Ind.). (Smaller coils are
St. , Philadelphia, PA 1 91 04. Address reprint ne- now available which can be introduced through a 5 French catheter.)
quests to E. J. Ring. Introduction of the embolization catheter was greatly helped by exchanging over a
special heavy duty transhepatic wire (Surgimed, Inc., Summerville, S.C.). This wire is
AJR133:1123-1125, December 1979
o361-8o3x/79/1336-1 123 $00.00 constructed of solid stainless steel with a welded flexible tip. It offers the firmness required
© American Roentgen Ray Society to exert sufficient force on the catheter to overcome resistance from the liver. The
 1124 FUNARO ET AL. AJR:133, December 1979
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Fig. 1 -53 year old man with Laennec’s cirrhosis and bleeding esopha-
geal vanices. A, Catheter placed transhepatically into portal vein. Hepatofugal
flow into splenic vein and inferior mesenteric veins. Large coronary vein filling
multiple esophageal vanices. B, Catheter selectively placed into coronary
vein. C, After embolization with combination of Gelfoam followed by five
stainless steel coils (arrow), flow in coronary vein ceased. Repeat portal
venognam demonstrates total occlusion of cononary vein with no flow into
esophageal vanices. Improved flow toward liven.

embolization catheter was then placed selectively into each of the Results
major branches supplying the varices and multiple stainless steel
Successful catheterization of the coronary vein was
coil emboli were introduced (fig. 1 B). Repeat splenic venograms in
each patient after embolization showed no evidence of collateral achieved in seven of eight patients. In one patient with an
reconstitution to the varices and no flow towards the esophagus excessively hand liver and massive ascites, a catheter could
(fig. 1 C). A final coil was positioned in the liver parenchyma as the not be introduced into the portal venous system. Immediate
catheter was removed in order to seal the tract and prevent bleeding cessation of bleeding occurred in all seven patients. How-
from the puncture site. ever, six of the seven patients rebled within 1 month. Two
 AJR:133, December 1979 OBLITERATION OF ESOPHAGEAL VARICES 1125

of these patients died during second bleeding episodes and the feasibility of introducing stainless steel coils into the
the other four underwent surgery for the recurrent bleeding. coronary vein for vaniceal obliteration, this technique seems
The seventh patient had no further bleeding with only a 3 to offer no more permanency than simpler embolic materials
month follow-up. such as Gelfoam.

Discussion REFERENCES
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Of the materials available for obliteration of the coronary 1 . Viamonte M Jr, Pereiras A, Aussel E, LePage J, Hutson 0:
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2. Pereiras A, Viamonte M Jr, Aussel E, LePage J, White P,
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few weeks [6]. The stainless steel coil is a permanent obliteration of the coronary vein in patients with portal hyper-
occluding device that is readily available [7]. Its only poten- tension and bleeding esophageal varices. N EngI J Med 291:
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