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Bleeding Stomal Varices

🎙️ Wisdom Radio: Managing Parastomal Variceal Bleeding—Embolization vs. TIPS

This episode dives into the high-stakes management of Parastomal Variceal Bleeding (PVB), a rare but life-threatening complication of portal hypertension, often seen in patients with significant comorbidities (like metastatic cancer) where a TIPS procedure is initially contraindicated.

  • The Clinical Dilemma: We explore a case study of a patient ruled out for TIPS due to metastatic disease, shifting the entire burden of hemorrhage control to local embolization techniques like Percutaneous Antegrade Transhepatic Venous Obliteration (PATVO).

  • Technical Mastery: The episode breaks down the critical need for a multimodal embolic approach—combining mechanical coils, sclerosing foam (STS/Gelfoam), and a final "cap" to ensure immediate and durable stasis against high portal pressures (mean 33 mmHg in our case).

  • The Recurrence Reality: While technical success for embolization is high (88-100%), the recurrence rate is stubbornly high, reaching up to 50% within the first year due to the recruitment of new collaterals.

  • TIPS vs. Embolization: We review data showing that TIPS—which treats the underlying portal hypertension—reduces recurrence risk by a staggering 78.5% compared to embolization alone.

  • The Provocative Question: We end by challenging the consensus: In cases of catastrophic, life-threatening bleed, when is a palliative TIPS justified purely for hemorrhage control, even in patients with poor oncologic prognoses?.

Tune in to master the technical nuances of PATVO and understand the critical decision matrix for treating these complex, high-pressure bleeds.

 

Based on comments from experts, content on Wysdom, and the article cited below.

Romano J, Welden CV, Orr J, McGuire B, Shoreibah M. Case Series Regarding Parastomal Variceal Bleeding: Presentation and Management. Ann Hepatol. 2019 Jan-Feb;18(1):250-257. doi: 10.5604/01.3001.0012.7934. PMID: 31113601.

Nadeem IM, Badar Z, Giglio V, Stella SF, Markose G, Nair S. Embolization of parastomal and small bowel ectopic varices utilizing a transhepatic antegrade approach: A case series. Acta Radiol Open. 2022 Jul
5;11(7):20584601221112618. doi: 10.1177/20584601221112618. PMID: 35833193; PMCID: PMC9272059.

Pabon-Ramos WM, Niemeyer MM, Dasika NL. Alternative treatment for bleeding peristomal varices:
percutaneous parastomal embolization. Cardiovasc Intervent Radiol. 2013 Oct;36(5):1399-404. doi:
10.1007/s00270-013-0588-0. Epub 2013 Mar 13. PMID: 23483282.

Pennick MO, Artioukh DY. Management of parastomal varices: who re-bleeds and who does not? A systematic review of the literature. Tech Coloproctol. 2013 Apr;17(2):163-70. doi: 10.1007/s10151-012-0922-6. Epub 2012 Nov 14. PMID: 23152077.