Transjugular Intrahepatic Portosystemic Shunt (TIPS) versus Balloon-occluded Retrograde Transvenous Obliteration (BRTO) for the Management of Gastric Varices

Clinical effects of a modified sandwich method for Lgf type gastric varices

AIM

To investigate the efficacy and safety of a modified sandwich method (endoscopic injection of tissue adhesive and lauromacrogol) for Lg_f type gastric varices.

METHODS

A retrospective study was performed to review the clinical and follow-up data of 30 patients with Lg_f type gastric varices, who were treated by the modified sandwich method (lauromacrogol-tissue adhesive-lauromacrogol). Then we analysed the endoscopic variceal manifestations, hemostatic rate, improvement of gastric varices, rebleeding rate and complications.

RESULTS

The average follow-up time was 6.43 mo ± 2.82 mo. Varices disappeared in 20 (66.67%) patients, were reduced in 7 (23.33%), and showed no change in 2 (10.00%). Intraoperative bleeding occurred in 1 case and rebleeding occurred in another case within 24 h. Abdominal pain occurred in 8 (26.7%) patients, low-grade fever and transient bacteremia in 2 (8.7%), all of which recovered after symptomatic treatment for 1-2 d. No patients had ectopic embolism.

CONCLUSION

The modified sandwich method is effective and safe for Lg_f type gastric varices.

Transjugular Intrahepatic Portosystemic Shunt Creation and Variceal Coil or Plug Embolization Ineffectively Attain Gastric Variceal Decompression or Occlusion: Results of a 26-Patient Retrospective Study

PURPOSE

To assess the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation with or without variceal coil and/or plug embolization in decompressing or occluding gastric varices (GVs).

MATERIALS AND METHODS

In this retrospective study, 78 patients with GV bleeding who underwent TIPS creation with or without embolotherapy with metallic coils and/or plugs from 1999 to 2014 were identified. Individuals who had a bare-metal TIPS and/or lacked post-TIPS imaging or endoscopic follow-up were excluded. The final cohort included 26 patients (16 men; median age, 54 y; median Model for End-stage Liver Disease score, 16). Variceal types, supplying vessels, and postprocedure GV patency on cross-sectional imaging or endoscopy were assessed. The primary study outcome measure was GV patency rate as a surrogate for efficacy of TIPS creation with or without embolization.

RESULTS

GVs included gastroesophageal varix types 1 (n = 10) and 2 (n = 2), isolated GV types 1 (n = 4) and 2 (n = 2), and unspecified (n = 8). TIPS creation resulted in a median final portosystemic pressure gradient of 7 mm Hg. Multiple GV-supplying vessels (left/posterior/short gastric veins) were present in 65% of patients (n = 17). Embolization was performed in 69% (n = 18). Thirteen, four, and nine patients had imaging, endoscopic, or both imaging/endoscopic follow-up. GV patency rate was 65% (n = 17; 61%/75% with/without embolization) at a median of 128.5 days (range, 1-1,295 d) after TIPS creation. Incidence of recurrent bleeding was 27% (n = 7), and the 90-day mortality rate was 15% (n = 4).

CONCLUSIONS

In this study, most GVs showed persistent patency despite TIPS decompression and variceal embolization, and the incidence of recurrent bleeding was high. The findings suggest suboptimal efficacy for GVs, and indicate a need for study of alternative or adjunctive approaches to GV treatment, such as chemical obliteration.

Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Variceal Hemorrhage

Objective

To evaluate the feasibility, safety, and clinical outcomes of plug-assisted retrograde transvenous obliteration (PARTO) to treat gastric variceal hemorrhage in patients with portal hypertension.

Materials and Methods

From May 2012 to June 2014, 19 patients (11 men and 8 women, median age; 61, with history of gastric variceal hemorrhage; 17, active bleeding; 2) who underwent PARTO using a vascular plug and a gelfoam pledget were retrospectively analyzed. Clinical and laboratory data were examined to evaluate primary (technical and clinical success, complications) and secondary (worsening of esophageal varix [EV], change in liver function) end points. Median follow-up duration was 11 months, from 6.5 to 18 months. The Wilcoxon signed-rank test was used to compare laboratory data before and after the procedure.

Results

Technical success (complete occlusion of the efferent shunt and complete filling of gastric varix [GV] with a gelfoam slurry) was achieved in 18 of 19 (94.7%) patients. The embolic materials could not reach the GV in 1 patient who had endoscopic glue injection before our procedure. The clinical success rate (no recurrence of gastric variceal bleeding) was the same because the technically failed patient showed recurrent bleeding later. Acute complications included fever (n = 2), fever and hypotension (n = 2; one diagnosed adrenal insufficiency), and transient microscopic hematuria (n = 3). Ten patients underwent follow-up endoscopy; all exhibited GV improvement, except 2 without endoscopic change. Five patients exhibited aggravated EV, and 2 of them had a bleeding event. Laboratory findings were significantly improved after PARTO.

Conclusion

PARTO is technically feasible, safe, and effective for gastric variceal hemorrhage in patients with portal hypertension.

Balloon-Occluded Retrograde Transvenous Obliteration for the Treatment of Gastric Varices: Polidocanol Foam Versus Liquid Ethanolamine Oleate

OBJECTIVE

The purpose of this study was to evaluate the clinical results of the management of gastric varices by balloon-occluded retrograde transvenous obliteration with polidocanol foam versus ethanolamine oleate.

MATERIALS AND METHODS

Twenty patients treated with ethanolamine oleate and 21 patients treated with polidocanol foam were enrolled in this study. Early therapeutic effects were assessed mainly by dynamic contrast-enhanced CT. Subjective symptoms, objective findings associated with the procedures, and changes in laboratory data during the obliteration process were evaluated. Rebleeding from gastric varices was assessed after the procedures.

RESULTS

Complete obliteration was confirmed in all but one case of early recanalization after treatment with polidocanol foam. One patient died of acute respiratory distress syndrome after treatment with ethanolamine oleate. The total sclerosant volume was significantly lower for 3% polidocanol foam (13.5 ± 6.8 mL) than for 5% ethanolamine oleate (30.6 ± 15.6 mL) (p < 0.01). Polidocanol foam caused fewer severe reactions, including pain, during and after injection. High body temperature, hemoglobinuria, and reactive pleural effusion were not observed with polidocanol foam. The variance in laboratory data values associated with hemolysis was significantly greater with ethanolamine oleate. No postprocedural rebleeding from the gastric varices was observed during a median follow-up time of 39.5 months after procedures with ethanolamine oleate and 34 months after procedures with polidocanol foam.

CONCLUSION

Polidocanol foam can achieve obliteration of gastric varices comparable to that of ethanolamine oleate but with a significantly lower sclerosant dose and reduced risk of hemolysis-induced complications and harmful reactions, including pain and fever.

Portal hypertensive gastropathy and gastric antral vascular ectasia

PURPOSE OF REVIEW

Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are two types of upper gastrointestinal bleeding that may present similarly, but are managed very differently. This article reviews the pathogenesis and guidelines in management of both of these conditions with emphasis on recent advances in the field.

RECENT FINDINGS

Off-label use of Hemospray has been shown in several case series to be useful in managing acute bleeding from PHG. Balloon-occluded retrograde transvenous obliteration presents an alternative approach for this condition. Radiofrequency ablation may be an alternative therapy to argon plasma coagulation in the endoscopic treatment of GAVE, as it consists of fewer sessions and has been shown to decrease gastrointestinal blood loss.

SUMMARY

The treatment options for PHG and GAVE are constantly evolving and expanding. In this review, we present the latest approaches in the gastroenterologist's arsenal to deal with these conditions.

Transjugular intrahepatic portosystemic shunt complications: prevention and management

Transjugular intrahepatic portosystemic shunt (TIPS) insertion has been well established as an effective treatment in the management of sequelae of portal hypertension. There are a wide variety of complications that can be encountered, such as hemorrhage, encephalopathy, TIPS dysfunction, and liver failure. This review article summarizes various approaches to preventing and managing these complications.

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) for Treatment of Gastric Varices: Review and Meta-Analysis

AIM

To perform a systematic review and meta-analysis of the effectiveness and complications of BRTO for gastric varices.

MATERIALS AND METHODS

A systematic review was performed to identify relevant articles. Inclusion criteria were applied to select studies with at least ten patients with acute bleeding or at-risk gastric varices treated with BRTO. Meta-analysis with random effects model was performed to calculate data for immediate technical success, clinical success, and complications.

RESULTS

A total of 1,016 Patients from 24 studies met inclusion criteria. Technical success rate for BRTO was 96.4 % (95 % CI 93.7, 98.3 %; Q = 3,269.26, p < 0.01, I (2) = 99.39 %). Clinical success (defined as no recurrence or rebleed of gastric varices, or complete obliteration of varices on subsequent imaging) rate was 97.3 % (95 % CI 95.2, 98.8 %; Q = 3,105.91, p < 0.01, I (2) = 99.29 %). Major complication rate was 2.6 % (95 % CI 1.1, 4.6 %; Q = 3,348.98, p < 0.01, I (2) = 99.34 %). Esophageal variceal recurrence rate was 33.3 % (95 % CI 24.6, 42.6 %; Q = 7,291.75, p < 0.01, I (2) = 99.74 %).

CONCLUSION

BRTO is safe and efficacious for gastric varices, and current best evidence suggests that BRTO could be considered as therapy for patients with gastric varices.

Endoscopic management of bleeding gastric varices--an updated overview

Gastric varices (GVs) are known to bleed massively and often difficult to manage with conventional techniques. This article aims to overview the endoscopic methods for the management of acute gastric variceal bleeding, especially the advantages and limits of GV obliteration with tissue adhesives, by comparison with band ligation and other direct endoscopic techniques of approach. The results of indirect radiological and surgical techniques of GV treatment are shortly discussed. A special attention is payed to the emerging role of endoscopic ultrasound in the therapy of bleeding GV, in the confirmation of its eradication and in follow-up strategies.

Nonendoscopic management strategies for acute esophagogastric variceal bleeding

Acute variceal bleeding is a potentially life-threatening complication of portal hypertension. Management consists of emergent hemostasis, therapy directed at hemodynamic resuscitation, protection of the airway, and prevention and treatment of complications including prophylactic use of antibiotics. Endoscopic treatment remains the mainstay in the management of acute variceal bleeding in combination with pharmacotherapy aimed at reducing portal pressure. This article intends to highlight only the current nonendoscopic treatment approaches for control of acute variceal bleeding.

Endovascular management of gastric varices

Bleeding from gastric varices is a major complication of portal hypertension. Although less common than bleeding associated with esophageal varices, gastric variceal bleeding has a higher mortality. From an endovascular perspective,transjugular intrahepatic portosystemic shunts (TIPS) to decompress the portal circulation and/or balloon-occluded retrograde transvenous obliteration (BRTO) are utilized to address bleeding gastric varices. Until recently, there was a clear medical cultural divide between the strategy of decompressing the portal circulation (TIPS creation, for example) and transvenous obliteration for the management of gastric varices. However, the practice of BRTO is gaining acceptance in the United States and its practice is spreading rapidly. Recently, the American College of Radiology has identified BRTO to be a viable alternative to TIPS in particular anatomical and clinical scenarios. However, the anatomical and clinical applications of BRTO were not defined beyond the conservative approach of resorting to BRTO in non-TIPS candidates. The article discusses the outcomes of BRTO and TIPS for the management of gastric varices individually or in combination. Definitions, endovascular technical concepts and contemporary vascular classifications of gastric variceal systems are described in order to help grasp the complexity of the hemodynamic pathology and hopefully help define the pathology better for future reporting and lay the ground for more defined stratification of patients not only based on comorbidity and hepatic reserve but on anatomy and hemodynamic classifications.

Combining Transjugular Intrahepatic Portosystemic Shunt with Balloon-Occluded Retrograde Transvenous Obliteration or Augmenting TIPS with Variceal Embolization for the Management of Gastric Varices: An Evolving Middle Ground?

The American College of Radiology Appropriateness Criteria Committee on interventional radiology has recently recognized balloon-occluded retrograde transvenous obliteration (BRTO) as a viable alternative to transjugular intrahepatic portosystemic shunt (TIPS) in certain anatomic and clinical scenarios for the management of gastric varices. However, it did not define these particular scenarios where BRTO would be a viable alternative. With the increased practice of BRTO in the United States, a debate ensues in the United States and Europe whether BRTO or TIPS should be the primary endovascular procedure of choice for gastric varices. From a conservative standpoint, BRTO is reserved for patients who are not TIPS candidates, while other institutions leave the decision to operator preference and "favorable anatomy" for either procedure. To add to the debate, there is a heightened interest in the improved efficacy of variceal embolization (metallic/bland embolization) concurrent with TIPS compared with TIPS without embolization, and a recent article describing a combination of TIPS and BRTO that demonstrated impressive results superior to BRTO or TIPS alone. This article discusses the most recent outcomes of TIPS and embolization of gastric varices as well as combining BRTO and TIPS.

Balloon-occluded retrograde transvenous obliteration for recurrent fundal gastric variceal bleeding in an adolescent

Gastric variceal bleeding is associated with high morbidity and mortality. Balloon-occluded retrograde transvenous obliteration is a relatively new treatment used to control bleeding gastric varices that involves transvenous sclerosis of gastric varices through a spontaneous gastrorenal shunt. Here, we report on a 14-yr-old patient that underwent balloon-occluded retrograde transvenous obliteration for refractory bleeding fundal varices in the setting of esophageal varices and cirrhosis, which did not respond to medical management or endoscopic injection. This case report serves as a reminder that balloon-occluded retrograde transvenous obliteration can successfully control fundal variceal bleeding in pediatric patients and may serve as a bridge to liver transplantation.

Update on gastric varices

Although less common than oesophageal variceal haemorrhage, gastric variceal bleeding remains a serious complication of portal hypertension, with a high associated mortality. In this review we provide an update on the aetiology, classification and management of gastric varices, including acute bleeding, prevention of rebleeding and primary prophylaxis. We describe the optimum management strategies for gastric varices including drug, endoscopic and radiological therapies, focusing on recent published evidence.

Long-term outcome of patients with gastric varices treated by balloon-occluded retrograde transvenous obliteration

BACKGROUND AND AIM

To assess the short- and long-term outcome of patients with gastric varices (GV) after balloon-occluded retrograde transvenous obliteration (B-RTO) by comparing bleeding cases with prophylactic cases.

METHODS

Consecutive 100 patients with GV treated by B-RTO were enrolled in this retrospective cohort study. We compared the technical success, complications, and survival rates between bleeding and prophylactic cases.

RESULTS

Of 100 patients, 61 patients were bleeding cases and 39 patients were prophylactic cases. Technical success was achieved in 95% of bleeding case and in 100% of prophylactic case, with no significant difference between these groups (overall technical success rate, 97%). The survival rates at 5 and 10 years were 50% and 22% in bleeding case, and 49% and 36% in prophylactic case, respectively. There was also no significant difference (P = 0.420). By multivariate analysis, survival rates correlated significantly with liver function (hazard ratio 2.371, 95% CI 1.457-3.860, P = 0.001) and hepatocellular carcinoma development (HR 4.782, 95% CI 2.331-9.810, P < 0.001). The aggravating rates of esophageal varices (EV) were 21%, 50%, and 54% at 12, 60, and 120 months after B-RTO. By multivariate analysis, aggravating rates significantly correlated with EV existing before B-RTO (HR 18.114, 95% CI 2.463-133.219, P = 0.004).

CONCLUSION

B-RTO for GV could provide the high rate of complete obliteration and favorable long-term prognosis even in bleeding cases as well as prophylactic cases. Management of EV after B-RTO, especially in coexisting case of GV and EV, would be warranted.

Ectopic varices: anatomical classification, hemodynamic classification, and hemodynamic-based management

Ectopic varices are dilated splanchnic (mesoportal) veins/varicosities and/or are dilated portosystemic collaterals that can occur along the entire gastrointestinal tract outside the common pathologic variceal sites. Ectopic varices are complex and highly variable entities that are not fully understood. Ectopic varices represent 2%-5% of a gastrointestinal tract variceal bleeding. However, ectopic varices have a 4-fold increased risk of bleeding when compared with esophageal varices and can have a mortality rate as high as 40%. All treatment strategies and techniques have been utilized in managing these potentially mortal varices and have shown poor outcomes. The debate of whether to manage these varices by decompression with a transjugular portosystemic shunt, or other portosystemic shunts, vs transvenous obliteration is unresolved. The rebleed rates after transjugular portosystemic shunt decompression are 20%-40%. The rebleed rates after transvenous obliteration and the mortality rate at 3-6 months are 30%-40% and 50%-60%, respectively. Hemodynamically from an etiology standpoint, there are 2 types: occlusive (type-b) and nonocclusive (oncotic or type-a). Hemodynamically from a vascular-shunting standpoint, there could be a component of portoportal or portosystemic shunting or both with varying dominance. This is the basis of the new classification system described herein. Management strategies (decompression vs sclerosis) are discussed. The ideal management strategy is a treatment that leads to prompt hemostasis but also addresses the etiology or hemodynamics of the ectopic varices. It is the hope that with better understanding, description, and categorization of ectopic varices comes a more systematic approach to this rare but menacing problem.

Vascular anatomy and the morphologic and hemodynamic classifications of gastric varices and spontaneous portosystemic shunts relevant to the BRTO procedure

The pathologic anatomy and hemodynamics of the left-sided portal circulation that is associated with gastric varices (GVs) are complex and highly variable. Understanding the pathologic anatomy and hemodynamics associated with GVs is important for clinical management decisions and for the technical descriptive details of the balloon-occluded retrograde transvenous obliteration (BRTO) and balloon-occluded antegrade transvenous obliteration procedures. A reflection of the considerable variability in anatomy, pathology, and hemodynamics is the numerous descriptive and categorical classifications that have been described in the past 2 decades. This article reviews the detailed descriptive gross anatomy, radiographic anatomy, and portosystemic venous hemodynamics that are associated with GVs and that can be encountered during the BRTO or balloon-occluded antegrade transvenous obliteration procedure(s) or both. Definitions are also set to clarify this detailed anatomy that received limited description in the prior literature. Moreover, all the classifications that have been described (to the best of the author's knowledge) that are relevant to the BRTO procedure are detailed in the article.

Balloon occlusion retrograde transvenous obliteration of gastric varices in two non-cirrhotic patients with portal vein thrombosis

This report describes two non-cirrhotic patients with portal vein thrombosis who underwent successful balloon occlusion retrograde transvenous obliteration (BRTO) of gastric varices with a satisfactory response and no complications. One patient was a 35-year-old female with a history of Crohn's disease, status post-total abdominal colectomy, and portal vein and mesenteric vein thrombosis. The other patient was a 51-year-old female with necrotizing pancreatitis, portal vein thrombosis, and gastric varices. The BRTO procedure was a useful treatment for gastric varices in non-cirrhotic patients with portal vein thrombosis in the presence of a gastrorenal shunt.

Balloon-occluded retrograde transvenous obliteration of gastric varices

Balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices is an image-guided transcatheter procedure used to treat gastric varices with sclerosants rather than decompression of the portal venous system. The history of its development, relevant portal venous, and systemic venous anatomic considerations, techniques, indications, and early results will be reviewed. In addition, the status of the practice of BRTO in the United States will be discussed.

Protective value of TIPS against the development of hydrothorax/ascites and upper gastrointestinal bleeding after balloon-occluded retrograde transvenous obliteration (BRTO)

OBJECTIVES

The objective of this study was to evaluate the incidence of post-balloon-occluded retrograde transvenous obliteration (BRTO) ascites/hepatic hydrothorax and rebleeding rate (variceal and non-variceal) in the presence and absence of a transjugular intrahepatic portosystemic shunt (TIPS).

METHODS

A retrospective audit of consecutive patients undergoing BRTO was performed (August 2007-October 2010). The population was divided into two groups: patients who underwent BRTO only (BRTO-only group) and those who underwent BRTO in the presence of TIPS (BRTO+TIPS group). Post-BRTO rebleeding was categorized for the source of bleeding. Ascites and/or hepatic hydrothorax were categorized according to clinical severity. Comparisons, utilizing the Kaplan-Meier method, between both groups were made for patient survival, incidence of ascites/hydrothorax, and rebleeding.

RESULTS

Thirty-nine patients underwent BRTO (three technical failures of BRTO-only group). Of the 36 technically successful BRTO procedures, 27 patients (75%) underwent BRTO-only and 9 patients (25%) underwent BRTO in the presence of a TIPS. Pre-BRTO ascites/hydrothorax resolved in BRTO-only vs. BRTO+TIPS in 7% (N=2/27) and 56% (N=5/9), respectively (P=0.006). The ascites/hydrothorax free rate at 6, 12, and 24 months after BRTO for BRTO-only vs. BRTO+TIPS was 58%, 43%, 29%, and 100%, 100%, 100%, respectively (P=0.01). Recurrent hemorrhage for BRTO-only vs. BRTO+TIPS groups, and for the same time periods was 9%, 9%, 21% vs. 0%, 0%, 0%, respectively (P=0.03). The 1-year patient survival of both groups (80-88%) was similar (P>0.05).

CONCLUSIONS

This study concludes that the presence of TIPS has a protective value against the development of post-BRTO ascites/hydrothorax as well as recurrent hemorrhage but this does not translate to improved patient survival.

Factors affecting re-bleeding after injection of cyanoacrylate for gastric varices

AIM: To investigate the rate of re-bleeding after injection of cyanoacrylate for gastric varices in patients with large gastric varices and to identify probable risk factors for re-bleeding.

METHODS: A retrospective analysis was carried out in 52 cirrhotic patients who had large gastric varices and underwent endoscopic cyanoacrylate injection at our hospital from June 2010 to April 2012. To identify probable risk factors for re-bleeding after injection of cyanoacrylate for gastric varices, various factors were collected and analyzed, including gender, age, types of cirrhosis, coexistent hepatocellular carcinoma, Child-Pugh classification, presence of ascites, portal vein thrombosis, diameter of portal vein and spleen vein, spleen length, spleen thickness, routine blood tests, liver function tests, renal function tests, coagulation function tests, fasting blood sugar, α fetal protein, Child score, MELD score, and endoscopic variceal characteristics.

RESULTS: Recurrent bleeding occurred in 18 patients (34.62%) after initial cyanoacrylate injection, and the mean re-bleeding time was 5.5 mo ± 4.9 mo. Logistic regression analysis revealed that Child-Pugh classification, gamma-glutamyl transpeptidase (GGT) and spleen length were probable risk factors for recurrent bleeding after cyanoacrylate injection (P = 0.036, 0.009, 0.033; OR = 15.262, 47.684, 38.249; 95%CI: 1.197-194.573, 2.604-873.328, 1.339-1 092.543). The areas under ROC curve of GGT and spleen length in the diagnosis of re-bleeding were 0.773 and 0.704, with sensitivities of 66.7% and 93.8% and specificities of 85.7% and 52.6%.

CONCLUSION: Recurrent bleeding after injection of cyanoacrylate for gastric varices is affected by Child-Pugh B or C, GGT and spleen length.

Balloon-occluded antegrade transvenous obliteration with or without balloon-occluded retrograde transvenous obliteration for the management of gastric varices: concept and technical applications

Alternative routes for transvenous obliteration are sometimes resorted in the management of gastric varices. These alternative routes can be classified into A, portal venous access routes and B, systemic venous access routes. The portal venous approach to transvenous obliteration is called balloon-occluded antegrade transvenous obliteration (BATO) and is a collective definition, including 1-percutaneous transhepatic obliteration (PTO), 2-through an existing transjugular intrahepatic portosystemic shunt [(Trans-TIPS), and 3-trans-iliocolic vein obliteration (TIO)]. PTO is usually out of necessity; however, trans-TIPS approach is usually used out of serendipity (because the low-risk access route is there). The TIPS for the trans-TIPS BATO is not formed for mere access, but is done to create a TIPS or is done when there is a preexisting TIPS. The trans-TIPS approach can be resorted to in the United States in up to 19% of balloon-occluded retrograde transvenous obliteration (BRTO) cases. PTO is resorted to, out of necessity, in the United States and Japan in 10% of BRTO cases (2%-19% of BRTO cases) and can increase the technical and obliterative success rate of the transvenous obliteration procedure from 84%-98% to 98%-100%. The advantage of BATO as an adjunct to BRTO (combining a BRTO and BATO approach to obliterate the gastric varices) is not only limited to increasing the technical success rate of the obliterative procedure. BATO reduces the risk of overspill of the sclerosant from the gastric variceal system into the portal vein. Moreover, if the BATO is performed from a trans-TIPS approach, any overspill of the sclerosant mixture will partly (if not mostly) go through the patent TIPS to the systemic circulation (lung) rather than the intrahepatic portal vein branches (prevent portal vein embolization). This article discusses the clinical and technical applications, technical considerations, and the outcomes of BATO.

Balloon-occluded retrograde transvenous obliteration of gastric varices

OBJECTIVE

The purpose of this review is to describe the clinical factors related to balloon-occluded retrograde transvenous obliteration, including the preparation needed, the technique and challenges, and the outcomes.

CONCLUSION

Although the procedure can be performed when transjugular intrahepatic portosystemic shunt is contraindicated or when endoscopic management fails, balloon-occluded retrograde transvenous obliteration is successful as a first-line or second-line therapy. Gastric variceal rebleeding rates are low and serious complications are rare. Randomized controlled trials are required to evaluate the superiority of this procedure over other methods of treating gastric varices and to determine which sclerosant should be used. In the near future, this procedure may play a larger role in emergency care and in the management of nongastric varices.

Balloon-occluded retrograde transvenous obliteration of gastric varices: concept, basic techniques, and outcomes

Patients with gastric variceal bleeding require a multidisciplinary team approach including hepatologists, endoscopists, diagnostic radiologists, and interventional radiologists. Upper gastrointestinal endoscopy is the first-line diagnostic and management tool for bleeding gastric varices, as it is in all upper gastrointestinal bleeding scenarios. In the United States when endoscopy fails to control gastric variceal bleeding, a transjugular intrahepatic portosystemic shunt (TIPS) traditionally is performed along the classic teachings of decompressing the portal circulation. However, TIPS has not shown the same effectiveness in controlling gastric variceal bleeding that it has with esophageal variceal bleeding. For the past 2 decades, the balloon-occluded retrograde transvenous obliteration (BRTO) procedure has become common practice in Asia for the management of gastric varices. BRTO is gaining popularity in the United States. It has been shown to be effective in controlling gastric variceal bleeding with low rebleed rates. BRTO has many advantages over TIPS in that it is less invasive and can be performed on patients with poor hepatic reserve and those with encephalopathy (and may even improve both). However, its by-product is occlusion of a spontaneous hepatofugal (TIPS equivalent) shunt, and thus it is contradictory to the traditional American doctrine of portal decompression. Indeed, BRTO causes an increase in portal hypertension, with potential aggravation of esophageal varices and ascites. This article discusses the concept, technique, and outcomes of BRTO within the broader management of gastric varices.