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Balloon Occlusion Variceal Ablation
Brandt C. Wible, MD
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Post Procedure

          • Outcomes

            TERMINOLOGY

            • Definitions

              • Balloon-occluded retrograde transvenous obliteration (BRTO): Method for treating gastric varices (GV), which are associated with large, spontaneous portosystemic venous shunt
                • Developed in Japan as transjugular intrahepatic portosystemic shunt (TIPS) adjunct/alternative; well established in Asia, slow acceptance in USA
                • Technique: Injection of sclerosant via balloon catheter positioned at outlet of vein draining GV
                  • Shunt is occluded with balloon, then sclerosant injected retrograde into varices
                  • Causes thrombosis/obliteration of varices and obliterates gastrorenal shunt (GRS) or gastrocaval shunt (GCS)
                • Sclerosants
                  • Ethanolamine oleate (EO): Sclerosant most reported with BRTO in literature; common in Asia, not popular in USA [sclerosant-induced renal failure antidote (haptoglobin) unavailable]; limited to 40-mL volume
                  • Sodium tetradecyl sulfate (STS): Detergent sclerosant used in USA; mixed with air, allowing it to travel to distant and nondependent varices
                  • Gelfoam: Gaining popularity, less risk of adverse event vs. EO; interventional radiologists more comfortable with its use vs. STS
                • BRTO variants
                  • Plug-assisted retrograde transvenous obliteration (PARTO): Placing Amplatzer plug in efferent shunt prior to delivery of sclerosant
                  • Coil-assisted retrograde transvenous obliteration (CARTO): Placing coil in dominant shunt prior to delivery of sclerosant
                  • Balloon-occluded antegrade transvenous obliteration (BATO): Accessing GV via percutaneous transhepatic or TIPS approach, often considered bail-out for failed BRTO
                • BRTO vs. TIPS
                  • BRTO: Flow redirected to liver, potentially improving hepatic encephalopathy and preserving liver function (6-9 months) but aggravating portal hypertension and potentially worsening esophageal varices (EV)
                  • TIPS: Flow directed away from liver can result in worsening of encephalopathy and liver failure, especially if model for end-stage liver disease (MELD) > 19
                  • Recurrent bleeding: Few studies comparing BRTO vs. TIPS with covered stent
                    • Rebleed rate of patients post BRTO is 3-9% from GV but as high as 19-31% from all gastrointestinal sources
                    • Rebleed rate for patients post TIPS is 11-22% when placed to treat EV but as high as 13-53% from GV
              • EV
                • Venous saccules in esophageal wall, typically associated with portal hypertension, prone to rupture
                • Gastroesophageal varices
                  • Located in lower esophagus and gastric cardia; drain into ascending EV
                  • Usually treated endoscopically or with TIPS
              • GV
                • Typically associated with portal hypertension and spontaneous portosystemic shunt (SPS)
                • Can be associated with occluded mesosplenoportal veins without portal hypertension
                • Incidence of bleed from GV
                  • 25% overall
                  • Fundal varices
                    • 1 year: 16%
                    • 3 years: 36%
                    • 5 years: 44%
                  • GV vs. EV
                    • Bleed is more common from EV (75%) than GV (25%), and endoscopic management is more effective for EV vs. GV
                    • Mortality higher with GV (45-55%) vs. EV; rationale for treatment of nonbleeding/at-risk GV patients
                • Isolated GV
                  • May bleed despite portal gradient < 12 mm Hg
                  • Located in fundus &/or cardia
                  • Majority of fundal GV drain into left inferior phrenic vein (IPV)
                    • Left IPV drains into left renal vein, forming GRS
                    • May drain into left renal vein with or separately from left adrenal vein
                  • Develop as part of large portosystemic shunt that runs through stomach wall
                  • Usually drain into left renal vein or inferior vena cava
                  • Endoscopy therapy poor; large, high-flow varices
                  • Gastric bleeding mortality > EV
                  • Post-TIPS rebleeding higher for GV
                  • Good indication for BRTO
              • SPS
                • Often due to high portal pressure; rarely due to obstruction of portal venous system
                • Dictates approach for treatment of GV; understand afferent and efferent vein anatomy of SPS
                • Left-sided SPS
                  • GRS: In 80-85% of GV cases
                    • May be associated with large pericardiophrenic vein and GCS
                    • Rarely communicates with ascending lumbar/azygos veins
                    • Access point for BRTO
                  • GCS: In 10-15% of GV cases
                    • Left inferior phrenic/afferent gastric veins drain directly into inferior vena cava (IVC); may drain into left hepatic vein
                    • Majority associated with collateral drainage: Left pericardial, thoracic wall, intercostal veins, anastomosis to right IPV
                    • BRTO more difficult than in GRS
                    • Least common of left-sided SPS
                  • Splenorenal shunt: Not present with GV
                • Afferent veins of SPS (portal venous inflow)
                  • Left gastric vein (LGV): a.k.a. coronary vein
                  • Short gastric veins (SGVs): Often multiple, can have dominant vein
                  • Posterior gastric vein (PGV): Often single, can bifurcate
                • Efferent veins of SPS (systemic venous outflow)
                  • GRS: Access point for BRTO
                  • IPV: May require embolization prior to BRTO
                  • Retroperitoneal veins: Small and variable
              • Gastric variceal complex (GVC)
                • Combined GV and GRS
                • Multiple classification systems exist
                • Efferent (systemic-based) classification
                  • Practical information to plan treatment
                  • Type A: Varices contiguous with single draining portosystemic shunt (no collateral flow)
                    • Treatment: Standard BRTO technique
                  • Type B: Varices contiguous with single shunt, plus 1 or more collateral veins
                    • 3 subtypes exist: When high-flow collateral veins present, requires modification of standard technique
                    • Treatment: Embolize collateral veins or advance occlusion catheter beyond collaterals
                  • Type C: Varices contiguous with both GRS and GCS
                    • Smaller shunt: Embolize one with coils
                    • Larger shunt: Place occlusion balloons into outflow of both shunts
                  • Type D: No GRS/GCS; varices drain via small collaterals not directly contiguous with either IVC or renal vein
                    • Treatment: No BRTO; cannot be catheterized
                • Afferent (portal based) classification
                  • Often unknown prior to procedure; may explain failures but not alter treatment plan
                  • Type 1: Supplied by single afferent gastric vein
                    • Sclerosant fills entire varix, no spill out
                  • Type 2: Supplied by multiple afferent gastric veins
                    • Sclerosant can fill entire varix or spill into portal system
                  • Type 3: Coexistent gastric branch veins directly contiguous with afferent feeder, not contributing to GV
                    • Sclerosant can easily pass into portal system

            PREPROCEDURE

            • Indications

              • Contraindications

                • Preprocedure Imaging

                  • Getting Started

                    PROCEDURE

                    • Procedure Steps

                      • Alternative Procedures/Therapies

                        POST PROCEDURE

                        • Things to Do

                          OUTCOMES

                          • Complications

                            • Expected Outcomes

                              Selected References

                              1. Luo X et al: Endoscopic cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration for prevention of gastric variceal bleeding: a randomized controlled trial. Hepatology. 74(4):2074-84, 2021
                              2. Waguri N et al: Balloon-occluded retrograde transvenous obliteration for treatment of gastric varices. World J Hepatol. 13(6):650-61, 2021
                              3. Wang ZW et al: Comparison of the effects of TIPS versus BRTO on bleeding gastric varices: a meta-analysis. Can J Gastroenterol Hepatol. 2020:5143013, 2020
                              4. Kobayakawa M et al: Recent development of balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 34(3):495-500, 2019
                              5. Hirota S et al: Balloon-occluded retrograde transvenous obliteration of varices: focusing on the portal hemodynamics and the recent techniques. Hepatol Int. 12(Suppl 1):102-11, 2018
                              6. Kim DJ et al: Modified balloon-occluded retrograde transvenous obliteration (BRTO) techniques for the treatment of gastric varices: vascular plug-assisted retrograde transvenous obliteration (PARTO)/coil-assisted retrograde transvenous obliteration (CARTO)/balloon-occluded antegrade transvenous obliteration (BATO). Cardiovasc Intervent Radiol. 41(6):835-47, 2018
                              7. Patel M et al: Evolution of retrograde transvenous obliteration techniques. Semin Intervent Radiol. 35(3):185-93, 2018
                              8. Chang MY et al: Plug-assisted retrograde transvenous obliteration for the treatment of gastric variceal hemorrhage. Korean J Radiol. 17(2):230-8, 2016
                              9. Kim T et al: Vascular plug assisted retrograde transvenous obliteration (PARTO) for gastric varix bleeding patients in the emergent clinical setting. Yonsei Med J. 57(4):973-9, 2016
                              10. Kim YH et al: Comparison of balloon-occluded retrograde transvenous obliteration (BRTO) using ethanolamine oleate (EO), BRTO using sodium tetradecyl sulfate (STS) foam and vascular plug-assisted retrograde transvenous obliteration (PARTO). Cardiovasc Intervent Radiol. 39(6):840-6, 2016
                              11. Gwon DI et al: Vascular plug-assisted retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy: a prospective multicenter study. J Vasc Interv Radiol. 26(11):1589-95, 2015
                              12. Park JK et al: Balloon-occluded retrograde transvenous obliteration (BRTO) for treatment of gastric varices: review and meta-Analysis. Dig Dis Sci. 60(6):1543-53, 2015
                              13. Saad WE: Vascular anatomy and the morphologic and hemodynamic classifications of gastric varices and spontaneous portosystemic shunts relevant to the BRTO procedure. Tech Vasc Interv Radiol. 16(2):60-100, 2013
                              14. Saad WE et al: Optimizing logistics for balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices by doing away with the indwelling balloon: concept and techniques. Tech Vasc Interv Radiol. 16(2):152-7, 2013
                              15. Yoshida H et al: Risk factors for bleeding esophagogastric varices. J Nippon Med Sch. 80(4):252-9, 2013
                              16. Akahoshi T et al: Long-term results of balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding and risky gastric varices: a 10-year experience. J Gastroenterol Hepatol. 23(11):1702-9, 2008
                              17. Cho SK et al: Balloon-occluded retrograde transvenous obliteration of gastric varices: outcomes and complications in 49 patients. AJR Am J Roentgenol. 189(6):W365-72, 2007
                              18. Ninoi T et al: Balloon-occluded retrograde transvenous obliteration of gastric varices with gastrorenal shunt: long-term follow-up in 78 patients. AJR Am J Roentgenol. 184(4):1340-6, 2005
                              19. Shimoda R et al: Short-term complications of retrograde transvenous obliteration of gastric varices in patients with portal hypertension: effects of obliteration of major portosystemic shunts. Abdom Imaging. 30(3):306-13, 2005
                              20. Kiyosue H et al: Transcatheter obliteration of gastric varices. Part 1. Anatomic classification. Radiographics. 23(4):911-20, 2003
                              21. Kiyosue H et al: Transcatheter obliteration of gastric varices: part 2. Strategy and techniques based on hemodynamic features. Radiographics. 23(4):921-37; discussion 937, 2003
                              22. Kato T et al: Therapeutic effect of balloon-occluded retrograde transvenous obliteration on portal-systemic encephalopathy in patients with liver cirrhosis. Intern Med. 40(8):688-91, 2001
                              23. Kanagawa H et al: Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 11(1):51-8, 1996
                              Related Anatomy
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                              Related Differential Diagnoses
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                              References
                              Tables

                              Tables

                              KEY FACTS

                              • Terminology

                                • Preprocedure

                                  • Procedure

                                    • Post Procedure

                                      • Outcomes

                                        TERMINOLOGY

                                        • Definitions

                                          • Balloon-occluded retrograde transvenous obliteration (BRTO): Method for treating gastric varices (GV), which are associated with large, spontaneous portosystemic venous shunt
                                            • Developed in Japan as transjugular intrahepatic portosystemic shunt (TIPS) adjunct/alternative; well established in Asia, slow acceptance in USA
                                            • Technique: Injection of sclerosant via balloon catheter positioned at outlet of vein draining GV
                                              • Shunt is occluded with balloon, then sclerosant injected retrograde into varices
                                              • Causes thrombosis/obliteration of varices and obliterates gastrorenal shunt (GRS) or gastrocaval shunt (GCS)
                                            • Sclerosants
                                              • Ethanolamine oleate (EO): Sclerosant most reported with BRTO in literature; common in Asia, not popular in USA [sclerosant-induced renal failure antidote (haptoglobin) unavailable]; limited to 40-mL volume
                                              • Sodium tetradecyl sulfate (STS): Detergent sclerosant used in USA; mixed with air, allowing it to travel to distant and nondependent varices
                                              • Gelfoam: Gaining popularity, less risk of adverse event vs. EO; interventional radiologists more comfortable with its use vs. STS
                                            • BRTO variants
                                              • Plug-assisted retrograde transvenous obliteration (PARTO): Placing Amplatzer plug in efferent shunt prior to delivery of sclerosant
                                              • Coil-assisted retrograde transvenous obliteration (CARTO): Placing coil in dominant shunt prior to delivery of sclerosant
                                              • Balloon-occluded antegrade transvenous obliteration (BATO): Accessing GV via percutaneous transhepatic or TIPS approach, often considered bail-out for failed BRTO
                                            • BRTO vs. TIPS
                                              • BRTO: Flow redirected to liver, potentially improving hepatic encephalopathy and preserving liver function (6-9 months) but aggravating portal hypertension and potentially worsening esophageal varices (EV)
                                              • TIPS: Flow directed away from liver can result in worsening of encephalopathy and liver failure, especially if model for end-stage liver disease (MELD) > 19
                                              • Recurrent bleeding: Few studies comparing BRTO vs. TIPS with covered stent
                                                • Rebleed rate of patients post BRTO is 3-9% from GV but as high as 19-31% from all gastrointestinal sources
                                                • Rebleed rate for patients post TIPS is 11-22% when placed to treat EV but as high as 13-53% from GV
                                          • EV
                                            • Venous saccules in esophageal wall, typically associated with portal hypertension, prone to rupture
                                            • Gastroesophageal varices
                                              • Located in lower esophagus and gastric cardia; drain into ascending EV
                                              • Usually treated endoscopically or with TIPS
                                          • GV
                                            • Typically associated with portal hypertension and spontaneous portosystemic shunt (SPS)
                                            • Can be associated with occluded mesosplenoportal veins without portal hypertension
                                            • Incidence of bleed from GV
                                              • 25% overall
                                              • Fundal varices
                                                • 1 year: 16%
                                                • 3 years: 36%
                                                • 5 years: 44%
                                              • GV vs. EV
                                                • Bleed is more common from EV (75%) than GV (25%), and endoscopic management is more effective for EV vs. GV
                                                • Mortality higher with GV (45-55%) vs. EV; rationale for treatment of nonbleeding/at-risk GV patients
                                            • Isolated GV
                                              • May bleed despite portal gradient < 12 mm Hg
                                              • Located in fundus &/or cardia
                                              • Majority of fundal GV drain into left inferior phrenic vein (IPV)
                                                • Left IPV drains into left renal vein, forming GRS
                                                • May drain into left renal vein with or separately from left adrenal vein
                                              • Develop as part of large portosystemic shunt that runs through stomach wall
                                              • Usually drain into left renal vein or inferior vena cava
                                              • Endoscopy therapy poor; large, high-flow varices
                                              • Gastric bleeding mortality > EV
                                              • Post-TIPS rebleeding higher for GV
                                              • Good indication for BRTO
                                          • SPS
                                            • Often due to high portal pressure; rarely due to obstruction of portal venous system
                                            • Dictates approach for treatment of GV; understand afferent and efferent vein anatomy of SPS
                                            • Left-sided SPS
                                              • GRS: In 80-85% of GV cases
                                                • May be associated with large pericardiophrenic vein and GCS
                                                • Rarely communicates with ascending lumbar/azygos veins
                                                • Access point for BRTO
                                              • GCS: In 10-15% of GV cases
                                                • Left inferior phrenic/afferent gastric veins drain directly into inferior vena cava (IVC); may drain into left hepatic vein
                                                • Majority associated with collateral drainage: Left pericardial, thoracic wall, intercostal veins, anastomosis to right IPV
                                                • BRTO more difficult than in GRS
                                                • Least common of left-sided SPS
                                              • Splenorenal shunt: Not present with GV
                                            • Afferent veins of SPS (portal venous inflow)
                                              • Left gastric vein (LGV): a.k.a. coronary vein
                                              • Short gastric veins (SGVs): Often multiple, can have dominant vein
                                              • Posterior gastric vein (PGV): Often single, can bifurcate
                                            • Efferent veins of SPS (systemic venous outflow)
                                              • GRS: Access point for BRTO
                                              • IPV: May require embolization prior to BRTO
                                              • Retroperitoneal veins: Small and variable
                                          • Gastric variceal complex (GVC)
                                            • Combined GV and GRS
                                            • Multiple classification systems exist
                                            • Efferent (systemic-based) classification
                                              • Practical information to plan treatment
                                              • Type A: Varices contiguous with single draining portosystemic shunt (no collateral flow)
                                                • Treatment: Standard BRTO technique
                                              • Type B: Varices contiguous with single shunt, plus 1 or more collateral veins
                                                • 3 subtypes exist: When high-flow collateral veins present, requires modification of standard technique
                                                • Treatment: Embolize collateral veins or advance occlusion catheter beyond collaterals
                                              • Type C: Varices contiguous with both GRS and GCS
                                                • Smaller shunt: Embolize one with coils
                                                • Larger shunt: Place occlusion balloons into outflow of both shunts
                                              • Type D: No GRS/GCS; varices drain via small collaterals not directly contiguous with either IVC or renal vein
                                                • Treatment: No BRTO; cannot be catheterized
                                            • Afferent (portal based) classification
                                              • Often unknown prior to procedure; may explain failures but not alter treatment plan
                                              • Type 1: Supplied by single afferent gastric vein
                                                • Sclerosant fills entire varix, no spill out
                                              • Type 2: Supplied by multiple afferent gastric veins
                                                • Sclerosant can fill entire varix or spill into portal system
                                              • Type 3: Coexistent gastric branch veins directly contiguous with afferent feeder, not contributing to GV
                                                • Sclerosant can easily pass into portal system

                                        PREPROCEDURE

                                        • Indications

                                          • Contraindications

                                            • Preprocedure Imaging

                                              • Getting Started

                                                PROCEDURE

                                                • Procedure Steps

                                                  • Alternative Procedures/Therapies

                                                    POST PROCEDURE

                                                    • Things to Do

                                                      OUTCOMES

                                                      • Complications

                                                        • Expected Outcomes

                                                          Selected References

                                                          1. Luo X et al: Endoscopic cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration for prevention of gastric variceal bleeding: a randomized controlled trial. Hepatology. 74(4):2074-84, 2021
                                                          2. Waguri N et al: Balloon-occluded retrograde transvenous obliteration for treatment of gastric varices. World J Hepatol. 13(6):650-61, 2021
                                                          3. Wang ZW et al: Comparison of the effects of TIPS versus BRTO on bleeding gastric varices: a meta-analysis. Can J Gastroenterol Hepatol. 2020:5143013, 2020
                                                          4. Kobayakawa M et al: Recent development of balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 34(3):495-500, 2019
                                                          5. Hirota S et al: Balloon-occluded retrograde transvenous obliteration of varices: focusing on the portal hemodynamics and the recent techniques. Hepatol Int. 12(Suppl 1):102-11, 2018
                                                          6. Kim DJ et al: Modified balloon-occluded retrograde transvenous obliteration (BRTO) techniques for the treatment of gastric varices: vascular plug-assisted retrograde transvenous obliteration (PARTO)/coil-assisted retrograde transvenous obliteration (CARTO)/balloon-occluded antegrade transvenous obliteration (BATO). Cardiovasc Intervent Radiol. 41(6):835-47, 2018
                                                          7. Patel M et al: Evolution of retrograde transvenous obliteration techniques. Semin Intervent Radiol. 35(3):185-93, 2018
                                                          8. Chang MY et al: Plug-assisted retrograde transvenous obliteration for the treatment of gastric variceal hemorrhage. Korean J Radiol. 17(2):230-8, 2016
                                                          9. Kim T et al: Vascular plug assisted retrograde transvenous obliteration (PARTO) for gastric varix bleeding patients in the emergent clinical setting. Yonsei Med J. 57(4):973-9, 2016
                                                          10. Kim YH et al: Comparison of balloon-occluded retrograde transvenous obliteration (BRTO) using ethanolamine oleate (EO), BRTO using sodium tetradecyl sulfate (STS) foam and vascular plug-assisted retrograde transvenous obliteration (PARTO). Cardiovasc Intervent Radiol. 39(6):840-6, 2016
                                                          11. Gwon DI et al: Vascular plug-assisted retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy: a prospective multicenter study. J Vasc Interv Radiol. 26(11):1589-95, 2015
                                                          12. Park JK et al: Balloon-occluded retrograde transvenous obliteration (BRTO) for treatment of gastric varices: review and meta-Analysis. Dig Dis Sci. 60(6):1543-53, 2015
                                                          13. Saad WE: Vascular anatomy and the morphologic and hemodynamic classifications of gastric varices and spontaneous portosystemic shunts relevant to the BRTO procedure. Tech Vasc Interv Radiol. 16(2):60-100, 2013
                                                          14. Saad WE et al: Optimizing logistics for balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices by doing away with the indwelling balloon: concept and techniques. Tech Vasc Interv Radiol. 16(2):152-7, 2013
                                                          15. Yoshida H et al: Risk factors for bleeding esophagogastric varices. J Nippon Med Sch. 80(4):252-9, 2013
                                                          16. Akahoshi T et al: Long-term results of balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding and risky gastric varices: a 10-year experience. J Gastroenterol Hepatol. 23(11):1702-9, 2008
                                                          17. Cho SK et al: Balloon-occluded retrograde transvenous obliteration of gastric varices: outcomes and complications in 49 patients. AJR Am J Roentgenol. 189(6):W365-72, 2007
                                                          18. Ninoi T et al: Balloon-occluded retrograde transvenous obliteration of gastric varices with gastrorenal shunt: long-term follow-up in 78 patients. AJR Am J Roentgenol. 184(4):1340-6, 2005
                                                          19. Shimoda R et al: Short-term complications of retrograde transvenous obliteration of gastric varices in patients with portal hypertension: effects of obliteration of major portosystemic shunts. Abdom Imaging. 30(3):306-13, 2005
                                                          20. Kiyosue H et al: Transcatheter obliteration of gastric varices. Part 1. Anatomic classification. Radiographics. 23(4):911-20, 2003
                                                          21. Kiyosue H et al: Transcatheter obliteration of gastric varices: part 2. Strategy and techniques based on hemodynamic features. Radiographics. 23(4):921-37; discussion 937, 2003
                                                          22. Kato T et al: Therapeutic effect of balloon-occluded retrograde transvenous obliteration on portal-systemic encephalopathy in patients with liver cirrhosis. Intern Med. 40(8):688-91, 2001
                                                          23. Kanagawa H et al: Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 11(1):51-8, 1996