Abstract
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.
Keywords BRTO - transvenous obliteration - gastric - varices - TIPS - portal hypertension
