Endovascular Treatment for Variceal Hemorrhage: TIPS, BRTO, and Combined Approaches

Andrew J. Lipnik; Mithil B. Pandhi; Ramzy C. Khabbaz; Ron C. Gaba

doi:10.1055/s-0038-1660795

Seminars in Interventional Radiology, Table of Contents

Semin intervent Radiol 2018; 35(03): 169-184
DOI: 10.1055/s-0038-1660795

Review Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Endovascular Treatment for Variceal Hemorrhage: TIPS, BRTO, and Combined Approaches

Andrew J. Lipnik

¹Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois

²Division of Interventional Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois

,

Mithil B. Pandhi

¹Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois

,

Ramzy C. Khabbaz

¹Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois

,

Ron C. Gaba

¹Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois

²Division of Interventional Radiology, University of Illinois Hospital & Health Sciences System, Chicago, Illinois

› Author Affiliations

Abstract

Variceal hemorrhage is a feared complication of portal hypertension, with high rates of morbidity and mortality. Optimal management requires a thoughtful, multidisciplinary approach. In cases of refractory or recurrent esophageal hemorrhage, endovascular approaches such as transjugular intrahepatic portosystemic shunt (TIPS) have a well-defined role. For hemorrhage related to gastric varices, the optimal treatment remains to be established; however, there is increasing adoption of balloon-occluded retrograde transvenous obliteration (BRTO). This article will review the concept, history, patient selection, basic technique, and outcomes for TIPS, BRTO, and combined TIPS + BRTO procedures for variceal hemorrhage.

Keywords

variceal hemorrhage - gastric varices - esophageal varices - transjugular intrahepatic portosystemic shunt - balloon-occluded retrograde transvenous obliteration

Full Text

References

References
1 D'Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol 2006; 44 (01) 217-231
2 Mallet M, Rudler M, Thabut D. Variceal bleeding in cirrhotic patients. Gastroenterol Rep (Oxf) 2017; 5 (03) 185-192
3 Saad WEA, Darcy MD. Transjugular intrahepatic portosystemic shunt (TIPS) versus balloon-occluded retrograde transvenous obliteration (BRTO) for the management of gastric varices. Semin Intervent Radiol 2011; 28 (03) 339-349
4 Saad WE. 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?. Semin Intervent Radiol 2014; 31 (03) 266-268
5 Fernandez M, Abraldes JG. Gastroesophageal varices. In: Muriel P. , ed. Liver Pathophysiology: Therapies and Antioxidants. New York, NY: Elsevier; 2017: 451-473
6 Groszmann RJ, Garcia-Tsao G, Bosch J. , et al; Portal Hypertension Collaborative Group. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med 2005; 353 (21) 2254-2261
7 Kovalak M, Lake J, Mattek N, Eisen G, Lieberman D, Zaman A. Endoscopic screening for varices in cirrhotic patients: data from a national endoscopic database. Gastrointest Endosc 2007; 65 (01) 82-88
8 Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992; 16 (06) 1343-1349
9 Kim T, Shijo H, Kokawa H. , et al. Risk factors for hemorrhage from gastric fundal varices. Hepatology 1997; 25 (02) 307-312
10 Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology 2017; 65 (01) 310-335
11 de Franchis R, Pascal JP, Ancona E. , et al. Definitions, methodology and therapeutic strategies in portal hypertension. A Consensus Development Workshop, Baveno, Lake Maggiore, Italy, April 5 and 6, 1990. J Hepatol 1992; 15 (1–2): 256-261
12 Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. ; Practice Guidelines Committee of the American Association for the Study of Liver Diseases; Practice Parameters Committee of the American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007; 46 (03) 922-938
13 Christensen E, Fauerholdt L, Schlichting P, Juhl E, Poulsen H, Tygstrup N. Aspects of the natural history of gastrointestinal bleeding in cirrhosis and the effect of prednisone. Gastroenterology 1981; 81 (05) 944-952
14 Merli M, Nicolini G, Angeloni S. , et al. Incidence and natural history of small esophageal varices in cirrhotic patients. J Hepatol 2003; 38 (03) 266-272
15 Gulamhusein AF, Kamath PS. The epidemiology and pathogenesis of gastrointestinal varices. Tech Gastrointest Endosc 2017; 19 (02) 62-68
16 Merkel C, Marin R, Angeli P. , et al; Gruppo Triveneto per l'Ipertensione Portale. A placebo-controlled clinical trial of nadolol in the prophylaxis of growth of small esophageal varices in cirrhosis. Gastroenterology 2004; 127 (02) 476-484
17 Chao Y, Lin H-C, Lee F-Y. , et al. Hepatic hemodynamic features in patients with esophageal or gastric varices. J Hepatol 1993; 19 (01) 85-89
18 Watanabe K, Kimura K, Matsutani S, Ohto M, Okuda K. Portal hemodynamics in patients with gastric varices. A study in 230 patients with esophageal and/or gastric varices using portal vein catheterization. Gastroenterology 1988; 95 (02) 434-440
19 Polio J, Groszmann RJ. Hemodynamic factors involved in the development and rupture of esophageal varices: a pathophysiologic approach to treatment. Semin Liver Dis 1986; 6 (04) 318-331
20 Polio J, Groszmann RJ, Reuben A, Sterzel RB, Better OS. Portal hypertension ameliorates arterial hypertension in spontaneously hypertensive rats. J Hepatol 1989; 8 (03) 294-301
21 Berzigotti A. Advances and challenges in cirrhosis and portal hypertension. BMC Med 2017; 15 (01) 200
22 Gaba RC, Couture PM, Lakhoo J. Gastroesophageal variceal filling and drainage pathways: an angiographic description of afferent and efferent venous anatomic patterns. J Clin Imaging Sci 2015; 5 (01) 61-66
23 Merkel C, Zoli M, Siringo S. , et al. Prognostic indicators of risk for first variceal bleeding in cirrhosis: a multicenter study in 711 patients to validate and improve the North Italian Endoscopic Club (NIEC) index. Am J Gastroenterol 2000; 95 (10) 2915-2920
24 El-Serag HB, Everhart JE. Improved survival after variceal hemorrhage over an 11-year period in the Department of Veterans Affairs. Am J Gastroenterol 2000; 95 (12) 3566-3573
25 D'Amico G, De Franchis R. ; Cooperative Study Group. Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators. Hepatology 2003; 38 (03) 599-612
26 Carbonell N, Pauwels A, Serfaty L, Fourdan O, Lévy VG, Poupon R. Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology 2004; 40 (03) 652-659
27 Reverter E, Tandon P, Augustin S. , et al. A MELD-based model to determine risk of mortality among patients with acute variceal bleeding. Gastroenterology 2014; 146 (02) 412-19.e3
28 D'Amico G, Pagliaro L, Bosch J. Pharmacological treatment of portal hypertension: an evidence-based approach. Semin Liver Dis 1999; 19 (04) 475-505
29 Bosch J, García-Pagán JC. Prevention of variceal rebleeding. Lancet 2003; 361 (9361): 952-954
30 Moitinho E, Escorsell A, Bandi JC. , et al. Prognostic value of early measurements of portal pressure in acute variceal bleeding. Gastroenterology 1999; 117 (03) 626-631
31 Monescillo A, Martínez-Lagares F, Ruiz-del-Arbol L. , et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 2004; 40 (04) 793-801
32 Morrison JD, Mendoza-Elias N, Lipnik AJ. , et al. Gastric varices bleed at lower portosystemic pressure gradients than esophageal varices. J Vasc Interv Radiol 2018; 29 (05) 636-641
33 Tripathi D, Therapondos G, Jackson E, Redhead DN, Hayes PC. The role of the transjugular intrahepatic portosystemic stent shunt (TIPSS) in the management of bleeding gastric varices: clinical and haemodynamic correlations. Gut 2002; 51 (02) 270-274
34 Mishra SR, Chander Sharma B, Kumar A, Sarin SK. Endoscopic cyanoacrylate injection versus beta-blocker for secondary prophylaxis of gastric variceal bleed: a randomised controlled trial. Gut 2010; 59 (06) 729-735
35 Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Correlation between endoscopic and angiographic findings in patients with esophageal and isolated gastric varices. Dig Surg 2001; 18 (03) 176-181
36 Kiyosue H, Ibukuro K, Maruno M, Tanoue S, Hongo N, Mori H. Multidetector CT anatomy of drainage routes of gastric varices: a pictorial review. Radiographics 2013; 33 (01) 87-100
37 de Franchis R. ; Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63 (03) 743-752
38 García-Pagán JC, Reverter E, Abraldes JG, Bosch J. Acute variceal bleeding. Semin Respir Crit Care Med 2012; 33 (01) 46-54
39 Rösch J. Development of transjugular intrahepatic portosystemic shunt. J Vasc Interv Radiol 2015; 26 (02) 220-222
40 Rösch J, Hanafee WN, Snow H. Transjugular portal venography and radiologic portacaval shunt: an experimental study. Radiology 1969; 92 (05) 1112-1114
41 Rössle M. TIPS: 25 years later. J Hepatol 2013; 59 (05) 1081-1093
42 Rösch J, Hanafee W, Snow H, Barenfus M, Gray R. Transjugular intrahepatic portacaval shunt. An experimental work. Am J Surg 1971; 121 (05) 588-592
43 Gutierrez OH, Burgener FA. Production of nonsurgical portosystemic venous shunts in dogs by transjugular approach. Radiology 1979; 130 (02) 507-509
44 Colapinto RF, Stronell RD, Birch SJ. , et al. Creation of an intrahepatic portosystemic shunt with a Grüntzig balloon catheter. Can Med Assoc J 1982; 126 (03) 267-268
45 Gordon JD, Colapinto RF, Abecassis M. , et al. Transjugular intrahepatic portosystemic shunt: a nonoperative approach to life-threatening variceal bleeding. Can J Surg 1987; 30 (01) 45-49
46 Palmaz JC, Garcia F, Sibbitt RR. , et al. Expandable intrahepatic portacaval shunt stents in dogs with chronic portal hypertension. AJR Am J Roentgenol 1986; 147 (06) 1251-1254
47 Rössle M, Richter GM, Nöldge G, Palmaz JC, Wenz W, Gerok W. New non-operative treatment for variceal haemorrhage. Lancet 1989; 2 (8655): 153
48 Rössle M, Richter GM, Noeldge G. , et al. The intrahepatic portosystemic shunt. Initial clinical experiences with patients with liver cirrhosis [in German]. Dtsch Med Wochenschr 1989; 114 (40) 1511-1516
49 Richter GM, Palmaz JC, Nöldge G. , et al. The transjugular intrahepatic portosystemic stent-shunt. A new nonsurgical percutaneous method [in German]. Radiologe 1989; 29 (08) 406-411
50 Richter GM, Noeldge G, Palmaz JC, Roessle M. The transjugular intrahepatic portosystemic stent-shunt (TIPSS): results of a pilot study. Cardiovasc Intervent Radiol 1990; 13 (03) 200-207
51 LaBerge JM, Ring EJ, Gordon RL. Transjugular intrahepatic portosystenlic shunts: TIPS. Surg Technol Int 1991; I: 300-305
52 Haskal ZJ, Scott M, Rubin RA, Cope C. Intestinal varices: treatment with the transjugular intrahepatic portosystemic shunt. Radiology 1994; 191 (01) 183-187
53 Sterling KM, Darcy MD. Stenosis of transjugular intrahepatic portosystemic shunts: presentation and management. AJR Am J Roentgenol 1997; 168 (01) 239-244
54 Saxon RR, Mendel-Hartvig J, Corless CL. , et al. Bile duct injury as a major cause of stenosis and occlusion in transjugular intrahepatic portosystemic shunts: comparative histopathologic analysis in humans and swine. J Vasc Interv Radiol 1996; 7 (04) 487-497
55 Wilkins LR, Sabri SS. Nonendoscopic management of gastric varices. Tech Gastrointest Endosc 2017; 19 (02) 96-100
56 Charon JP, Alaeddin FH, Pimpalwar SA. , et al. Results of a retrospective multicenter trial of the Viatorr expanded polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt creation. J Vasc Interv Radiol 2004; 15 (11) 1219-1230
57 Jung HS, Kalva SP, Greenfield AJ. , et al. TIPS: comparison of shunt patency and clinical outcomes between bare stents and expanded polytetrafluoroethylene stent-grafts. J Vasc Interv Radiol 2009; 20 (02) 180-185
58 Kalva SP, Salazar GM, Walker TG. Transjugular intrahepatic portosystemic shunt for acute variceal hemorrhage. Tech Vasc Interv Radiol 2009; 12 (02) 92-101
59 Boyer TD, Haskal ZJ. ; American Association for the Study of Liver Diseases. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: update 2009. Hepatology 2010; 51 (01) 306
60 Dariushnia SR, Haskal ZJ, Midia M. , et al; Society of Interventional Radiology Standards of Practice Committee. Quality improvement guidelines for transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol 2016; 27 (01) 1-7
61 Gaba RC, Omene BO, Podczerwinski ES. , et al. TIPS for treatment of variceal hemorrhage: clinical outcomes in 128 patients at a single institution over a 12-year period. J Vasc Interv Radiol 2012; 23 (02) 227-235
62 Gaba RC, Khiatani VL, Knuttinen MG. , et al. Comprehensive review of TIPS technical complications and how to avoid them. AJR Am J Roentgenol 2011; 196 (03) 675-685
63 Sommer CM, Gockner TL, Stampfl U. , et al. Technical and clinical outcome of transjugular intrahepatic portosystemic stent shunt: bare metal stents (BMS) versus viatorr stent-grafts (VSG). Eur J Radiol 2012; 81 (09) 2273-2280
64 Gaba RC, Parvinian A, Minocha J. , et al. Should transjugular intrahepatic portosystemic shunt stent grafts be underdilated?. J Vasc Interv Radiol 2015; 26 (03) 382-387
65 Taylor AG, Kolli KP, Kerlan Jr RK. Techniques for transjugular intrahepatic portosystemic shunt reduction and occlusion. Tech Vasc Interv Radiol 2016; 19 (01) 74-81
66 Sahagun G, Benner KG, Saxon R. , et al. Outcome of 100 patients after transjugular intrahepatic portosystemic shunt for variceal hemorrhage. Am J Gastroenterol 1997; 92 (09) 1444-1452
67 Lopera JE. Role of emergency transjugular intrahepatic portosystemic shunts. Semin Intervent Radiol 2005; 22 (04) 253-265
68 Loffroy R, Favelier S, Pottecher P. , et al. Transjugular intrahepatic portosystemic shunt for acute variceal gastrointestinal bleeding: Indications, techniques and outcomes. Diagn Interv Imaging 2015; 96 (7–8): 745-755
69 Martin M, Zajko AB, Orons PD. , et al. Transjugular intrahepatic portosystemic shunt in the management of variceal bleeding: indications and clinical results. Surgery 1993; 114 (04) 719-726 , discussion 726–727
70 Bizollon T, Dumortier J, Jouisse C. , et al. Transjugular intra-hepatic portosystemic shunt for refractory variceal bleeding. Eur J Gastroenterol Hepatol 2001; 13 (04) 369-375
71 Rössle M. When endoscopic therapy or pharmacotherapy fails to control variceal bleeding: what should be done? Immediate control of bleeding by TIPS?. Langenbecks Arch Surg 2003; 388 (03) 155-162
72 Tesdal IK, Filser T, Weiss C, Holm E, Dueber C, Jaschke W. Transjugular intrahepatic portosystemic shunts: adjunctive embolotherapy of gastroesophageal collateral vessels in the prevention of variceal rebleeding. Radiology 2005; 236 (01) 360-367
73 Qi X, Liu L, Bai M. , et al. Transjugular intrahepatic portosystemic shunt in combination with or without variceal embolization for the prevention of variceal rebleeding: a meta-analysis. J Gastroenterol Hepatol 2014; 29 (04) 688-696
74 Wu X-J, Cao J-M, Han J-M, Li J-S. Long-term results of TIPS, TIPS with CVO and combined TIPS and portal azygous disconnection for the treatment of portal hypertension [in Chinese]. Zhonghua Wai Ke Za Zhi 2009; 47 (06) 446-449
75 Wei B, Chen S, Li X, Tang CW. Prevention of variceal rebleeding by TIPS combined with embolization of gastric coronary veins: a clinical controlled study [in Chinese]. Zhonghua Gan Zang Bing Za Zhi 2011; 19 (07) 494-497
76 Chen S, Li X, Wei B. , et al. Recurrent variceal bleeding and shunt patency: prospective randomized controlled trial of transjugular intrahepatic portosystemic shunt alone or combined with coronary vein embolization. Radiology 2013; 268 (03) 900-906
77 Shi Y, Tian X, Hu J. , et al. Efficacy of transjugular intrahepatic portosystemic shunt with adjunctive embolotherapy with cyanoacrylate for esophageal variceal bleeding. Dig Dis Sci 2014; 59 (09) 2325-2332
78 Xiao T, Chen L, Chen W. , et al. Comparison of transjugular intrahepatic portosystemic shunt (TIPS) alone versus TIPS combined with embolotherapy in advanced cirrhosis: a retrospective study. J Clin Gastroenterol 2011; 45 (07) 643-650
79 Xue H, Yuan J, Chao-Li Y. , et al. Follow-up study of transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension. Dig Dis Sci 2011; 56 (11) 3350-3356
80 García-Pagán JC, Caca K, Bureau C. , et al; Early TIPS (Transjugular Intrahepatic Portosystemic Shunt) Cooperative Study Group. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010; 362 (25) 2370-2379
81 Garcia-Pagán JC, Di Pascoli M, Caca K. , et al. Use of early-TIPS for high-risk variceal bleeding: results of a post-RCT surveillance study. J Hepatol 2013; 58 (01) 45-50
82 Tripathi D, Ferguson J, Barkell H. , et al. Improved clinical outcome with transjugular intrahepatic portosystemic stent-shunt utilizing polytetrafluoroethylene-covered stents. Eur J Gastroenterol Hepatol 2006; 18 (03) 225-232
83 Wan YM, Li YH, Xu Y. , et al. Predictors of shunt dysfunction and overall survival in patients with variceal bleeding treated with transjugular portosystemic shunt creation using the fluency stent graft. Acad Radiol 2018; (e-pub ahead of print)
84 Triantafyllou T, Aggarwal P, Gupta E, Svetanoff WJ, Bhirud DP, Singhal S. Polytetrafluoroethylene-covered stent graft versus bare stent in transjugular intrahepatic portosystemic shunt: systematic review and meta-analysis. J Laparoendosc Adv Surg Tech A 2018; (e-pub ahead of print)
85 Gaba RC. Transjugular intrahepatic portosystemic shunt creation with embolization or obliteration for variceal bleeding. Tech Vasc Interv Radiol 2016; 19 (01) 21-35
86 Chau TN, Patch D, Chan YW, Nagral A, Dick R, Burroughs AK. “Salvage” transjugular intrahepatic portosystemic shunts: gastric fundal compared with esophageal variceal bleeding. Gastroenterology 1998; 114 (05) 981-987
87 Barange K, Péron JM, Imani K. , et al. Transjugular intrahepatic portosystemic shunt in the treatment of refractory bleeding from ruptured gastric varices. Hepatology 1999; 30 (05) 1139-1143
88 Choi YH, Yoon CJ, Park JH, Chung JW, Kwon JW, Choi GM. Balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding: its feasibility compared with transjugular intrahepatic portosystemic shunt. Korean J Radiol 2003; 4 (02) 109-116
89 Mahadeva S, Bellamy MC, Kessel D, Davies MH, Millson CE. Cost-effectiveness of N-butyl-2-cyanoacrylate (histoacryl) glue injections versus transjugular intrahepatic portosystemic shunt in the management of acute gastric variceal bleeding. Am J Gastroenterol 2003; 98 (12) 2688-2693
90 Lo GH, Liang HL, Chen WC. , et al. A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding. Endoscopy 2007; 39 (08) 679-685
91 Procaccini NJ, Al-Osaimi AMS, Northup P, Argo C, Caldwell SH. Endoscopic cyanoacrylate versus transjugular intrahepatic portosystemic shunt for gastric variceal bleeding: a single-center U.S. analysis. Gastrointest Endosc 2009; 70 (05) 881-887
92 Anderson CL, Saad WEA, Kalagher SD. , et al. Effect of transjugular intrahepatic portosystemic shunt placement on renal function: a 7-year, single-center experience. J Vasc Interv Radiol 2010; 21 (09) 1370-1376
93 Lin L-L, Du S-M, Fu Y. , et al. Combination therapy versus pharmacotherapy, endoscopic variceal ligation, or the transjugular intrahepatic portosystemic shunt alone in the secondary prevention of esophageal variceal bleeding: a meta-analysis of randomized controlled trials. Oncotarget 2017; 8 (34) 57399-57408
94 Koulia K, Brountzos EN. Use of early-TIPS for high-risk variceal bleeding: results of a post-RCT surveillance study. Ann Gastroenterol 2013; 26 (02) 180-181
95 Rudler M, Cluzel P, Corvec TL. , et al. Early-TIPSS placement prevents rebleeding in high-risk patients with variceal bleeding, without improving survival. Aliment Pharmacol Ther 2014; 40 (09) 1074-1080
96 Halabi SA, Sawas T, Sadat B. , et al. Early TIPS versus endoscopic therapy for secondary prophylaxis after management of acute esophageal variceal bleeding in cirrhotic patients: a meta-analysis of randomized controlled trials. J Gastroenterol Hepatol 2016; 31 (09) 1519-1526
97 Njei B, McCarty TR, Laine L. Early transjugular intrahepatic portosystemic shunt in US patients hospitalized with acute esophageal variceal bleeding. J Gastroenterol Hepatol 2017; 32 (04) 852-858
98 Thabut D, Pauwels A, Carbonell N. , et al; des Hépato-Gastroentérologues des Hôpitaux Généraux (ANGH). Cirrhotic patients with portal hypertension-related bleeding and an indication for early-TIPS: a large multicentre audit with real-life results. J Hepatol 2017; (e-pub ahead of print)
99 Stanley AJ, Jalan R, Ireland HM, Redhead DN, Bouchier IA, Hayes PC. A comparison between gastric and oesophageal variceal haemorrhage treated with transjugular intrahepatic portosystemic stent shunt (TIPSS). Aliment Pharmacol Ther 1997; 11 (01) 171-176
100 Sanyal AJ, Freedman AM, Luketic VA. , et al. The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts. Gastroenterology 1997; 112 (03) 889-898
101 Lakhoo J, Bui JT, Lokken RP, Ray Jr CE, Gaba RC. 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. J Vasc Interv Radiol 2016; 27 (07) 1001-1011
102 Olson E, Yune HY, Klatte EC. Transrenal-vein reflux ethanol sclerosis of gastroesophageal varices. AJR Am J Roentgenol 1984; 143 (03) 627-628
103 Richter GM, Noeldge G, Roessle M, Palmaz JC. Evolution and clinical introduction of TIPSS, the transjugular intrahepatic portosystemic stent-shunt. Semin Intervent Radiol 1991; 8 (04) 331-340
104 Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol 1996; 11 (01) 51-58
105 Takuma Y, Nouso K, Makino Y, Saito S, Shiratori Y. Prophylactic balloon-occluded retrograde transvenous obliteration for gastric varices in compensated cirrhosis. Clin Gastroenterol Hepatol 2005; 3 (12) 1245-1252
106 Araki T, Hori M, Motosugi U. , et al. Can balloon-occluded retrograde transvenous obliteration be performed for gastric varices without gastrorenal shunts?. J Vasc Interv Radiol 2010; 21 (05) 663-670
107 Sabri SS, Saad WEA. Balloon-occluded retrograde transvenous obliteration (BRTO): technique and intraprocedural imaging. Semin Intervent Radiol 2011; 28 (03) 303-313
108 Koizumi J, Hashimoto T, Myojin K. , et al. Balloon-occluded retrograde transvenous obliteration of gastric varices: use of CT-guided foam sclerotherapy to optimize technique. AJR Am J Roentgenol 2012; 199 (01) 200-207
109 Saad WE, Kitanosono T, Koizumi J, Hirota S. The conventional balloon-occluded retrograde transvenous obliteration procedure: indications, contraindications, and technical applications. Tech Vasc Interv Radiol 2013; 16 (02) 101-151
110 Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori Y, Okino Y. Transcatheter obliteration of gastric varices: Part 2. Strategy and techniques based on hemodynamic features. Radiographics 2003; 23 (04) 921-937 , discussion 937
111 Patel A, Fischman AM, Saad WE. Balloon-occluded retrograde transvenous obliteration of gastric varices. AJR Am J Roentgenol 2012; 199 (04) 721-729
112 Saad WE, Nicholson D, Koizumi J. Inventory used for balloon-occluded retrograde (BRTO) and antegrade (BATO) transvenous obliteration: sclerosants and balloon occlusion devices. Tech Vasc Interv Radiol 2012; 15 (03) 226-240
113 Saad WE, Nicholson DB. 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 2013; 16 (02) 152-157
114 Lee EW, Saab S, Gomes AS. , et al. Coil-assisted retrograde transvenous obliteration (CARTO) for the treatment of portal hypertensive variceal bleeding: preliminary results. Clin Transl Gastroenterol 2014; 5: e61
115 Gwon DI, Ko GY, Yoon HK. , et al. Gastric varices and hepatic encephalopathy: treatment with vascular plug and gelatin sponge-assisted retrograde transvenous obliteration--a primary report. Radiology 2013; 268 (01) 281-287
116 Park JK, Saab S, Kee ST. , et al. Balloon-occluded retrograde transvenous obliteration (BRTO) for treatment of gastric varices: review and meta-analysis. Dig Dis Sci 2015; 60 (06) 1543-1553
117 Cho SK, Shin SW, Do YS. , et al. Development of thrombus in the major systemic and portal veins after balloon-occluded retrograde transvenous obliteration for treating gastric variceal bleeding: its frequency and outcome evaluation with CT. J Vasc Interv Radiol 2008; 19 (04) 529-538
118 Park SJ, Chung JW, Kim HC, Jae HJ, Park JH. The prevalence, risk factors, and clinical outcome of balloon rupture in balloon-occluded retrograde transvenous obliteration of gastric varices. J Vasc Interv Radiol 2010; 21 (04) 503-507
119 Sabri SS, Swee W, Turba UC. , et al. Bleeding gastric varices obliteration with balloon-occluded retrograde transvenous obliteration using sodium tetradecyl sulfate foam. J Vasc Interv Radiol 2011; 22 (03) 309-316 , quiz 316
120 Arai H, Abe T, Takayama H. , et al. Respiratory effects of balloon occluded retrograde transvenous obliteration of gastric varices: a prospective controlled study. J Gastroenterol Hepatol 2011; 26 (09) 1389-1394
121 Ninoi T, Nishida N, Kaminou 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 2005; 184 (04) 1340-1346
122 Watanabe M, Shiozawa K, Ikehara T. , et al. Short-term effects and early complications of balloon-occluded retrograde transvenous obliteration for gastric varices. ISRN Gastroenterol 2012; 2012: 919371
123 Wang YB, Zhang JY, Gong JP, Zhang F, Zhao Y. Balloon-occluded retrograde transvenous obliteration versus transjugular intrahepatic portosystemic shunt for treatment of gastric varices due to portal hypertension: A meta-analysis. J Gastroenterol Hepatol 2016; 31 (04) 727-733
124 Saad WE, Wagner CC, Lippert A. , et al. Protective value of TIPS against the development of hydrothorax/ascites and upper gastrointestinal bleeding after balloon-occluded retrograde transvenous obliteration (BRTO). Am J Gastroenterol 2013; 108 (10) 1612-1619
125 Farsad K, Fuss C, Kolbeck KJ. , et al. Transjugular intrahepatic portosystemic shunt creation using intravascular ultrasound guidance. J Vasc Interv Radiol 2012; 23 (12) 1594-1602
126 Harman JT, Reed JD, Kopecky KK, Harris VJ, Haggerty MF, Strzembosz AS. Localization of the portal vein for transjugular catheterization: percutaneous placement of a metallic marker with real-time US guidance. J Vasc Interv Radiol 1992; 3 (03) 545-547
127 Wenz F, Nemcek Jr AA, Tischler HA, Minor PL, Vogelzang RL. US-guided paraumbilical vein puncture: an adjunct to transjugular intrahepatic portosystemic shunt (TIPS) placement. J Vasc Interv Radiol 1992; 3 (03) 549-551
128 Warner DL, Owens CA, Hibbeln JF, Ray Jr CE. Indirect localization of the portal vein during a transjugular intrahepatic portosystemic shunt procedure: placement of a radiopaque marker in the hepatic artery. J Vasc Interv Radiol 1995; 6 (01) 87-89 , discussion 89–90