586 – Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) Versus Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Treatment of Gastric Varices Due to Portal Hypertension: A Systematic Review and Meta-Analysis

Paleti, Swathi; Nutalapati, Venkat; Fathallah, Jihan; Jeepalyam, Sravan; Rustagi, Tarun

doi:10.1016/s0016-5085(19)37077-5

Cited by 10 publications

(18 citation statements)

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“…There are very limited high level data (e. g. RCTs) comparing TIPS and BRTO for cases where endoscopic hemostasis has failed and/or early recurrent gastric variceal bleeding occurs 116 117 . In summary, BRTO and TIPS have similar technical success rates and AE rates.…”

Section: Endoscopic Managementmentioning

confidence: 99%

Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

et al. 2022

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Main Recommendations 1 ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m2] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa) should receive, if no contraindications, nonselective beta blocker (NSBB) therapy (preferably carvedilol) to prevent the development of variceal bleeding.Strong recommendation, moderate quality evidence. 2 ESGE recommends that in those patients unable to receive NSBB therapy with a screening upper gastrointestinal (GI) endoscopy that demonstrates high risk esophageal varices, endoscopic band ligation (EBL) is the endoscopic prophylactic treatment of choice. EBL should be repeated every 2–4 weeks until variceal eradication is achieved. Thereafter, surveillance EGD should be performed every 3–6 months in the first year following eradication.Strong recommendation, moderate quality evidence. 3 ESGE recommends, in hemodynamically stable patients with acute upper GI hemorrhage (UGIH) and no history of cardiovascular disease, a restrictive red blood cell (RBC) transfusion strategy, with a hemoglobin threshold of ≤ 70 g/L prompting RBC transfusion. A post-transfusion target hemoglobin of 70–90 g/L is desired.Strong recommendation, moderate quality evidence. 4 ESGE recommends that patients with ACLD presenting with suspected acute variceal bleeding be risk stratified according to the Child–Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper GI endoscopy.Strong recommendation, high quality of evidence. 5 ESGE recommends the vasoactive agents terlipressin, octreotide, or somatostatin be initiated at the time of presentation in patients with suspected acute variceal bleeding and be continued for a duration of up to 5 days.Strong recommendation, high quality evidence. 6 ESGE recommends antibiotic prophylaxis using ceftriaxone 1 g/day for up to 7 days for all patients with ACLD presenting with acute variceal hemorrhage, or in accordance with local antibiotic resistance and patient allergies.Strong recommendation, high quality evidence. 7 ESGE recommends, in the absence of contraindications, intravenous erythromycin 250 mg be given 30–120 minutes prior to upper GI endoscopy in patients with suspected acute variceal hemorrhage.Strong recommendation, high quality evidence. 8 ESGE recommends that, in patients with suspected variceal hemorrhage, endoscopic evaluation should take place within 12 hours from the time of patient presentation provided the patient has been hemodynamically resuscitated.Strong recommendation, moderate quality evidence. 9 ESGE recommends EBL for the treatment of acute esophageal variceal hemorrhage (EVH).Strong recommendation, high quality evidence. 10 ESGE recommends that, in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis (Child–Pugh C ≤ 13 or Child–Pugh B > 7 with active EVH at the time of endoscopy despite vasoactive agents, or HVPG > 20 mmHg), pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours (preferably within 24 hours) must be considered.Strong recommendation, high quality evidence. 11 ESGE recommends that, for persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy, urgent rescue TIPS should be considered (where available).Strong recommendation, moderate quality evidence. 12 ESGE recommends endoscopic cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage.Strong recommendation, high quality evidence. 13 ESGE recommends endoscopic cyanoacrylate injection or EBL in patients with GOV1-specific bleeding.Strong recommendations, moderate quality evidence. 14 ESGE suggests urgent rescue TIPS or balloon-occluded retrograde transvenous obliteration (BRTO) for gastric variceal bleeding when there is a failure of endoscopic hemostasis or early recurrent bleeding.Weak recommendation, low quality evidence. 15 ESGE recommends that patients who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis).Strong recommendation, moderate quality evidence. 16 ESGE recommends the use of NSBBs (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in EVH in patients with ACLD.Strong recommendation, high quality evidence.

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Section: Endoscopic Managementmentioning

confidence: 99%

Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

et al. 2022

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“…There was a higher rate of encephalopathy with TIPS, with higher although non-significant exacerbation of ascites with BRTO. In another meta-analysis by Paleti et al [11], BRTO was associated with a lower rate of rebleeding (OR = 0.30, 95% CI: 0.18-0.48) and overall mortality (OR = 0.43, 95% CI: 0.21-0.87). The results of our meta-analysis are in agreement with the previous series with BRTO having the lowest probability of overall rebleeding.…”

Section: Discussionmentioning

confidence: 91%

“…For patients with recurrent gastric variceal bleeding, endoscopic ultrasound (EUS) guided glue with or without coil injection is increasingly becoming popular [10]. Radiological therapies such as balloon occluded retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunt (TIPS) have also been used primarily as rescue therapy with emerging data on its role as primary therapy in a select subset of patients [11,12]. The existing literature has a paucity of head-to-head trials comparing different endoscopic and radiological modalities for gastric variceal therapy.…”

Section: Introductionmentioning

confidence: 99%

Comparison of efficacy and safety of endoscopic and radiological interventions for gastric varices: A systematic review and network meta-analysis

Jearth¹,

Seth²,

Darak³

et al. 2023

ceh

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Aim of the study:There is a paradigm shift in the management of gastric varices with the availability of endoscopic ultrasound and radiologic interventions. The optimal choice of intervention remains a dilemma for most treating physicians. Material and methods: We searched MEDLINE, the Cochrane Central Register of Controlled Trials, and Science-Direct for studies comparing endoscopic glue injection, endoscopic thrombin injection (THB), variceal band ligation, EUS-guided coiling, EUS-guided glue injection, EUS-guided coiling with glue (EUS-C+G), balloon occluded retrograde transvenous obliteration (BRTO), and transjugular intrahepatic portosystemic shunt (TIPS) for gastric varices in adults. The data on four outcomes -obliteration of varices, rebleeding, adverse effects, and mortalitywere pooled using a random-effects model. Treatment estimates were calculated as odds ratios (ORs) along with their 95% confidence interval (CI). The relative ranking of interventions for various outcomes was calculated as their surface under the cumulative ranking curve (SUCRA). Results: We identified 34 studies (10 randomized controlled trials, 24 non-randomized trials) with 2783 patients. Based on SUCRA plots, BRTO (SUCRA 95.1) had the highest rate of variceal obliteration followed by EUS-C+G (SUCRA 80.9). The risk of rebleeding was lowest with BRTO (SUCRA 85.1) followed by EUS-C+G (SUCRA 78.8). Moderate-severe adverse effects were least likely with THB (SUCRA 92.5) and highest with TIPS (SUCRA 3.7). In terms of mortality, EUS-C+G (73.5) had the lowest probability of overall mortality followed by TIPS (69.1). Conclusions: In this network meta-analysis, we found BRTO and EUS-guided therapies to be superior to endoscopic glue injection. However, the level of evidence remains low.

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“…62 These findings suggest that BRTO may be a less invasive and more effective therapy than TIPS creation for patients with gastric variceal hemorrhage. 63 64…”

Section: Varices With a Splenorenal Shuntmentioning

confidence: 99%

Variceal Hemorrhage: Decompression, Obliteration, or Both?

McCafferty

Khudari

Salei

et al. 2022

Digestive Disease Interventions

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Variceal hemorrhage is a morbid condition that frequently mandates the involvement of interventional radiology to achieve successful and sustained hemostasis. Primary image-guided therapies for variceal hemorrhage include a transjugular intrahepatic portosystemic shunt and transvenous obliteration. Knowledge of variceal pathophysiology and anatomy, current techniques, and the evidence supporting therapeutic selection is paramount to successful patient outcomes. The purpose of this review is to provide the reader a framework of the available literature on image-guided management of bleeding varices to assist in clinical management.

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586 – Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) Versus Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Treatment of Gastric Varices Due to Portal Hypertension: A Systematic Review and Meta-Analysis

Cited by 10 publications

References 0 publications

Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Comparison of efficacy and safety of endoscopic and radiological interventions for gastric varices: A systematic review and network meta-analysis

Variceal Hemorrhage: Decompression, Obliteration, or Both?

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