Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Variceal Bleeding: Its Feasibility Compared with Transjugular Intrahepatic Portosystemic Shunt

Abstract

ObjectiveTo assess the feasibility of balloon-occluded retrograde transvenous obliteration (BRTO) in active gastric variceal bleeding, and to compare the findings with those of transjugular intrahepatic portosystemic shunt (TIPS).Materials and MethodsTwenty-one patients with active gastric variceal bleeding due to liver cirrhosis were referred for radiological intervention. In 15 patients, contrast-enhanced CT scans demonstrated gastrorenal shunt, and the remaining six (Group 1) underwent TIPS. Seven of the 15 with gastrorenal shunt (Group 2) were also treated with TIPS, and the other eight (Group 3) underwent BRTO. All patients were followed up for 6 to 21 (mean, 14.4) months. For statistical inter-group comparison of immediate hemostasis, rebleeding and encephalopathy, Fisher's exact test was used. Changes in the Child-Pugh score before and after each procedure in each group were statistically analyzed by means of Wilcoxon's signed rank test.ResultsOne patient in Group 1 died of sepsis, acute respiratory distress syndrome, and persistent bleeding three days after TIPS, while the remaining 20 survived the procedure with immediate hemostasis. Hepatic encephalopathy developed in four patients (one in Group 1, three in Group 2, and none in Group 3); one, in Group 2, died while in an hepatic coma 19 months after TIPS. Rebleeding occurred in one patient, also in Group 2. Except for transient fever in two Group-3 patients, no procedure-related complication occurred. In terms of immediate hemostasis, rebleeding and encephalopathy, there were no statistically significant differences between the groups (p > 0.05). In Group 3, the Child-Pugh score showed a significant decrease after the procedure (p = 0.02).ConclusionBRTO can effectively control active gastric variceal bleeding, and because of immediate hemostasis, the absence of rebleeding, and improved liver function, is a good alternative to TIPS in patients in whom such bleeding, accompanied by gastrorenal shunt, occurs.

The Management of Bleeding from Anorectal Varices

“…In BRTO, an occlusion balloon is used to isolate gastric varices and collateral veins, followed by endovascular injection of a sclerosing agent and/or microcoils directly into the gastro-variceal system, resulting in variceal obliteration [78]. A small randomized study by Choi et al compared BRTO with TIPS for treatment of active gastric variceal bleeding and found no differences with regard to rates of hemostasis, rebleeding, or encephalopathy [79]. BRTO has some potential advantages over TIPS: it is less invasive, can be performed in patients with advanced liver disease and is suitable in patients with hepatic encephalopathy [80].…”

The History and Evolution of Balloon-occluded Retrograde Transvenous Obliteration (BRTO): From the United States to Japan and Back

“…[32][33][34][35][36] These percutaneous transhepatic obliterations were mostly performed utilizing coils, Gelfoam, and/or sclerosants (such as absolute alcohol and 30-50% glucose solution) without utilizing occlusive balloons to modulate blood flow. [32][33][34][35][36] These procedures, utilizing current terminology, are now referred to as percutaneous transhepatic obliteration (PTO) 6,15,24,37,38 ), which is a type of balloon-occluded antegrade transvenous obliteration (BATO; please see ''Modifications of Transvenous Obliteration: Balloonoccluded Antegrade Transvenous Obliteration (BATO) and Alternative/Adjunctive Routes for BRTO'' in this issue). The initial transhepatic obliterative experience in the 1970s was short lived due to relatively poor clinical success [32][33][34][35][36] and possibly the advent of the TIPS procedure.…”

“…In addition (reinforcing the theory of decompression over sclerosis) the initial experience of transhepatic obliteration of gastroesophageal varices in Europe and the United States did not have a satisfactory technical, hemodynamic, or clinical success. [32][33][34][35][36] The technical success varied from 54-88% with a rebleed rate of succesful cases of 29-86% and an overall intent-to-treat clinical success rate of 25-31% and an image-based variceal recannulation of over 80%. [32][33][34] To the best of my knowledge, the institution that has purposely pursued the practice of BRTO earliest in the United States was Stanford University.…”

“…[32][33][34][35][36] The technical success varied from 54-88% with a rebleed rate of succesful cases of 29-86% and an overall intent-to-treat clinical success rate of 25-31% and an image-based variceal recannulation of over 80%. [32][33][34] To the best of my knowledge, the institution that has purposely pursued the practice of BRTO earliest in the United States was Stanford University. The first BRTO procedure performed at Stanford was in December 1999 and it was performed by Daniel Sze and Michael Dake utilizing a mix of Gelfoam and ethanolamine oleate (Personal communication with Dr. Daniel Sze, December 17, 2010).…”

Safe and successful endoscopic initial treatment and long-term eradication of gastric varices by endoscopic ultrasound-guided Histoacryl (N-butyl-2-cyanoacrylate) injection

“…The rubber band principle is therefore not working, neither are simple local mechanical interventions like clips effective. To date three different treatment options are available: endoscopic treatment, transjugular porto-systemic shunting (TIPSS) [3] and the most recent described balloon-occluded retrograde transvenous obliteration (BRTO) [4]; the latter two are confined to an interventional radiology service.From all endoscopic interventions only the injection of Nbutyl-2-cyanoacrylate with or without coil application promises valuable success. However without active bleeding site, identification of gastric varices might be difficult.…”