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Liver Diseases pp 627-635 | Cite as

Procedure for Gastric Variceal Bleeding: From BRTO to PARTO to CARTO, Three Decades of Progress

  • Edward Wolfgang LeeEmail author
  • Damian Hall
Chapter

Abstract

Gastric varices are less common than esophageal varices. However, it is known to be associated with a poor prognosis and mortality due to its high propensity to bleed massively. There are several management options for gastric variceal bleeding including medical management, endoscopic treatment, transjugular intrahepatic portosystemic shunt, shunt surgery, and liver transplantation. However, clinical outcomes and recurrent bleeding rate of these current treatments are widely varying, and an alternative treatment method for gastric variceal bleeding is needed. In this chapter, we present a relatively novel treatment option for gastric varices called BRTO (Balloon-occluded retrograde transvenous obliteration) and its modified methods. In brief, BRTO and modified BRTO (PARTO = plug-assisted or CARTO = coil-assisted retrograde transvenous obliteration) appear safe and effective treatment options for gastric variceal bleeding.

Keywords

BRTO CARTO PARTO Gastric varices Variceal bleeding Portal hypertension 

References

  1. 1.
    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;268:281–7.PubMedCrossRefPubMedCentralGoogle Scholar
  2. 2.
    Kim DJ, Darcy MD, Mani NB, 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. 2018;41:835–47.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    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.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    Kanagawa H, Mima S, Kouyama H, et al. Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 1996;11:51–8.PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Lee EW, Saab S, Kaldas F, et al. Coil-assisted retrograde transvenous obliteration (CARTO): an alternative treatment option for refractory hepatic encephalopathy. Am J Gastroenterol. 2018;113:1187.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Saad WE. The history and evolution of balloon-occluded retrograde transvenous obliteration (BRTO): from the United States to Japan and back. Semin Intervent Radiol. 2011;28:283–7.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Arai H, Abe T, Shimoda R, et al. Emergency balloon-occluded retrograde transvenous obliteration for gastric varices. J Gastroenterol. 2005;40:964–71.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    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;60:1543.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Olson E, Yune HY, Klatte EC. Transrenal-vein reflux ethanol sclerosis of gastroesophageal varices. AJR Am J Roentgenol. 1984;143:627–8.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Kim SK, Lee KA, Sauk S, et al. Comparison of transjugular intrahepatic portosystemic shunt with covered stent and balloon-occluded retrograde transvenous obliteration in managing isolated gastric varices. Korean J Radiol. 2017;18:345–54.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Saad WE, Darcy MD. Transjugular intrahepatic portosystemic shunt (TIPS) versus balloon-occluded retrograde transvenous obliteration (BRTO) for the management of gastric varices. Semin Intervent Radiol. 2011;28:339–49.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Ryan BM, Stockbrugger RW, Ryan JM. A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices. Gastroenterology. 2004;126:1175–89.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Saad WE. Balloon-occluded retrograde transvenous obliteration of gastric varices: concept, basic techniques, and outcomes. Semin Intervent Radiol. 2012;29:118–28.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Saad WE, Simon PO Jr, Rose SC. Balloon-occluded retrograde transvenous obliteration of gastric varices. Cardiovasc Intervent Radiol. 2014;37:299–315.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Chao Y, Lin HC, Lee FY, et al. Hepatic hemodynamic features in patients with esophageal or gastric varices. J Hepatol. 1993;19:85–9.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    de Franchis R, Primignani M. Natural history of portal hypertension in patients with cirrhosis. Clin Liver Dis. 2001;5:645–63.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Garcia-Pagan JC, Barrufet M, Cardenas A, et al. Management of gastric varices. Clin Gastroenterol Hepatol. 2014;12:919.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Lopera JE. Gastric varices. Radiographics. 2013;33:100–1.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Laleman W, Simon-Talero M, Maleux G, et al. Embolization of large spontaneous portosystemic shunts for refractory hepatic encephalopathy: a multicenter survey on safety and efficacy. Hepatology. 2013;57:2448–57.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Cho SK, Shin SW, Lee IH, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices: outcomes and complications in 49 patients. AJR Am J Roentgenol. 2007;189:W365–72.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Binmoeller KF, Borsatto R. Variceal bleeding and portal hypertension. Endoscopy. 2000;32:189–99.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Segawa M, Sakaida I. Diagnosis and treatment of portal hypertension. Hepatol Res. 2009;39:1039–43.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Toubia N, Sanyal AJ. Portal hypertension and variceal hemorrhage. Med Clin North Am. 2008;92:551–74, viii.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Turon F, Casu S, Hernandez-Gea V, et al. Variceal and other portal hypertension related bleeding. Best Pract Res Clin Gastroenterol. 2013;27:649–64.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Kirby JM, Cho KJ, Midia M. Image-guided intervention in management of complications of portal hypertension: more than TIPS for success. Radiographics. 2013;33:1473–96.PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Ninoi T, Nakamura K, Kaminou T, et al. TIPS versus transcatheter sclerotherapy for gastric varices. AJR Am J Roentgenol. 2004;183:369–76.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Maruyama H, Yokosuka O. Current management of gastric varices. JNMA J Nepal Med Assoc. 2007;46:143–50.PubMedPubMedCentralGoogle Scholar
  28. 28.
    Sarin SK, Agarwal SR. Gastric varices and portal hypertensive gastropathy. Clin Liver Dis. 2001;5:727–67, x.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Sarin SK, Lahoti D, Saxena SP, et al. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology. 1992;16:1343–9.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Yoshida H, Mamada Y, Taniai N, et al. Treatment modalities for bleeding esophagogastric varices. J Nippon Med Sch. 2012;79:19–30.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Ali SM, Wu S, Xu H, et al. A prospective study of endoscopic injection sclerotherapy and endoscopic variceal ligation in the treatment of esophageal varices. J Laparoendosc Adv Surg Tech A. 2017;27:333–41.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Emori K, Toyonaga A, Oho K, et al. Balloon-occluded retrograde transvenous obliteration versus endoscopic injection sclerotherapy for isolated gastric varices: a comparative study. Kurume Med J. 2014;60:105–13.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Caldwell S. Gastric varices: is there a role for endoscopic cyanoacrylates, or are we entering the BRTO era? Am J Gastroenterol. 2012;107:1784–90.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Al-Osaimi AM, Caldwell SH. Medical and endoscopic management of gastric varices. Semin Intervent Radiol. 2011;28:273–82.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Hong CH, Kim HJ, Park JH, et al. Treatment of patients with gastric variceal hemorrhage: endoscopic N-butyl-2-cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 2009;24:372–8.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Huang YH, Yeh HZ, Chen GH, et al. Endoscopic treatment of bleeding gastric varices by N-butyl-2-cyanoacrylate (Histoacryl) injection: long-term efficacy and safety. Gastrointest Endosc. 2000;52:160–7.PubMedCrossRefPubMedCentralGoogle Scholar
  37. 37.
    Akahoshi T, Hashizume M, Tomikawa M, 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. 2008;23:1702–9.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Akahoshi T, Tomikawa M, Kamori M, et al. Impact of balloon-occluded retrograde transvenous obliteration on management of isolated fundal gastric variceal bleeding. Hepatol Res. 2012;42:385–93.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Fukuda T, Hirota S, Sugimura K. Long-term results of balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy. J Vasc Interv Radiol. 2001;12:327–36.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Hirota S, Matsumoto S, Tomita M, et al. Retrograde transvenous obliteration of gastric varices. Radiology. 1999;211:349–56.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Sonomura T, Ono W, Sato M, et al. Three benefits of microcatheters for retrograde transvenous obliteration of gastric varices. World J Gastroenterol. 2012;18:1373–8.PubMedPubMedCentralCrossRefGoogle Scholar
  42. 42.
    Kobayakawa M, Kokubu S, Hirota S, et al. Short-term safety and efficacy of balloon-occluded retrograde transvenous obliteration using ethanolamine oleate: results of a prospective, multicenter, single-arm trial. J Vasc Interv Radiol. 2017;28:1108–1115 e2.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Chu HH, Kim M, Kim HC, et al. Long-term outcomes of balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices: a comparison of ethanolamine oleate and sodium tetradecyl sulfate. Cardiovasc Intervent Radiol. 2018;41:578–86.PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    Gwon DI, Kim YH, Ko GY, 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. 2015;26:1589–95.PubMedCrossRefPubMedCentralGoogle Scholar
  45. 45.
    Saad WE, Kitanosono T, Koizumi J, et al. The conventional balloon-occluded retrograde transvenous obliteration procedure: indications, contraindications, and technical applications. Tech Vasc Interv Radiol. 2013;16:101–51.PubMedCrossRefPubMedCentralGoogle Scholar
  46. 46.
    Saad WE, Sabri SS. Balloon-occluded retrograde transvenous obliteration (BRTO): technical results and outcomes. Semin Intervent Radiol. 2011;28:333–8.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Sabri SS, Saad WE. Balloon-occluded retrograde transvenous obliteration (BRTO): technique and intraprocedural imaging. Semin Intervent Radiol. 2011;28:303–13.PubMedPubMedCentralCrossRefGoogle Scholar
  48. 48.
    Chang MY, Kim MD, Kim T, et al. Plug-assisted retrograde transvenous obliteration for the treatment of gastric variceal hemorrhage. Korean J Radiol. 2016;17:230–8.PubMedPubMedCentralCrossRefGoogle Scholar
  49. 49.
    Kim YH, Kim YH, Kim CS, 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. 2016;39:840–6.PubMedCrossRefPubMedCentralGoogle Scholar
  50. 50.
    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;22:309–16; quiz 316.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    Gandini R, Chiocchi M, Konda D, et al. Transcatheter foam sclerotherapy of symptomatic female varicocele with sodium-tetradecyl-sulfate foam. Cardiovasc Intervent Radiol. 2008;31:778–84.PubMedCrossRefPubMedCentralGoogle Scholar
  52. 52.
    Yamaki T, Nozaki M, Sakurai H, et al. Prospective randomized efficacy of ultrasound-guided foam sclerotherapy compared with ultrasound-guided liquid sclerotherapy in the treatment of symptomatic venous malformations. J Vasc Surg. 2008;47:578–84.PubMedCrossRefPubMedCentralGoogle Scholar
  53. 53.
    Kessler J, Trerotola SO. Use of the Amplatzer Vascular Plug for embolization of a large retroperitoneal shunt during transjugular intrahepatic portosystemic shunt creation for gastric variceal bleeding. J Vasc Interv Radiol. 2006;17:135–40.PubMedCrossRefPubMedCentralGoogle Scholar
  54. 54.
    Yoo H, Ko GY, Gwon DI, et al. Preoperative portal vein embolization using an amplatzer vascular plug. Eur Radiol. 2009;19:1054–61.PubMedCrossRefPubMedCentralGoogle Scholar
  55. 55.
    Park JK, Cho SK, Kee S, et al. Vascular plug-assisted retrograde transvenous obliteration of portosystemic shunts for refractory hepatic encephalopathy: a case report. Case Rep Radiol. 2014;2014:391420.PubMedPubMedCentralGoogle Scholar
  56. 56.
    Itou C, Koizumi J, Hashimoto T, et al. Balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices: polidocanol foam versus liquid ethanolamine oleate. AJR Am J Roentgenol. 2015;205:659–66.PubMedCrossRefPubMedCentralGoogle Scholar
  57. 57.
    Jang SY, Kim GH, Park SY, et al. Clinical outcomes of balloon-occluded retrograde transvenous obliteration for the treatment of gastric variceal hemorrhage in Korean patients with liver cirrhosis: a retrospective multicenter study. Clin Mol Hepatol. 2012;18:368–74.PubMedPubMedCentralCrossRefGoogle Scholar
  58. 58.
    Kiyosue H, Tanoue S, Kondo Y, et al. Balloon-occluded retrograde transvenous obliteration of complex gastric varices assisted by temporary balloon occlusion of the splenic artery. J Vasc Interv Radiol. 2011;22:1045–8.PubMedCrossRefPubMedCentralGoogle Scholar
  59. 59.
    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;184:1340–6.PubMedCrossRefPubMedCentralGoogle Scholar
  60. 60.
    Rossle M, Piotraschke J. Transjugular intrahepatic portosystemic shunt and hepatic encephalopathy. Dig Dis. 1996;14(Suppl 1):12–9.PubMedCrossRefPubMedCentralGoogle Scholar
  61. 61.
    Kumamoto M, Toyonaga A, Inoue H, et al. Long-term results of balloon-occluded retrograde transvenous obliteration for gastric fundal varices: hepatic deterioration links to portosystemic shunt syndrome. J Gastroenterol Hepatol. 2010;25:1129–35.PubMedCrossRefPubMedCentralGoogle Scholar
  62. 62.
    Saad WE, Wagner CC, Al-Osaimi A, et al. The effect of balloon-occluded transvenous obliteration of gastric varices and gastrorenal shunts on the hepatic synthetic function: a comparison between Child-Pugh and model for end-stage liver disease scores. Vasc Endovascular Surg. 2013;47:281–7.PubMedCrossRefPubMedCentralGoogle Scholar
  63. 63.
    Mukund A, Rajesh S, Arora A, et al. Efficacy of balloon-occluded retrograde transvenous obliteration of large spontaneous lienorenal shunt in patients with severe recurrent hepatic encephalopathy with foam sclerotherapy: initial experience. J Vasc Interv Radiol. 2012;23:1200–6.PubMedCrossRefPubMedCentralGoogle Scholar
  64. 64.
    Suraweera D, Sundaram V, Saab S. Evaluation and management of hepatic encephalopathy: current status and future directions. Gut Liver. 2016;10:509–19.PubMedPubMedCentralCrossRefGoogle Scholar
  65. 65.
    Kasuga A, Mizumoto H, Matsutani S, et al. Portal hemodynamics and clinical outcomes of patients with gastric varices after balloon-occluded retrograde transvenous obliteration. J Hepatobiliary Pancreat Sci. 2010;17:898–903.PubMedCrossRefPubMedCentralGoogle Scholar
  66. 66.
    Hiraga N, Aikata H, Takaki S, et al. The long-term outcome of patients with bleeding gastric varices after balloon-occluded retrograde transvenous obliteration. J Gastroenterol. 2007;42:663–72.PubMedCrossRefPubMedCentralGoogle Scholar
  67. 67.
    Kitamoto M, Imamura M, Kamada K, et al. Balloon-occluded retrograde transvenous obliteration of gastric fundal varices with hemorrhage. AJR Am J Roentgenol. 2002;178:1167–74.PubMedCrossRefPubMedCentralGoogle Scholar
  68. 68.
    Chikamori F, Kuniyoshi N, Shibuya S, et al. Eight years of experience with transjugular retrograde obliteration for gastric varices with gastrorenal shunts. Surgery. 2001;129:414–20.PubMedCrossRefPubMedCentralGoogle Scholar
  69. 69.
    Koito K, Namieno T, Nagakawa T, et al. Balloon-occluded retrograde transvenous obliteration for gastric varices with gastrorenal or gastrocaval collaterals. AJR Am J Roentgenol. 1996;167:1317–20.PubMedCrossRefPubMedCentralGoogle Scholar

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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Interventional Radiology and Liver/Pancreas Transplant SurgeryUCLA Medical CenterLos AngelesUSA
  2. 2.Interventional RadiologyUCLA Medical CenterLos AngelesUSA

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