Balloon-Occluded Retrograde Transvenous Obliteration (BRTO)

Abstract

Approximately 30% of patients with cirrhosis develop variceal bleeding of which approximately 10–20% are comprised of gastric variceal bleeding. Balloon-occluded retrograde transvenous obliteration (BRTO) is an endovascular technique used to treat gastric varices, particularly when endoscopy fails or in patients with contraindications to a transjugular intrahepatic portosystemic shunt (TIPS) procedure. BRTO is less invasive than a TIPS procedure and can be utilized in patients with hepatic encephalopathy and diminished hepatic reserve with suggestion of a liver protective role. Pre-procedural evaluation includes determination of gastric-variceal system/complex anatomy, including portal vein patency and the presence and size of gastrorenal and other portosystemic shunts. BRTO entails using standard angiographic technique to access the gastrorenal shunt by catheterizing the left renal vein and placing an occlusion balloon into the shunt. Balloon occlusion enables diagnostic evaluation of the gastric-variceal system/complex and also aids in the therapeutic sclerosis of the varix by minimizing reflux of sclerosant into the systemic or portal systems. Meta-analyses of studies comparing BRTO with TIPS for the treatment of gastric varices due to portal hypertension have found significantly lower incidence of re-bleeding and post-operative encephalopathy post-BRTO with no significant difference in technical success rate, hemostasis rate, or incidence of procedure-related complication.