Digestive Disease Interventions
DOI: 10.1055/s-0043-1772853
Review Article

Interventions in Gastric Varices: TIPS versus BRTO

1   Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia
Jorge E. Lopera
2   Department of Radiology, University of Texas at San Antonio, San Antonio, Texas
André Moreira de Assis
3   Radiology Institute, University of Sao Paulo Medical School, Hospital Sírio-Libanês/SP, Sao Paulo, Brazil
José Andrade de Carvalho Melo Junior
4   Radiology Institute, Hospital Sírio-Libanês/SP, Sao Paulo, Brazil
Sergio Alvarez
1   Department of Radiology, Hospital Pablo Tobón Uribe, Medellín, Colombia
› Author Affiliations


Gastric varices (GV) are a relatively uncommon cause of bleeding in the gastrointestinal tract. Compared with esophageal varices (EV), GV have been less well studied and therefore there is less consensus on the best treatment alternative. GV have distinct hemodynamic and anatomic considerations which must be well understood to provide adequate treatments. The purpose of this review is to describe the endovascular treatment options available: transjugular intrahepatic portosystemic shunt and balloon-occluded retrograde transvenous obliteration (BRTO) and its variants. Each of these alternatives has its indications for different clinical scenarios. Both are effective in controlling acute bleeding, but BRTO seems to have better long-term results. A detailed description of indications, techniques, complications, and results is included.

Publication History

Received: 12 September 2022

Accepted: 02 August 2023

Article published online:
30 August 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

  • References

  • 1 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
  • 2 Henry Z, Patel K, Patton H, Saad W. AGA clinical practice update on management of bleeding gastric varices: expert review. Clin Gastroenterol Hepatol 2021; 19 (06) 1098-1107.e1
  • 3 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
  • 4 Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori Y, Okino Y. Transcatheter obliteration of gastric varices. Part 1. Anatomic classification. Radiographics 2003; 23 (04) 911-920
  • 5 Saad WE. Vascular anatomy and the morphologic and hemodynamic classifications of gastric varices and spontaneous portosystemic shunts relevant to the BRTO procedure. Tech Vasc Interv Radiol 2013; 16 (02) 60-100
  • 6 Rajesh S, George T, Philips CA. et al. Transjugular intrahepatic portosystemic shunt in cirrhosis: an exhaustive critical update. World J Gastroenterol 2020; 26 (37) 5561-5596
  • 7 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
  • 8 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
  • 9 Alqadi MM, Chadha S, Patel SS, Chen YF, Gaba RC. Transjugular intrahepatic portosystemic shunt creation for treatment of gastric varices: systematic literature review and meta-analysis of clinical outcomes. Cardiovasc Intervent Radiol 2021; 44 (08) 1231-1239
  • 10 Saad WE. The history and future of transjugular intrahepatic portosystemic shunt: food for thought. Semin Intervent Radiol 2014; 31 (03) 258-261
  • 11 Saad WE, Kitanosono T, Koizumi J. Balloon-occluded antegrade transvenous obliteration with or without balloon-occluded retrograde transvenous obliteration for the management of gastric varices: concept and technical applications. Tech Vasc Interv Radiol 2012; 15 (03) 203-225
  • 12 Shah RP, Sze DY. Complications during transjugular intrahepatic portosystemic shunt creation. Tech Vasc Interv Radiol 2016; 19 (01) 61-73
  • 13 Pereira K, Carrion AF, Salsamendi J, Doshi M, Baker R, Kably I. Endovascular management of refractory hepatic encephalopathy complication of transjugular intrahepatic portosystemic shunt (TIPS): comprehensive review and clinical practice algorithm. Cardiovasc Intervent Radiol 2016; 39 (02) 170-182
  • 14 Perarnau JM, Le Gouge A, Nicolas C. et al; STIC-TIPS Group. Covered vs. uncovered stents for transjugular intrahepatic portosystemic shunt: a randomized controlled trial. J Hepatol 2014; 60 (05) 962-968
  • 15 Yang Z, Han G, Wu Q. et al. Patency and clinical outcomes of transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stents versus bare stents: a meta-analysis. J Gastroenterol Hepatol 2010; 25 (11) 1718-1725
  • 16 Lipnik AJ, Pandhi MB, Khabbaz RC, Gaba RC. Endovascular treatment for variceal hemorrhage: TIPS, BRTO, and combined approaches. Semin Intervent Radiol 2018; 35 (03) 169-184
  • 17 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
  • 18 de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C. Baveno VII Faculty. Baveno VII - Renewing consensus in portal hypertension. J Hepatol 2022; 76 (04) 959-974
  • 19 Bai M, Qi XS, Yang ZP, Wu KC, Fan DM, Han GH. EVS vs TIPS shunt for gastric variceal bleeding in patients with cirrhosis: a meta-analysis. World J Gastrointest Pharmacol Ther 2014; 5 (02) 97-104
  • 20 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
  • 21 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 (10) e61
  • 22 Waguri N, Osaki A, Watanabe Y. Balloon-occluded retrograde transvenous obliteration for treatment of gastric varices. World J Hepatol 2021; 13 (06) 650-661
  • 23 Paleti S, Nutalapati V, Fathallah J, Jeepalyam S, Rustagi T. Balloon-occluded retrograde transvenous obliteration (BRTO) versus transjugular intrahepatic portosystemic shunt (TIPS) for treatment of gastric varices because of portal hypertension: a systematic review and meta-analysis. J Clin Gastroenterol 2020; 54 (07) 655-660
  • 24 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
  • 25 Restrepo C, Lopera J. Adrenal infarction post-retrograde transvenous obliteration: a case report. Intervencionismo 2017; 17 (05) 17-23
  • 26 Saad WE. Balloon-occluded retrograde transvenous obliteration of gastric varices: concept, basic techniques, and outcomes. Semin Intervent Radiol 2012; 29 (02) 118-128