Download PDF
Semin intervent Radiol 2011; 28(3): 333-338
DOI: 10.1055/s-0031-1284460
© Thieme Medical Publishers

Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Technical Results and Outcomes

Wael E. A. Saad1 , Saher S. Sabri1
  • 1Division of Vascular Interventional Radiology, Department of Radiology, University of Virginia Health System, Charlottesville, Virginia
Further Information

Publication History

Publication Date:
15 August 2011 (online)

Also available at
    Permissions and Reprints

ABSTRACT

Variceal bleeding is one of the major complications of portal hypertension. Gastric variceal (GV) bleeding is less common than esophageal variceal (EV) bleeding, however, is associated with a high morbidity and mortality. Balloon-occluded retrograde transvenous obliteration (BRTO) is an established procedure for the management of gastric varices in Japan and has shown promising results in the past decade. The technical success rate, intent-to-treat (including technically failed BRTO-procedures) obliteration rate, and the obliteration rate of gastric varices of technically successful BRTO procedures was 91% (79–100%), 86% (73–100%), and 94% (75–100), respectively. BRTO is successful in controlling active gastric variceal bleeding in 95% of cases (91–100%) and in significantly reducing or resolving encephalopathy in 100% of cases. However, BRTO diverts blood into the portal circulation and increases the portal hypertension, thus aggravating esophageal varices with their potential for bleeding. The 1-, 2-, and 3-year esophageal variceal aggravation rates are 27–35%, 45–66%, and 45–91%, respectively. The gastric variceal rebleed rate of successful BRTO procedures, the intent-to-treat gastric variceal rebleed rate, and the global (all types of varices) variceal rebleed rate are 3.2–8.7%, 10–20%, and 19–31%, respectively. However, the advantage of diverting blood into the portal circulation and potentially toward the liver is improved hepatic function and possible patient survival. Unfortunately, the improved hepatic function is transient (for 6–12 months); however, it is preserved in the long-term (1–3 years). Patient 1-, 2-, 3-, and 5-year survival rates are 83–98%, 76–79%, 66–85%, and 39–69%, respectively. Patient survival is determined by baseline hepatic reserve and the presence of hepatocellular carcinoma.

KEYWORDS

BRTO - transvenous obliteration - varices - rebleeding - hepatic function - survival

REFERENCES

  • 1 Hong C H, Kim H J, Park J H 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 (3) 372-378
    CrossrefPubMedGoogle Scholar
  • 2 Ryan B M, Stockbrugger R W, Ryan J M. A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices.  Gastroenterology. 2004;  126 (4) 1175-1189
    CrossrefPubMedGoogle Scholar
  • 3 Hirota S, Matsumoto S, Tomita M, Sako M, Kono M. Retrograde transvenous obliteration of gastric varices.  Radiology. 1999;  211 (2) 349-356
    CrossrefPubMedGoogle Scholar
  • 4 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 (5) 1167-1174
    CrossrefPubMedGoogle Scholar
  • 5 Sarin S K, Lahoti D, Saxena S P, Murthy N S, Makwana U K. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients.  Hepatology. 1992;  16 (6) 1343-1349
    CrossrefPubMedGoogle Scholar
  • 6 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 (3) 327-336
    CrossrefPubMedGoogle Scholar
  • 7 Trudeau W, Prindiville T. Endoscopic injection sclerosis in bleeding gastric varices.  Gastrointest Endosc. 1986;  32 (4) 264-268
    CrossrefPubMedGoogle Scholar
  • 8 Korula J, Chin K, Ko Y, Yamada S. Demonstration of two distinct subsets of gastric varices. Observations during a seven-year study of endoscopic sclerotherapy.  Dig Dis Sci. 1991;  36 (3) 303-309
    CrossrefPubMedGoogle Scholar
  • 9 Oho K, Iwao T, Sumino M, Toyonaga A, Tanikawa K. Ethanolamine oleate versus butyl cyanoacrylate for bleeding gastric varices: a nonrandomized study.  Endoscopy. 1995;  27 (5) 349-354
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Kim H G, Han K H, Lee C Y et al.. Outcome of endoscopic injection therapy of histoacryl in bleeding gastric varices.  Gastroenterology. 1998;  114 A1273
    PubMedGoogle Scholar
  • 11 Rockey D C. Management of gastric varices.  Gastroenterology. 2001;  120 (7) 1875-1876 discussion 1876-1877
    CrossrefPubMedGoogle Scholar
  • 12 Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori Y, Okino Y. Transcatheter obliteration of gastric varices. Part 1. Anatomic classification.  Radiographics. 2003;  23 (4) 911-920
    CrossrefPubMedGoogle Scholar
  • 13 Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori Y, Okino Y. Transcatheter obliteration of gastric varices: Part 2. Strategy and techniques based on hemodynamic features.  Radiographics. 2003;  23 (4) 921-937 discussion 937
    CrossrefPubMedGoogle Scholar
  • 14 Ibukuro K, Sugihara T, Tanaka R et al.. Balloon-occluded retrograde transvenous obliteration (BRTO) for a direct shunt between the inferior mesenteric vein and the inferior vena cava in a patient with hepatic encephalopathy.  J Vasc Interv Radiol. 2007;  18 (1 Pt 1) 121-125
    CrossrefPubMedGoogle Scholar
  • 15 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 (4) 1340-1346
    CrossrefPubMedGoogle Scholar
  • 16 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 (11) 1702-1709
    CrossrefPubMedGoogle Scholar
  • 17 Cho S K, Shin S W, Lee I H et al.. Balloon-occluded retrograde transvenous obliteration of gastric varices: outcomes and complications in 49 patients.  AJR Am J Roentgenol. 2007;  189 (6) W365-W372
    CrossrefPubMedGoogle Scholar
  • 18 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 (6) 1129-1135
    CrossrefPubMedGoogle Scholar
  • 19 Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Eight years of experience with transjugular retrograde obliteration for gastric varices with gastrorenal shunts.  Surgery. 2001;  129 (4) 414-420
    CrossrefPubMedGoogle Scholar
  • 20 Kanagawa H, Mima S, Kouyama H et al.. A successfully treated case of fundic varices by retrograde transvenous obliteration with balloon.  Jpn J Gastroenterol. 1991;  88 1452-1462
    PubMedGoogle Scholar
  • 21 Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration.  J Gastroenterol Hepatol. 1996;  11 (1) 51-58
    CrossrefPubMedGoogle Scholar
  • 22 de Franchis R, Primignani M. Natural history of portal hypertension in patients with cirrhosis.  Clin Liver Dis. 2001;  5 (3) 645-663
    CrossrefPubMedGoogle Scholar
  • 23 Hayashi S, Saeki S, Hosoi H et al.. A clinical and portal hemodynamic analysis for obliteration of gastric-renal shunt communicated with gastric fundic varices.  Nippon Shokakibyo Gakkai Zasshi. 1998;  95 (7) 755-763
    PubMedGoogle Scholar
  • 24 Tanihata H, Minamiguchi H, Sato M et al.. Changes in portal systemic pressure gradient after balloon-occluded retrograde transvenous obliteration of gastric varices and aggravation of esophageal varices.  Cardiovasc Intervent Radiol. 2009;  32 (6) 1209-1216
    CrossrefPubMedGoogle Scholar
  • 25 Choi Y S, Lee J H, Sinn D H et al.. Effect of balloon-occluded retrograde transvenous obliteration on the natural history of coexisting esophageal varices.  J Clin Gastroenterol. 2008;  42 (9) 974-979
    CrossrefPubMedGoogle Scholar
  • 26 Nakamura S, Torii N, Yatsuji S et al.. Long-term follow up of esophageal varices after balloon-occluded retrograde transvenous obliteration for gastric varices.  Hepatol Res. 2008;  38 (4) 340-347
    CrossrefPubMedGoogle Scholar
  • 27 Yamagami T, Kato T, Hirota T, Yoshimatsu R, Matsumoto T, Nishimura T. Infusion of 50% glucose solution before injection of ethanolamine oleate during balloon-occluded retrograde transvenous obliteration.  Australas Radiol. 2007;  51 (4) 334-338
    CrossrefPubMedGoogle Scholar
  • 28 Ninoi T, Nakamura K, Kaminou T et al.. TIPS versus transcatheter sclerotherapy for gastric varices.  AJR Am J Roentgenol. 2004;  183 (2) 369-376
    CrossrefPubMedGoogle Scholar
  • 29 Sonomura T, Sato M, Kishi K et al.. Balloon-occluded retrograde transvenous obliteration for gastric varices: a feasibility study.  Cardiovasc Intervent Radiol. 1998;  21 (1) 27-30
    CrossrefPubMedGoogle Scholar
  • 30 Kiyosue H, Matsumoto S, Onishi R et al.. Balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices: therapeutic results and problems.  Nippon Igaku Hoshasen Gakkai Zasshi. 1999;  59 (1) 12-19
    PubMedGoogle Scholar
  • 31 Koito K, Namieno T, Nagakawa T, Morita K. Balloon-occluded retrograde transvenous obliteration for gastric varices with gastrorenal or gastrocaval collaterals.  AJR Am J Roentgenol. 1996;  167 (5) 1317-1320
    CrossrefPubMedGoogle Scholar
  • 32 Chikamori F, Kuniyoshi N, Kawashima T, Takase Y. Gastric varices with gastrorenal shunt: combined therapy using transjugular retrograde obliteration and partial splenic embolization.  AJR Am J Roentgenol. 2008;  191 (2) 555-559
    CrossrefPubMedGoogle Scholar
  • 33 Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Transjugular retrograde obliteration for chronic portosystemic encephalopathy.  Abdom Imaging. 2000;  25 (6) 567-571
    CrossrefPubMedGoogle Scholar
  • 34 Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Combination treatment of transjugular retrograde obliteration and endoscopic embolization for portosystemic encephalopathy with esophageal varices.  Hepatogastroenterology. 2004;  51 (59) 1379-1381
    PubMedGoogle Scholar
  • 35 Miyamoto Y, Oho K, Kumamoto M, Toyonaga A, Sata M. Balloon-occluded retrograde transvenous obliteration improves liver function in patients with cirrhosis and portal hypertension.  J Gastroenterol Hepatol. 2003;  18 (8) 934-942
    CrossrefPubMedGoogle Scholar
  • 36 Sugimori K, Morimoto M, Shirato K et al.. Retrograde transvenous obliteration of gastric varices associated with large collateral veins or a large gastrorenal shunt.  J Vasc Interv Radiol. 2005;  16 (1) 113-118
    CrossrefPubMedGoogle Scholar
  • 37 Fukuda T, Hirota S, Matsumoto S et al.. Application of balloon-occluded retrograde transvenous obliteration to gastric varices complicating refractory ascites.  Cardiovasc Intervent Radiol. 2004;  27 (1) 64-67
    PubMedGoogle Scholar
  • 38 Shimoda R, Horiuchi K, Hagiwara S et al.. Short-term complications of retrograde transvenous obliteration of gastric varices in patients with portal hypertension: effects of obliteration of major portosystemic shunts.  Abdom Imaging. 2005;  30 (3) 306-313
    CrossrefPubMedGoogle Scholar
  • 39 Takuma Y, Nouso K, Makino Y, Saito S, Shiratori Y. Prophylactic balloon-occluded retrograde transvenous obliteration for gastric varices in compensated cirrhosis.  Clin Gastroenterol Hepatol. 2005;  3 (12) 1245-1252
    CrossrefPubMedGoogle Scholar
  • 40 Arai H, Abe T, Takagi H, Mori M. Efficacy of balloon-occluded retrograde transvenous obliteration, percutaneous transhepatic obliteration and combined techniques for the management of gastric fundal varices.  World J Gastroenterol. 2006;  12 (24) 3866-3873
    PubMedGoogle Scholar
  • 41 Arai H, Abe T, Shimoda R, Takagi H, Yamada T, Mori M. Emergency balloon-occluded retrograde transvenous obliteration for gastric varices.  J Gastroenterol. 2005;  40 (10) 964-971
    CrossrefPubMedGoogle Scholar
  • 42 Choi Y H, Yoon C J, Park J H, Chung J W, Kwon J W, Choi G M. Balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding: its feasibility compared with transjugular intrahepatic portosystemic shunt.  Korean J Radiol. 2003;  4 (2) 109-116
    CrossrefPubMedGoogle Scholar
  • 43 Park K S, Kim Y H, Choi J S et al.. Therapeutic efficacy of balloon-occluded retrograde transvenous obliteration in patients with gastric variceal bleeding.  Korean J Gastroenterol. 2006;  47 (5) 370-378
    PubMedGoogle Scholar
  • 44 Kim E S, Park S Y, Kwon K T et al.. The clinical usefulness of balloon occluded retrograde transvenous obliteration in gastric variceal bleeding.  Taehan Kan Hakhoe Chi. 2003;  9 (4) 315-323
    PubMedGoogle Scholar
  • 45 Matsumoto A, Hamamoto N, Nomura T et al.. Balloon-occluded retrograde transvenous obliteration of high risk gastric fundal varices.  Am J Gastroenterol. 1999;  94 (3) 643-649
    CrossrefPubMedGoogle Scholar
  • 46 Park S J, Chung J W, Kim H-C, Jae H J, Park J H. The prevalence, risk factors, and clinical outcome of balloon rupture in balloon-occluded retrograde transvenous obliteration of gastric varices.  J Vasc Interv Radiol. 2010;  21 (4) 503-507
    CrossrefPubMedGoogle Scholar
  • 47 Hassab M A. Gastroesophageal decongestion and splenectomy in the treatment of esophageal varices in bilharzial cirrhosis: further studies with a report on 355 operations.  Surgery. 1967;  61 (2) 169-176
    PubMedGoogle Scholar

Wael E. A. SaadM.D. F.S.I.R. 

Department of Radiology and Medical Imaging, University of Virginia Health System

Box 800170, 1215 Lee Street, Charlottesville, VA 22908

Email: wspikes@yahoo.com

      >