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Semin intervent Radiol 2011; 28(3): 339-349
DOI: 10.1055/s-0031-1284461
© Thieme Medical Publishers

Transjugular Intrahepatic Portosystemic Shunt (TIPS) versus Balloon-occluded Retrograde Transvenous Obliteration (BRTO) for the Management of Gastric Varices

Wael E. A. Saad1 , Michael D. Darcy2
  • 1Division of Vascular Interventional Radiology, Department of Radiology, University of Virginia Health System, Charlottesville, Virginia
  • 2Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri
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Publication History

Publication Date:
15 August 2011 (online)

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ABSTRACT

Variceal bleeding is one of the major complications of portal hypertension. Gastric variceal bleeding is less common than esophageal variceal bleeding; however, it is associated with a high morbidity and mortality rate and its management is largely uncharted due to a relatively less-established literature. In the West (United States and Europe), the primary school of management is to decompress the portal circulation utilizing the transjugular intrahepatic portosystemic shunt (TIPS). In the East (Japan and South Korea), the primary school of management is to address the gastric varices (GVs) specifically by sclerosing them utilizing the balloon-occluded retrograde transvenous obliteration (BRTO) procedure. The concept (1970s), evolution, and development (1980s–1990s) of both procedures run parallel to one another; neither is newer than the other is. The difference is that one was adopted mostly by the East (BRTO), while the other has been adopted mostly by the West (TIPS). TIPS is effective in emergently controlling bleeding for GVs even though the commonly referenced studies about managing GVs with TIPS are studies with TIPS created by bare stents. However, the results have improved with the use of stent grafts for creating TIPS. Nevertheless, TIPS cannot be tolerated by patients with poor hepatic reserve. BRTO is equally effective in controlling bleeding GVs as well as significantly reducing the GV rebleed rate. But the resultant diversion of blood flow into the portal circulation, and in turn the liver, increases the risk of developing esophageal varices and ectopic varices with their potential to bleed. Unlike TIPS, the blood diversion that occurs after BRTO improves, if not preserves, hepatic function for 6–9 months post-BRTO. The authors discuss the detailed results and critique the literature, which has evaluated and remarked on both procedures. Future research prospects and speculation as to the ideal patients for each procedure are discussed.

KEYWORDS

History - BRTO - transvenous obliteration - varices - TIPS - rebleeding

REFERENCES

  • 1 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
  • 2 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
  • 3 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
  • 4 Trudeau W, Prindiville T. Endoscopic injection sclerosis in bleeding gastric varices.  Gastrointest Endosc. 1986;  32 (4) 264-268
    CrossrefPubMedGoogle Scholar
  • 5 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
  • 6 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
  • 7 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
  • 8 Rockey D C. Management of gastric varices.  Gastroenterology. 2001;  120 (7) 1875-1876 discussion 1876-1877
    CrossrefPubMedGoogle Scholar
  • 9 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
  • 10 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
  • 11 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
  • 12 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
  • 13 Hirota S, Matsumoto S, Tomita M, Sako M, Kono M. Retrograde transvenous obliteration of gastric varices.  Radiology. 1999;  211 (2) 349-356
    CrossrefPubMedGoogle Scholar
  • 14 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
  • 15 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
  • 16 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
  • 17 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
  • 18 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
  • 19 Funaro A H, Ring E J, Freiman D B, Oleaga J A, Gordon R L. Transhepatic obliteration of esophageal varices using the stainless steel coil.  AJR Am J Roentgenol. 1979;  133 (6) 1123-1125
    CrossrefPubMedGoogle Scholar
  • 20 Scott J, Dick R, Long R G, Sherlock S. Percutaneous transhepatic obliteration of gastro-oesophageal varices.  Lancet. 1976;  2 (7976) 53-55
    CrossrefPubMedGoogle Scholar
  • 21 Lunderquist A, Simert G, Tylén U, Vang J. Follow-up of patients with portal hypertension and esophageal varices treated with percutaneous obliteration of gastric coronary vein.  Radiology. 1977;  122 (1) 59-63
    PubMedGoogle Scholar
  • 22 Lunderquist A, Vang J. Transhepatic catheterization and obliteration of the coronary vein in patients with portal hypertension and esophageal varices.  N Engl J Med. 1974;  291 (13) 646-649
    CrossrefPubMedGoogle Scholar
  • 23 Lunderquist A, Vang J. Sclerosing injection of esophageal varices through transhepatic selective catheterization of the gastric coronary vein. A preliminary report.  Acta Radiol Diagn (Stockh). 1974;  15 (5) 546-550
    PubMedGoogle Scholar
  • 24 Olson E, Yune H Y, Klatte E C. Transrenal-vein reflux ethanol sclerosis of gastroesophageal varices.  AJR Am J Roentgenol. 1984;  143 (3) 627-628
    CrossrefPubMedGoogle Scholar
  • 25 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
  • 26 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
  • 27 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
  • 28 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
  • 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 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
  • 34 Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Transjugular retrograde obliteration for chronic portosystemic encephalopathy.  Abdom Imaging. 2000;  25 (6) 567-571
    CrossrefPubMedGoogle Scholar
  • 35 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
  • 36 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
  • 37 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
  • 38 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
  • 39 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
  • 40 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
  • 41 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
  • 42 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
  • 43 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
  • 44 Burgener F A, Gutierrez O H. Nonsurgical production of intrahepatic portosystemic venous shunts in portal hypertension with the double lumen balloon catheter (author's transl).  Rofo. 1979;  130 (6) 686-688
    Article in Thieme ConnectPubMedGoogle Scholar
  • 45 Burgener F A, Gutierrez O H. Production of an intrahepatic portocaval fistula in the dog with liver cirrhosis and portal hypertension.  Rofo. 1984;  141 (3) 327-332
    Article in Thieme ConnectPubMedGoogle Scholar
  • 46 Burgener F A, Gutierrez O H. Production of nonsurgical intrahepatic portacaval shunt in portal hypertension using a Gruntzig balloon dilatation catheter.  J Radiol. 1985;  66 (1) 7-11
    PubMedGoogle Scholar
  • 47 Burgener F A, Gutierrez O H. Experimental intrahepatic portocaval shunts created in portal hypertension by balloon angioplasty catheters.  Invest Radiol. 1988;  23 (1) 24-29
    CrossrefPubMedGoogle Scholar
  • 48 Rösch J, Uchida B T, Putnam J S, Buschman R W, Law R D, Hershey A L. Experimental intrahepatic portacaval anastomosis: use of expandable Gianturco stents.  Radiology. 1987;  162 (2) 481-485
    PubMedGoogle Scholar
  • 49 LaBerge J M, Ring E J, Gordon R L. Percutaneous intrahepatic portosystemic shunt created via a femoral vein approach.  Radiology. 1991;  181 (3) 679-681
    PubMedGoogle Scholar
  • 50 Ring E J, Lake J R, Roberts J P et al.. Using transjugular intrahepatic portosystemic shunts to control variceal bleeding before liver transplantation.  Ann Intern Med. 1992;  116 (4) 304-309
    PubMedGoogle Scholar
  • 51 LaBerge J M, Ring E J, Lake J R et al.. Transjugular intrahepatic portosystemic shunts: preliminary results in 25 patients.  J Vasc Surg. 1992;  16 (2) 258-267
    CrossrefPubMedGoogle Scholar
  • 52 Sahagun G, Benner K G, Saxon R et al.. Outcome of 100 patients after transjugular intrahepatic portosystemic shunt for variceal hemorrhage.  Am J Gastroenterol. 1997;  92 (9) 1444-1452
    PubMedGoogle Scholar
  • 53 LaBerge J M, Ring E J, Gordon R L et al.. Creation of transjugular intrahepatic portosystemic shunts with the wallstent endoprosthesis: results in 100 patients.  Radiology. 1993;  187 (2) 413-420
    CrossrefPubMedGoogle Scholar
  • 54 Echenagusia A J, Camúñez F, Simó G et al.. Variceal hemorrhage: efficacy of transjugular intrahepatic portosystemic shunts created with Strecker stents.  Radiology. 1994;  192 (1) 235-240
    PubMedGoogle Scholar
  • 55 Sterling K M, Darcy M D. Stenosis of transjugular intrahepatic portosystemic shunts: presentation and management.  AJR Am J Roentgenol. 1997;  168 (1) 239-244
    PubMedGoogle Scholar
  • 56 Saxon R S, Ross P L, Mendel-Hartvig J et al.. Transjugular intrahepatic portosystemic shunt patency and the importance of stenosis location in the development of recurrent symptoms.  Radiology. 1998;  207 (3) 683-693
    CrossrefPubMedGoogle Scholar
  • 57 Haskal Z J, Pentecost M J, Soulen M C, Shlansky-Goldberg R D, Baum R A, Cope C. Transjugular intrahepatic portosystemic shunt stenosis and revision: early and midterm results.  AJR Am J Roentgenol. 1994;  163 (2) 439-444
    PubMedGoogle Scholar
  • 58 Nazarian G K, Bjarnason H, Dietz Jr C A et al.. Refractory ascites: midterm results of treatment with a transjugular intrahepatic portosystemic shunt.  Radiology. 1997;  205 (1) 173-180
    PubMedGoogle Scholar
  • 59 Saxon R R, Timmermans H A, Uchida B T et al.. Stent-grafts for revision of TIPS stenoses and occlusions: a clinical pilot study.  J Vasc Interv Radiol. 1997;  8 (4) 539-548
    CrossrefPubMedGoogle Scholar
  • 60 Haskal Z J, Davis A, McAllister A, Furth E E. PTFE-encapsulated endovascular stent-graft for transjugular intrahepatic portosystemic shunts: experimental evaluation.  Radiology. 1997;  205 (3) 682-688
    CrossrefPubMedGoogle Scholar
  • 61 Haskal Z J. Improved patency of transjugular intrahepatic portosystemic shunts in humans: creation and revision with PTFE stent-grafts.  Radiology. 1999;  213 (3) 759-766
    PubMedGoogle Scholar
  • 62 Otal P, Smayra T, Bureau C et al.. Preliminary results of a new expanded-polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt procedures.  AJR Am J Roentgenol. 2002;  178 (1) 141-147
    PubMedGoogle Scholar
  • 63 Cejna M, Peck-Radosavljevic M, Thurnher S A, Hittmair K, Schoder M, Lammer J. Creation of transjugular intrahepatic portosystemic shunts with stent-grafts: initial experiences with a polytetrafluoroethylene-covered nitinol endoprosthesis.  Radiology. 2001;  221 (2) 437-446
    CrossrefPubMedGoogle Scholar
  • 64 Cejna M, Peck-Radosavljevic M, Thurnher S et al.. ePTFE-covered stent-grafts for revision of obstructed transjugular intrahepatic portosystemic shunt.  Cardiovasc Intervent Radiol. 2002;  25 (5) 365-372
    CrossrefPubMedGoogle Scholar
  • 65 Angermayr B, Cejna M, Koenig F Vienna TIPS Study Group et al. Survival in patients undergoing transjugular intrahepatic portosystemic shunt: ePTFE-covered stentgrafts versus bare stents.  Hepatology. 2003;  38 (4) 1043-1050
    CrossrefPubMedGoogle Scholar
  • 66 Bureau C, Garcia-Pagan J C, Otal P et al.. Improved clinical outcome using polytetrafluoroethylene-coated stents for TIPS: results of a randomized study.  Gastroenterology. 2004;  126 (2) 469-475
    CrossrefPubMedGoogle Scholar
  • 67 Angeloni S, Merli M, Salvatori F M et al.. Polytetrafluoroethylene-covered stent grafts for TIPS procedure: 1-year patency and clinical results.  Am J Gastroenterol. 2004;  99 (2) 280-285
    CrossrefPubMedGoogle Scholar
  • 68 Rossi P, Salvatori F M, Fanelli F et al.. Polytetrafluoroethylene-covered nitinol stent-graft for transjugular intrahepatic portosystemic shunt creation: 3-year experience.  Radiology. 2004;  231 (3) 820-830
    CrossrefPubMedGoogle Scholar
  • 69 Charon J-PM, Alaeddin F H, Pimpalwar S A et al.. Results of a retrospective multicenter trial of the Viatorr expanded polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt creation.  J Vasc Interv Radiol. 2004;  15 (11) 1219-1230
    CrossrefPubMedGoogle Scholar
  • 70 Hausegger K A, Karnel F, Georgieva B et al.. Transjugular intrahepatic portosystemic shunt creation with the Viatorr expanded polytetrafluoroethylene-covered stent-graft.  J Vasc Interv Radiol. 2004;  15 (3) 239-248
    CrossrefPubMedGoogle Scholar
  • 71 Vignali C, Bargellini I, Grosso M et al.. TIPS with expanded polytetrafluoroethylene-covered stent: results of an Italian multicenter study.  AJR Am J Roentgenol. 2005;  185 (2) 472-480
    CrossrefPubMedGoogle Scholar
  • 72 Rössle M, Siegerstetter V, Euringer W et al.. The use of a polytetrafluoroethylene-covered stent graft for transjugular intrahepatic portosystemic shunt (TIPS): Long-term follow-up of 100 patients.  Acta Radiol. 2006;  47 (7) 660-666
    CrossrefPubMedGoogle Scholar
  • 73 Tripathi D, Ferguson J, Barkell H et al.. Improved clinical outcome with transjugular intrahepatic portosystemic stent-shunt utilizing polytetrafluoroethylene-covered stents.  Eur J Gastroenterol Hepatol. 2006;  18 (3) 225-232
    CrossrefPubMedGoogle Scholar
  • 74 Bureau C, Pagan J C, Layrargues G P et al.. Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: long-term results of a randomized multicentre study.  Liver Int. 2007;  27 (6) 742-747
    CrossrefPubMedGoogle Scholar
  • 75 Saxon R R. A new era for transjugular intrahepatic portosystemic shunts?.  J Vasc Interv Radiol. 2004;  15 (3) 217-219
    CrossrefPubMedGoogle Scholar
  • 76 Ferral H, Gamboa P, Postoak D W et al.. Survival after elective transjugular intrahepatic portosystemic shunt creation: prediction with model for end-stage liver disease score.  Radiology. 2004;  231 (1) 231-236
    CrossrefPubMedGoogle Scholar
  • 77 Ferral H, Patel N H. Selection criteria for patients undergoing transjugular intrahepatic portosystemic shunt procedures: current status.  J Vasc Interv Radiol. 2005;  16 (4) 449-455
    CrossrefPubMedGoogle Scholar
  • 78 Montgomery A, Ferral H, Vasan R, Postoak D W. MELD score as a predictor of early death in patients undergoing elective transjugular intrahepatic portosystemic shunt (TIPS) procedures.  Cardiovasc Intervent Radiol. 2005;  28 (3) 307-312
    CrossrefPubMedGoogle Scholar
  • 79 Anderson C L, Saad W E, Kalagher S D et al.. Effect of transjugular intrahepatic portosystemic shunt placement on renal function: a 7-year, single-center experience.  J Vasc Interv Radiol. 2010;  21 (9) 1370-1376
    CrossrefPubMedGoogle Scholar
  • 80 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
  • 81 Chau T N, Patch D, Chan Y W, Nagral A, Dick R, Burroughs A K. “Salvage” transjugular intrahepatic portosystemic shunts: gastric fundal compared with esophageal variceal bleeding.  Gastroenterology. 1998;  114 (5) 981-987
    CrossrefPubMedGoogle Scholar
  • 82 Barange K, Péron J-M, Imani K et al.. Transjugular intrahepatic portosystemic shunt in the treatment of refractory bleeding from ruptured gastric varices.  Hepatology. 1999;  30 (5) 1139-1143
    CrossrefPubMedGoogle Scholar
  • 83 Lo G-H, Liang H-L, Chen W-C et al.. A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding.  Endoscopy. 2007;  39 (8) 679-685
    Article in Thieme ConnectPubMedGoogle Scholar
  • 84 Rees C J, Nylander D L, Thompson N P, Rose J D, Record C O, Hudson M. Do gastric and oesophageal varices bleed at different portal pressures and is TIPS an effective treatment?.  Liver. 2000;  20 (3) 253-256
    PubMedGoogle Scholar
  • 85 Saad W EA, Darwish W M, Davies M G, Waldman D L. Stent-grafts for transjugular intrahepatic portosystemic shunt creation: specialized TIPS stent-graft versus generic stent-graft/bare stent combination.  J Vasc Interv Radiol. 2010;  21 (10) 1512-1520
    CrossrefPubMedGoogle Scholar
  • 86 Sanyal A J, Freedman A M, Luketic V A et al.. The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts.  Gastroenterology. 1997;  112 (3) 889-898
    CrossrefPubMedGoogle Scholar
  • 87 Chao Y, Lin H C, Lee F Y et al.. Hepatic hemodynamic features in patients with esophageal or gastric varices.  J Hepatol. 1993;  19 (1) 85-89
    CrossrefPubMedGoogle Scholar
  • 88 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
  • 89 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
  • 90 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
  • 91 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) W365-72
    PubMedGoogle Scholar
  • 92 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
  • 93 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
  • 94 Jalan R, Hayes P C. Reply to: Management of gastric fundal varices associated with a gastrorenal shunt, written by Matsumoto A, Matsumoto H, Hamamoto N, Kayazawa M.  Gut. 2001;  48 440-441
    CrossrefPubMedGoogle Scholar
  • 95 Knechtle S J, Rikkers L F. The place of portosystemic shunting. In: Blumgart L H, Belghiti J, DeMatteo R P, et al, eds. Surgery of the Liver, Biliary Tract, and Pancreas. 4th ed. Vol. 2. Philadelphia, PA: Saunders Elsevier; 2007
    Google Scholar
  • 96 Henderson J M. Distal splenorenal shunt. In: Blumgart L H, Belghiti J, DeMatteo R P, et al, eds. Surgery of the Liver, Biliary Tract, and Pancreas. 4th ed. Vol. 2. Philadelphia, PA: Saunders Elsevier; 2007
    Google 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

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