Balloon-occluded Retrograde Transvenous Obliteration Research Articles

Balloon-occluded retrograde transvenous obliteration for bleeding gastric varices in a patient without a gastrorenal shunt

Balloon-occluded retrograde transvenous obliteration for bleeding gastric varices in a patient without a gastrorenal shunt

Comparison of the management of gastric variceal bleeding techniques.

Managing gastric variceal (GV) hemorrhage is more complicated than managing esophageal variceal (EV) bleeding, resulting in significantly higher morbidity and mortality. We aim to compare the outcomes of endoscopic variceal ligation (EVL), transhepatic intrahepatic portosystemic shunt (TIPS), and balloon-occluded retrograde transvenous obliteration (BRTO) in the management of GV bleeding. We utilized the National Inpatient Sample (NIS) database from January 2016 to December 2019 to include adult patients with GV hemorrhage. Our study identified 7160 hospitalizations with a primary diagnosis of GV hemorrhage who underwent the interventions of interest. EVL was performed in 69.83%, TIPS in 8.72%, and BRTO in 4.88%. Patients with liver cirrhosis had a higher frequency of undergoing BRTO (68.6%), followed by TIPS (64.0%) and esophagogastroduodenoscopy (EGD) + TIPS (63.7%) (P < 0.001). Patients with cirrhosis secondary to alcoholism had a higher prevalence of TIPS (62.4%), followed by EGD + TIPS (69.4%) and BRTO (52.9%) (P < 0.001). Overall, the inpatient mortality was 6.5%. Overall inpatient mortality was highest in the TIPS cohort (8.8%), followed by BRTO (7.1%), EGD + TIPS (6.5%), EVL (6.2%), and EGD + BRTO (2.8%) (P < 0.001); However, the Kaplan-Meier graph showed endoscopy with BRTO had the most favorable 30-day survival, trailed by TIPS alone and BRTO alone. EVL remains a prominent therapeutic strategy. Remarkably, the combination of endoscopy with BRTO shows promising 30-day survival outcomes. Considering these observations, although EVL holds its primacy, it is essential to further explore the potential benefits of combined therapies in larger studies to ascertain the best treatment strategies.

S3458 Mechanical Thrombectomy: A Novel Approach for Portal Vein Thrombosis After Balloon-Occluded Retrograde Transvenous Obliteration

S3458 Mechanical Thrombectomy: A Novel Approach for Portal Vein Thrombosis After Balloon-Occluded Retrograde Transvenous Obliteration

Balloon-occluded retrograde transvenous obliteration and simultaneous endoscopic cyanoacrylate injection for treating gastric varices draining through gastrorenal shunts

Background and study aimsBalloon-occluded retrograde transvenous obliteration-assisted endoscopic cyanoacrylate injection (E-BRTO) temporarily treats gastric fundic varices draining through gastrorenal shunts (GRS) occluding the GRS with a balloon, then endoscopically injecting cyanoacrylate. We retrospectively examined the safety, feasibility, and efficacy of E-BRTO. Patients and MethodsWe enrolled 85 patients with hepatic cirrhosis plus gastric fundic varices with GRS; 34 underwent E-BRTO. The 51 patients who refused all secondary prophylactic treatments served as controls. ResultsFinally, 33 of the 34 patients underwent successful E-BRTO without major adverse events. Gastric varices were eradicated from all 33 patients in the E-BRTO group; the average follow-up time was 161.0 (74.0) weeks (mean [SD]). Four end-point events (12%) were recorded during the follow-up period. In the control group, 33 patients (65%) suffered repeat variceal bleeding, resulting in seven deaths. The cumulative rebleeding rates of the E-BRTO group on the 6th, 24th, 48th, 96th, 144th, 192nd, 240th, and 288th week were 0%, 3%, 9%, 9%, 13%, 13%, 13%, and 13%, while the cumulative rebleeding rates of the control group in the same period were 10%, 20%, 35%, 46%, 55%, 65%, 76%, and 76%. ConclusionsE-BRTO was safe, feasible, and well tolerated by patients with hepatic cirrhosis plus gastric fundic varices with GRS. Over the long-term follow-up period, the E-BRTO group demonstrated a lower rate of repeat bleeding than the control group.

Woman With Hematochezia.

As a consequence of cirrhosis, portal hypertension causes resistance to blood flow and leads to the formation of varices. However, colonic variceal hemorrhages are rarely reported but could be a lethal cause of lower gastrointestinal hemorrhage. Currently, there is no consensus on the management of colonic variceal hemorrhage. Variceal ligation, injection sclerotherapy, transjugular intrahepatic portosystemic shunt placement, and balloon-occluded retrograde transvenous obliteration or a combination of the above therapies have been reported with inconsistent success rates. We advocate considering colonic variceal bleeding as a crucial differential diagnosis of lower gastrointestinal bleeding in cirrhotic patients and initiating time-sensitive, definite operative treatment or combination therapy as soon as possible in colonic variceal patients with life-threatening bleeding events, which are often refractory to conservative treatment.

Interventions in Gastric Varices: TIPS versus BRTO

AbstractGastric 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.

Management of Gastric Varices: IR Perspective

AbstractGastric varices are a sequela of portal hypertension. If left untreated, life-threatening bleeding can occur. While endoscopic treatment is traditionally considered as a first-line interventional option, endovascular techniques have emerged to become the superior option in certain clinical scenarios, either as a first-line therapy or a salvage therapy. Endovascular techniques for managing gastric varices include transjugular intrahepatic portosystemic shunt (TIPS) placement, balloon-occluded retrograde transvenous obliteration (BRTO), coil, and plug-assisted retrograde transvenous obliteration, as well as a combination of both. Studies have shown that endovascular techniques can effectively control bleeding from gastric varices, with high success rates and low complication rates, and significantly reduce recurrence. TIPS placement has shown to be more effective in controlling bleeding from gastroesophageal varices, while BRTO, coil, or plug-assisted embolizations are more suitable for patients with isolated gastric varices. Endovascular interventions are a valuable option for managing gastric varices, especially in patients who are not candidates for endoscopic treatment or who have failed previous endoscopic interventions. In this two-part series editorial, we aim to initially review the complex anatomy and classification of gastric varices, medical management, and current endovascular interventional techniques, and how they compare with one another. In part 2, we draw a parallel between endovascular versus endoscopic techniques, and highlight and critically review current literature as it pertains to gastric variceal management.

Long-Term Prognosis and Related Factors in Patients with Cirrhosis Treated with Balloon-Occluded Retrograde Transvenous Obliteration

Introduction: Balloon-occluded retrograde transvenous obliteration (BRTO) was developed as an effective treatment for gastric varices in patients with cirrhosis. Because liver fibrosis in these patients is assumed to be advanced, their prognosis is expected to be poor. In this study, we investigated the prognosis and characteristics of the patients. Methods: We enrolled 55 consecutive patients with liver cirrhosis treated with BRTO between 2009 and 2021 at our department. To evaluate factors related to variceal recurrence and long-term prognosis, survival analysis was performed on 45 patients, excluding those who died within 1 month, had an unknown prognosis, or whose treatments were converted to other treatments. Results: During a mean follow-up period of 2.3 years, esophageal varices recurred in 10 patients and could be treated endoscopically. Non-alcoholic steatohepatitis (NASH) was related to the variceal recurrence (hazard ratio [HR] = 4.27, 95% CI: 1.17–15.5, p = 0.028). The survival rate after the procedure at 1, 3, and 5 years was 94.2%, 74.0%, and 63.5%, respectively, and 10 patients died of hepatocellular carcinoma (n = 6), liver failure (n = 1), sepsis (n = 1), and unknown reasons (n = 2). The estimated glomerular filtration rate (eGFR) level was proved to be a significant poor prognostic factor (HR = 0.96, 95% CI: 0.93–0.99, p = 0.023). The comorbid hypertension (HTN) was the main cause of low eGFR, and HTN was also significantly related to survival (HR = 6.18, 95% CI: 1.57–24.3, p = 0.009). Most of the patients with HTN were treated with calcium channel blocker and/or angiotensin receptor blocker. Conclusion: The clinical course of patients with cirrhosis treated with BRTO was dependent on the metabolic factors including renal function, comorbid HTN, and NASH.

Use of Balloon Occluded Retrograde Transvenous Obliteration (BRTO) for Treatment of Gastric Varices: A Narrative Review.

Gastric Varices occur as a result of portal hypertension. Balloon Retrograde Transvenous Obliteration (BRTO) is a modality for managing gastric varices. The ultimate goal of this review is to promote the broader adoption of BRTO in managing gastric varices and to promote further research to improve patient outcomes. Before this study, an electronic literature search was undertaken based on identified concepts, keywords, and other pertinent descriptions. Search databases were developed and included "Gastric varices" AND "BRTO" OR "intervention" OR "treatment" OR "procedure" OR "glue" OR "adhesive". The databases selected and thoroughly searched were PubMed, Cochrane Library and ScienceDirect. Following the first search, 274 articles were found in total. By applying inclusion criteria of full-text articles and a period of fewer than five years, the database was reduced to 37 articles, which was then further filtered to include only articles on adults over 19 years old, leaving a total count of 17 articles. BRTO is a relatively simple procedure to perform once the essential skill is attained and helpful in both emergency and elective management of gastric varices. Its use still needs to be improved by the unavailability and lack of skills. However, there are side effects associated with BRTO as it causes elevation of portal hypertension, recurrent bleeding, hemoglobinuria and pain post procedure. This review emphasizes the need for further research in this field, focusing on refining patient selection criteria, improving the technical aspect of the procedure and enhancing long-term outcomes.

Endoscopic N-butyl-2-cyanoacrylate and ethanolamine oleate injection is equivalent to balloon-occluded retrograde transvenous obliteration for preventing gastric variceal bleeding.

Endoscopic injection sclerotherapy (EIS) is effective for temporary hemostasis, but EIS and balloon-occluded retrograde transvenous obliteration (BRTO) have been reported as effective for secondary prophylaxis of gastric varices (GV) bleeding. This study retrospectively compared EIS and BRTO in patients with GV in terms of the efficacy for secondary prevention of GV bleeding and effects on liver function. From our database of patients with GV who underwent EIS or BRTO between February 2011 and April 2020, a total of 42 patients with GV were retrospectively enrolled. The primary endpoint was the bleeding rate from GV, which was compared between EIS and BRTO groups. Secondary endpoints were liver function after treatment and rebleeding rate from EV, compared between EIS and BRTO groups. Rebleeding rates from GV and EV and liver function after treatment were also compared between EIS-ethanolamine oleate (EO)/histoacryl (HA) and EIS-HA groups. Technical success was achieved for all EIS cases, but two cases were unsuccessful in the BRTO group and underwent additional EIS. No significant differences in bleeding rates or endoscopic findings for GV improvement were seen between EIS and BRTO groups. Liver function also showed no significant difference in the amount of change after treatment between groups. EIS therapy appears effective for GV in terms of preventing GV rebleeding and effects on liver function after treatment. EIS appears to represent an effective treatment for GV.

Transvenous obliteration of gastric varices

Gastric varices on the background of portal hypertension occur less frequently than esophageal varices but they develop at lower portal pressure and are associated with more massive bleedings and higher mortality rate. Balloon-occluded retrograde transvenous obliteration (BRTO) has been well documented as an effective therapy for gastric varices caused by portal hypertension. However, BRTO requires long-term, higher-level post-procedural monitoring and can have complications related to balloon rupture and adverse effects of sclerosing agents. Several modified BRTO techniques have been developed, including vascular plug-assisted retrograde transvenous obliteration, coil-assisted retrograde transvenous obliteration, and balloon-occluded antegrade transvenous obliteration. This article provides an overview of BRTO various and modified BRTO techniques.

Nylon ring with titanium clip assists endoscopic cyanoacrylate injection for the treatment of GOV1-type gastric varices.

There is an estimated approximately 20 % chance of having gastric varices in patients with portal hypertension [1]. Gastric varices bleed less frequently than esophageal varices but are much more severe when they do occur. Therefore, effective treatment of such bleeding or prevention of rebleeding is vital. According to the Baveno VI Consensus Symposium, endoscopic injection of cyanoacrylate is the recommended treatment for hemostasis and prevention of rebleeding from gastric varices [2] (de Franchis and Baveno 2015). However, a number of serious adverse events has been reported including ectopic embolism, especially in bleeding patients with gastric varices and gastrorenal shunts (GOV2 or IGV1 varices) [3] [4]. As an alternative to endoscopic therapy guided by endoscopic ultrasound (EUS) and balloon-occluded retrograde transvenous obliteration, we hope to provide a new simple and effective method for the treatment of GOV1 gastric varices. By using nylon rings and clips we attempted to completely block blood flow to the gastric varices before injecting cyanoacrylate into the gastric varices. This method can effectively reduce the risk of ectopic embolism in GOV1 gastric varices and reduce the dosage of cyanoacrylate.

A246 BALLOON-OCCLUDED RETROGRADE TRANSVENOUS OBLITERATION FOR PRIMARY PROPHYLAXIS OF GASTRIC VARICEAL BLEEDING: A SYSTEMATIC REVIEW

Abstract Background Gastric variceal (GV) bleeding is an infrequent but serioous complication of cirrhosis that is associated with high mortality. Balloon-occluded retrograde transvenous obliteration (BRTO) is an effective treatment to prevent rebleeding from GV. The role of BRTO for primary prophylaxis of GV bleeding has not been established. Purpose The aim of the current study is to establish the efficacy and safety of BRTO for primary prophylaxis of GV bleeding. Method We searched EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials from inception to November 2021. Randomized controlled trials and observational studies involving adults with cirrhosis related GV that had never bled and were treated with BRTO were included. Studies without clinical outcomes or those not reporting primary prophylaxis outcomes separately were excluded. Risk of bias was assessed using the Newcastle-Ottawa scale. Result(s) We identified 791 unique citations with 9 eligible studies after a full-text review. A total of 577 patients were included from 9 observational studies (1 prospective, 8 retrospective). Technical success after the first procedure ranged from 82.4-100% (7 studies) and GV eradication on follow-up endoscopy ranged from 88.2-100% (4 studies). GV bleeding occurred in 0-7.3% of patients with follow-up ranging from 15.8-66.2 months (9 studies). Eight studies were considered at high risk of bias due to the lack of a control group or poor comparability between the cohorts. Conclusion(s) BRTO appears to be effective for primary prophylaxis of GV bleeding. Further controlled studies are needed before BRTO can be routinely performed for primary prevention of gastric variceal bleeding. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Comparison of efficacy and safety of endoscopic and radiological interventions for gastric varices: A systematic review and network meta-analysis.

There is a paradigm shift in the management of gastric varices with the availability of endoscopic ultrasound and radiologic interventions. The optimal choice of intervention remains a dilemma for most treating physicians. We searched MEDLINE, the Cochrane Central Register of Controlled Trials, and ScienceDirect for studies comparing endoscopic glue injection, endoscopic thrombin injection (THB), variceal band ligation, EUS-guided coiling, EUS-guided glue injection, EUS-guided coiling with glue (EUS-C+G), balloon occluded retrograde transvenous obliteration (BRTO), and transjugular intrahepatic portosystemic shunt (TIPS) for gastric varices in adults. The data on four outcomes - obliteration of varices, rebleeding, adverse effects, and mortality - were pooled using a random-effects model. Treatment estimates were calculated as odds ratios (ORs) along with their 95% confidence interval (CI). The relative ranking of interventions for various outcomes was calculated as their surface under the cumulative ranking curve (SUCRA). We identified 34 studies (10 randomized controlled trials, 24 non-randomized trials) with 2783 patients. Based on SUCRA plots, BRTO (SUCRA 95.1) had the highest rate of variceal obliteration followed by EUS-C+G (SUCRA 80.9). The risk of rebleeding was lowest with BRTO (SUCRA 85.1) followed by EUS-C+G (SUCRA 78.8). Moderate-severe adverse effects were least likely with THB (SUCRA 92.5) and highest with TIPS (SUCRA 3.7). In terms of mortality, EUS-C+G (73.5) had the lowest probability of overall mortality followed by TIPS (69.1). In this network meta-analysis, we found BRTO and EUS-guided therapies to be superior to endoscopic glue injection. However, the level of evidence remains low.

Efficacy and safety of EUS-guided coil embolization combined with endoscopic cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration for gastric varices with high-risk ectopic embolism: A multicenter and retrospective cohort study.

Gastric varices (GV) with spontaneous portosystemic shunt (SPSS) are associated with ectopic embolism in endoscopic cyanoacrylate. This study targeted to assess the efficacy and safety of EUS-guided coil embolization combined with endoscopic cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration (BRTO) for GV with high-risk ectopic embolism. We retrospectively analyzed six tertiary hospitals' 104 patients with GV at high-risk ectopic embolism (the narrowest diameter of SPSS was greater than or equal to 5 mm and the maximum diameter usually >8 mm) who underwent EUS-guided coil embolization combined with endoscopic cyanoacrylate injection or BRTO from January 2014 to December 2020. The outcomes included rebleeding, survival, and complications. The EUS group and BRTO group contained 59 and 45 patients, respectively. The technical success rate between the two groups was similar (96.6% vs. 95.6%, P = 1.000). During the follow-up, both groups' 5-day rebleeding rate and 6-week mortality rate were 0%. One-year all-cause rebleeding rate (20.0% vs. 18.9%, P = 0.900) and 1-year mortality rate (2.0% vs. 0%, P = 1.000) in the EUS group were similar to the BRTO group. One patient experienced ectopic embolism in the EUS group, while the BRTO group did not. Both groups had similar mean days (16.0 [interquartile range (IQR), 12.0-19.0] vs. 16.5 [IQR, 11.8-26.0], P = 0.165) and cost of hospitalization (¥ 45950.6 [IQR, 39330.2-55768.2] vs. ¥ 51205.8 [IQR, 31628.8-74251.5], P = 0.680). Multivariate analysis showed that the narrowest diameter of the shunt (odds ratio [OR] = 1.86; 95% confidence interval [CI]: 1.062-3.258; P = 0.03) and content of hemoglobin (OR = 0.941; 95% CI: 0.892-0.992; P = 0.025) were the prognostic factors for survival. The efficacy and safety of EUS-guided coil embolization combined with endoscopic cyanoacrylate injection for GV with high-risk ectopic embolism are comparable to BRTO.

A curious case of confusion

A curious case of confusion

Balloon-occluded retrograde transvenous obliteration combined with EUS-guided coil embolization and endoscopic cyanoacrylate injection therapy of gastric varices with huge gastrorenal shunt (with videos).

Balloon-occluded retrograde transvenous obliteration combined with EUS-guided coil embolization and endoscopic cyanoacrylate injection therapy of gastric varices with huge gastrorenal shunt (with videos).

A Combined Treatment of Life-threatening and Difficult to Treat Bleeding Gastro-oesophageal Varices in a Patient with Cirrhosis and Portal Cavernomatosis

Balloon-occluded retrograde transvenous obliteration (BRTO) is an endovascular secondary prophylactic approach to gastroesophageal variceal (GOV) bleeding. However, standard primary prophylaxis is olten inef-fective and GOV bleeding is more severe than esophageal variceal (EV) bleeding. Portal vein thrombosis and its evolution to cavernomatosis are common complications of cirrhosis. There are no data in the literature on the safety of BRTO in patients with portal cavernomatosis and on the risk of excessively increasing portal hypertension in patients with esophageal varices at risk of bleeding. Portal cavernomatosis is a relative con-traindication to TIPS placement. Furthermore, in our knowledge there are no great experiences on the com-bined use of BRTO and TIPS and no information in patients with portal cavernomatosis.

Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Varix with Both Gastrorenal and Gastrocaval Shunts: A Case Report

Gastric variceal bleeding has a poor prognosis and a high mortality rate. Balloon-occluded retrograde transvenous obliteration has traditionally been applied in the treatment of gastric varix. Recently, plug-assisted retrograde transvenous obliteration (PARTO) has been widely and popularly applied for the treatment of gastric varix. There have been no reports of cases in which PARTO was performed in patients with both gastrorenal shunt and gastrocaval shunt. We report a case in which PARTO was performed on a patient with gastric varix who had both a gastrorenal shunt and a gastrocaval shunt.

A combination of liver stiffness and international normalized ratio is an ideal prognostic predictor of portosystemic shunt occlusion in patients with portal hypertension.

We previously reported liver stiffness (LS) as a prognostic predictor of portosystemic shunt (PSS) occlusion. This study aims to reinvestigate the predictive factors of the model for end-stage liver disease-sodium (MELD-Na) score amelioration following balloon-occluded retrograde transvenous obliteration (BRTO) and to evaluate the postoperative prognoses of patients with portal hypertension by using newly identified factors. Seventy-five patients who underwent BRTO between 2008 and 2021 were retrospectively enrolled. The MELD-Na scores were calculated preoperatively and one month postoperatively. We monitored long-term outcomes and analyzed postoperative survival. At one month postoperatively, the MELD-Na score decreased in 46 (61.3%) patients. Univariate analyses revealed a significant association of the score amelioration with nine factors, including lower LS levels and a higher international normalized ratio (INR). A multivariate logistic regression analysis with receiver operating characteristic curve analyses identified preoperative LS levels and INR as significant independent predictors of the postoperative MELD-Na score amelioration, with optimal cutoffs of 28.1kPa and 1.06, respectively. The combination of LS < 28.1kPa and INR ≥ 1.06 showed a sensitivity and specificity of 84.8% and 75.9% for the prediction of the score amelioration, respectively. For the propensity score model, we matched 24 patients with similar age, sex, MELD-Na score, and concomitant hepatocellular carcinoma. Kaplan-Meier analysis determined significantly higher cumulative survival rates in patients with LS < 28.1kPa and INR ≥ 1.06 than in other populations. A combination of LS and INR can predict the MELD-Na score amelioration and prognosis improvement following PSS occlusion.