Coil-assisted Retrograde Transvenous Obliteration Research Articles

Clinical Implications and Management of Spontaneous Portosystemic Shunts in Liver Cirrhosis.

Portal hypertension from chronic liver disease leads to the formation of collateral blood vessels called spontaneous portosystemic shunts (SPSS). These shunts may form from existing vessels or through neo-angiogenesis. Their location affects clinical outcomes due to varying risks and complications. This review summarizes current knowledge on SPSS, covering their clinical impact and management strategies. Recent data suggest that SPSS increases the risk of variceal bleeding, regardless of shunt size. The size of the shunt is crucial in the rising incidence of hepatic encephalopathy (HE) linked to SPSS. It also increases the risk of portopulmonary hypertension and portal vein thrombosis. Detecting and assessing SPSS rely on computed tomography (CT) and magnetic resonance imaging. CT enables precise measurements and the prediction of cirrhosis progression. Management focuses on liver disease progression and SPSS-related complications, like HE, variceal bleeding, and portopulmonary hypertension. Interventional radiology techniques such as balloon-occluded, plug-assisted, and coil-assisted retrograde transvenous obliteration play a pivotal role. Surgical options are rare but are considered when other methods fail. Liver transplantation (LT) often resolves SPSS. Intraoperative SPSS ligation is still recommended in patients at high risk for developing HE or graft hypoperfusion.

Coil-Assisted Retrograde Transvenous Obliteration (CARTO) for the Treatment of Gastric Variceal Bleeding in a Patient with a Gastrorenal Shunt: A Case Report

Background 
 Portal hypertension (pHTN) is primarily caused by liver cirrhosis, which can lead to varices at portosystemic anastomoses.1,2 Gastric variceal bleeding (GVB) is rare but can be life-threatening with a mortality up to 50% for each bleeding episode. When endoscopic banding is ineffective and TIPS placement is contra-indicated due to risk of post-TIPS encephalopathy, coil-assisted retrograde transvenous obliteration (CARTO), which has shown great success in some studies, can be an effective treatment.5,8,9,10 This case demonstrates successful use of CARTO to treat GVB in a patient with a gastrorenal shunt (GRS) who presented with pHTN. 
 
 Case Overview 
 A 62-year-old female with cirrhosis due to nonalcoholic steatohepatitis (NASH) presented with pHTN and GVB. The patient had a massive GRS, which permitted access through the systemic venous circulation to treat the bleeding varices. Furthermore, the patient had hepatic encephalopathy (HE), making TIPS placement a poor choice due to risk of HE exacerbation. CARTO was performed to treat the bleeding varices and had the added benefit of decreasing risk of HE. 
 
 Discussion/Results 
 This case highlights CARTO in a patient with a 22mm GRS using a dual catheter system. Eighteen detachable 035 coils were first deployed in the GRS, followed by complete occlusion with a Gelfoam slurry to obliterate the gastric varices. Studies have described CARTO, all of which have shown incredibly high technical (complete embolization by angiography and/or CT) and clinical (no variceal rebleeding) success rates. This patient returned for follow-up CT and endoscopic imaging, which confirmed technically and clinically successful CARTO. 
 
 Conclusion and Potential Impact 
 CARTO appears to be a safe alternative to TIPS when treating GVB caused by pHTN, especially in patients who have HE and a GRS. Thus, CARTO should be discussed as a treatment option for these patients. Although portal pressure increases post-CARTO, the improvement of HE can lead to an improved safety profile with future TIPS.

S2358 A Case of Coil Assisted Retrograde Transvenous Obliteration Used to Treat Colonic Varices

S2358 A Case of Coil Assisted Retrograde Transvenous Obliteration Used to Treat Colonic Varices

S2585 Does Size Matter? A Case Series on Management of Duodenal Varices

Introduction: Duodenal varices (DVs) are a rare cause of life-threatening bleeding in cirrhotic patients. No standardized guidelines for their management exist. We present two cases of DV hemorrhage who were successfully managed by endoscopic variceal band ligation (EVL) and coil embolization respectively. Case Description/Methods: Case 1: A 63-year-old male with cirrhosis was admitted for upper GI bleeding and Hemoglobin (hgb) of 7.1. Endoscopy showed small to medium-sized DVs with stigmata of recent bleeding with a platelet plug in the second portion of duodenum. EVL was done with adequate decompression and no immediate bleeding. One week later, he developed recurrent hematochezia. Full GI work up including upper endoscopy, small bowel capsule and colonoscopy showed previously noted non-bleeding ulcers in the duodenum with no new active bleeding sites. Case 2: A 68-year-old male with cryptogenic cirrhosis complicated by large hepatocellular carcinoma causing portal vein obstruction was admitted for GI bleeding and hgb of 4.3. Endoscopy showed multiple large DVs with active bleeding. Successful hemostasis was achieved using three hemostatic clips but without adequate decompression. However, given the size of the varix, the patient then underwent successful percutaneous transsplenic porto-venous variceal coil embolization by interventional radiology (IR). Discussion: Variceal bleeding occurs in 25-30% of cirrhotic patients with ectopic varices accounting for 1-5% of these bleeds. DVs are uncommon but can cause massive hemorrhage with a high mortality up to 40%, due to challenges with treatment. Management options include EVL, sclerotherapy, clipping or IR guided Trans Jugular Intrahepatic Portosystemic Shunt (TIPS), Balloon-Occluded or Coil Assisted Retrograde Transvenous obliteration. One concern with EVL is the size of the DV and risk of re-bleeding. Among case reports using EVL, re-bleeding was seen only in 3/19 cases with hemostasis achieved with repeat banding in 2 out of the three cases. However, for successful band ligation, accessibility, and size of the varices to fit into the banding cap are important factors to consider. Small – medium duodenal varices (case 1) were adequately managed by EVL, however endoscopic decompression could not be completely achieved in large varices (case 2) and eventually required IR guided coil embolization. Therefore, the size and location of the duodenal varices are important factors to be considered in choosing the appropriate management modality for DVs (Figure 1).Figure 1.: A, Percutaneous transsplenic splenic venogram demonstrating large duodenal varix(white arrows) with linear endoscopically placed clip corresponding with site of hemorrhage in the vertical segment of the duodenum (black arrow). The splenic vein (white arrowhead) drains via the large varix as the main portal vein is occluded secondary to hepatic tumor; B, Percutaneous transsplenic splenic venogram demonstrating successful coil embolization of the varix (black arrowheads); C, Endoscopic view of large varices in second portion of duodenum, post hemostatic clip placement.

Usefulness of coil-assisted retrograde transvenous obliteration II (CARTO-II) for the treatment of ascending colonic varix: a case report

BackgroundColonic varices are rare among ectopic varices. A previous report demonstrated that once bleeding from colonic varices occurs, it can be fatal. Several treatments for colonic varices exist, including surgical, endoscopic, and endovascular treatments; however, management of colonic varices has not been standardized. For colonic varices, minimally invasive therapies would be desirable. Balloon-occluded retrograde transvenous obliteration (B-RTO) is one of the treatment options for colonic varices to prevent their rupture. Two cases of successful conventional B-RTO for these varices have already been reported. However, B-RTO using coil-assisted retrograde transvenous obliteration II (CARTO-II) procedure for these varices has not been reported.Case presentationA 71-year-old male patient had liver cirrhosis caused by hepatitis C virus infection. A varix was located at the ascending colon, which was coincidentally found on colonic endoscopy. Contrast-enhanced computed tomography (CT) showed that the feeder vein was the ileocolic vein and that the main draining vein was the right renal vein. Physicians concluded that treatment was required to avoid the risk of death from massive bleeding due to varix rupture. However, endoscopic and surgical treatments were difficult due to the anatomical location of the varix and the high risk of operative compilations, respectively. This ascending colonic varix was treated by balloon-occluded retrograde transvenous obliteration (B-RTO) using coil-assisted retrograde transvenous obliteration II (CARTO-II) procedure via the right renal vein. There were no complications during the procedure and no recurrences for 36 months during long-term follow-up.ConclusionsCARTO-II can be one of the effective treatment techniques for ascending colonic varices.

S0986 Outcomes of Balloon-Occluded Retrograde Transvenous Obliteration and Its Variants for Treatment of Gastric Varices at a High-Volume North American Center

INTRODUCTION: BRTO is a common alternative to TIPS or endoscopy for controlling gastric variceal bleeding. Its universal adoption has however been limited due to lack of expertise and fears regarding complications. This study evaluates outcomes of BRTO and its variants, Coil-Assisted Retrograde Transvenous Obliteration (CARTO) and Balloon-Occluded Antegrade Transvenous Obliteration (BATO) at a single center. METHODS: A retrospective review of patients undergoing BRTO or a variant procedure from 6/2013-6/2019 at our institution was performed. Data was collected on demographics, indication, MELD score at time of, 1 month and 1-year post procedure, technical success, complications, rebleed events, mortality, worsening of ascites, encephalopathy, esophageal varices, systemic thrombosis and hepatocellular carcinoma (HCC) incidence up to 1 year post procedure. Statistics were calculated using univariate two-group t-tests or Wilcoxon rank-sum test for continuous variables and non-parametric tests. RESULTS: A total of 65 patients, 11 (16.9%) BATO, 6 (9.2%) BRTO, 45 (69.2%) BRTO/CARTO and 3 (4.6%) BATO/BRTO were evaluated. A 93.8% technical success rate was noted with 2 failures in BATO and 2 in BRTO due to intraprocedural vessel rupture and anatomic issues. High risk gastric varices or bleeding was the most common indication occurring in 53 (81.5%) cases. 1 BATO/BRTO case was complicated by post-procedural sepsis. There were a total of 3 (5%) rebleeding events. 1 BATO patient died from rebleeding on day of procedure and 1 BRTO/CARTO patient died the following day. 4 patients developed new esophageal varices of which 2 bled within one year that was controllable endoscopically. 4 (6.5%) patients developed worsening ascites, 2 (3%) had new or worsened encephalopathy and 9 (13%) developed systemic thrombosis. No patients developed HCC post-procedurally. Mean change in MELD was −0.88 1 month post-procedure with no significant difference in MELD scores from procedure time to 1 month (P = 0.769) or 1 month to 1 year (P = 0.132) when comparing BRTO to its variants. CONCLUSION: Our data demonstrates that BRTO and its variants are effective alternatives to TIPS for treatment of gastric varices without significant adverse effect on MELD scores and minimal to no worsening of portal hypertension related complications. Physicians however must remain vigilant for risk of systemic thromboses and esophageal variceal formation. Of note, previous fears of worsening ascites or increased risk for HCC are not supported by our study.

Coil-assisted retrograde transvenous obliteration (CARTO) for the treatment of gastric varices via a single access route using steerable microcatheter: a case report

BackgroundCoil-assisted retrograde transvenous obliteration (CARTO) is a modified balloon-occluded retrograde transvenous obliteration (BRTO) technique using coils instead of an indwelling balloon. A method involving two microcatheter systems forming a double access route has been reported. We report a case of CARTO using a steerable microcatheter to successfully treat gastric varices (GV).Case presentationA 79-year-old man was admitted for treatment of intractable GV due to liver cirrhosis. The GV were drained mainly into the left inferior phrenic vein, not the usual gastrorenal shunt. Introducing the balloon catheter to the left inferior phrenic vein was difficult due to mild stenosis between the inferior vena cava and inferior phrenic vein and the shunt angle. A CARTO technique was performed with 5% ethanolamine oleate with iopamidol from a single access route by inverting the steerable microcatheter distal to the coil placement site.ConclusionCARTO has advantages in cases where performing BRTO is difficult. Using a steerable microcatheter simplifies the procedure by reducing the required access routes in CARTO.

3:18 PM Abstract No. 319 Incidence of shunt rupture during retrograde transvenous obliteration of symptomatic gastric varices and its effect on technical and clinical outcomes

To evaluate the incidence and significance of intraprocedural shunt rupture in patients undergoing retrograde transvenous obliteration procedures (RTO) for symptomatic gastric varices. Retrospective review over a 13-year period (August 1, 2007 – August 1, 2019) was performed of all patients undergoing a RTO procedure for symptomatic gastric varices at a single academic institution. Over the study period, three techniques were utilized at the discretion of the treating physician: balloon-assisted retrograde transvenous obliteration (BRTO), plug-assisted retrograde transvenous obliteration (PARTO), or coil-assisted retrograde transvenous obliteration (CARTO). All patients underwent follow-up evaluation of their gastric varices with endoscopic US and/or CT/MRI at the discretion of the treatment team. Technical success was defined as satisfactory delivery of embolic/sclerosant material into the shunt with angiographic evidence of shunt occlusion. Clinical success was defined as resolution of gastric variceal bleeding. Intraprocedural shunt rupture occurred in 18 of 149 (12%) RTO procedures performed during the study period. Rupture occurred in the retroperitoneal segment in 16 patients (11%), intraperitoneal segment in 1 patient (<1%), and left renal vein in 1 patient (<1%). Thirteen of 18 (72%) ruptures occurred during shunt/side branch selection while 4/18 (22%) occurred during sclerosant/embolic administration. Technical success was 89%, with 2 cases requiring conversion to an antegrade approach following rupture. Overall clinical success was 94%. Patients who had residual flow within the shunt on follow-up imaging were subsequently treated successfully with endoscopic glue injection and did not require a repeat RTO procedure. Additional periprocedural complications included non-target embolization in 1 patient and postprocedural bleeding requiring transfusion in 2 patients. Shunt rupture during RTO for symptomatic gastric varices is an infrequent but observed intraprocedural complication. Even in the setting of this complication, high technical and clinical success rates can still be achieved comparable to reported rates in RTO patients without shunt rupture.

Retrograde Transvenous Obliteration (RTO): A New Treatment Option for Hepatic Encephalopathy.

Hepatic Encephalopathy (HE) is a complication of liver disease, consisting of brain dysfunction often due to portosystemic shunting of blood flow in the liver. HE can range from minimal HE, presenting with normal neurological function, to overt HE, with neurological and neuropsychiatric abnormalities. Various clinical grading systems are used to differentiate HE to provide the appropriate treatments. Traditional treatment of HE aims to identify and resolve precipitating factors through targeting hyperammonemia and administering antibiotics or probiotics. While retrograde transvenous obliteration (RTO), including balloon-occluded retrograde transvenous obliteration, coil-assisted retrograde transvenous obliteration or plug-assisted retrograde tranvenous obliteration, is an established procedure to manage gastric varices, little is known about its potential to treat HE. RTO is a procedure to occlude a spontaneous portosystemic shunt, minimizing shunting of portal blood to systemic circulation. Though there is not a large study with HE patients who have undergone RTO; the results appear promising in reducing HE. Side effects, however, should be considered in the treatment of HE such as the transient worsening of portal hypertension and the formation of additional shunts. While additional studies are needed to assess the long-term success, RTO appears to be an effective alternative method to alleviate clinical symptoms of HE when pharmacological therapies and other conservative medical managements have failed.

Combined Balloon-, Plug- and Coil-assisted Retrograde Transvenous Obliteration of Multiple Portosystemic Shunts to Treat Recurrent Hepatic Encephalopathy: A Case Report

Balloon- or plug-assisted retrograde transvenous obliteration of portosystemic shunts is an effective endovascular technique for the treatment of type B bypass hepatic encephalopathy. We describe a patient who underwent balloon- and plug-assisted obliteration for a lienorenal and lienogonadal shunt, respectively. He returned with symptoms of recurrent hepatic encephalopathy two years later due to reformation of new lienorenal and lienogonadal shunts. Repeat obliteration of these new shunts was now performed using balloon and coil assistance. We describe the treatment for multiple portosystemic shunts with combined usage of vascular plug, balloon and coils depending on anatomical and technically factors. Our case also highlights that after shunt obliteration increased portal pressure may form new portosystemic collateral pathways which leads to clinical failure and may require repeat treatment.

Utility of Coil-Assisted Retrograde Transvenous Obliteration II (CARTO-II) for the Treatment of Gastric Varices.

PurposeTo investigate the technical feasibility, safety and clinical outcomes of coil-assisted retrograde transvenous obliteration II (CARTO-II) for gastric varices (GV).Materials and MethodsThirty-six consecutive patients who had undergone CARTO-II between June 2016 and April 2018 were included in the study. In the CARTO procedure, coil embolization of the drainage vein is performed “before” injection of the sclerosant to replace the use of balloon catheter. In the CARTO-II procedure, coil embolization of the drainage vein was performed “after” injection of the sclerosant to prevent migration of the sclerosant. CARTO-II was performed with ethanolamine oleate iopamidol, and the balloon catheter was immediately removed after coil placement. Technical and clinical success rates, number of coils used, presence or absence of severe complications, timing of the procedure, and rate of GV recurrence after the procedure were analyzed retrospectively.ResultsIn all patients, GV sclerosis, coil placement and removal of the balloon catheter were successfully completed. The technical success rate was 100%. No patients experienced severe complications such as coil migration or pulmonary embolization. The mean number of metallic coils used per procedure was 3.36. Mean length of the procedure was 132.8 min. Contrast-enhanced computed tomography after CARTO-II confirmed complete variceal thrombosis in all cases. The recurrence rate of GV during follow-up was 2.8% (mean follow-up, 207 days).ConclusionCARTO-II was feasible and safe and could be performed relatively quickly. The number of coils used and the rate of GV recurrence were both low. CARTO-II may have an important role to play in the management of GV.

Role of Interventional Radiology in Complications of Portal Hypertension.

Portal hypertension, a consequence of end-stage liver disease and liver cirrhosis can lead to significant morbidity and mortality for patients through abnormal fluid accumulation as well as the formation of portosystemic shunts and varices. Treatment of the sequelae of portal hypertension can be achieved through endovascular management by referral to an interventional radiologist on an outpatient or emergent basis as required. Current techniques include the placement of peritoneovenous shunts and tunneled peritoneal drains, the creation of transjugular intrahepatic portosystemic shunts, or the obliteration of shunts via balloon-occluded retrograde transvenous obliteration (BRTO). In addition, newer procedural techniques utilizing vascular plugs and coils have reduced risks of the traditional BRTO procedure. Modified-BRTO procedures, known as plug-assisted and coil-assisted retrograde transvenous obliteration (PARTO and CARTO, respectively) have become the standard of care at many institutions for the treatment of gastric varices and portosystemic shunt-induced hepatic encephalopathy. This review examines the most recent literature of the management of portal hypertension by interventional radiologists, evaluating treatment options as well as the clinical and technical outcomes of TIPS, peritoneovenous shunts, tunneled peritoneal drains, BRTOs, and modified-BRTOs as well as future directions in the development of procedural techniques.

Endoscopic Ultrasound-Guided Coil Injection Therapy for Gastric Variceal Bleeding Not Amenable to Interventional Radiology-Guided Therapies

Gastric varices account for 10%–30% of all variceal bleeds and are associated with significant morbidity and mortality. Interventional radiology–guided therapies such as balloon-occluded retrograde transvenous obliteration and coil-assisted retrograde transvenous obliteration can provide hemostasis when traditional endoscopic treatments such as cyanoacrylate injection fail. However, their applicability in certain cases can be limited because of anatomical constraints. We describe the use of endoscopic ultrasound–guided coil and absorbable gelatin sponge injection for the treatment of bleeding gastric varices arising from pancreatitis-induced splenic vein thrombosis not amenable to interventional radiology–guided therapies.

Recent development of balloon-occluded retrograde transvenous obliteration.

Gastric varices (GVs) are a major complication of portal hypertension in patients with liver cirrhosis. The mortality rate associated with the bleeding from GVs is not low. Balloon-occluded retrograde transvenous obliteration (BRTO) was first introduced by Kanagawa et al. as a treatment for isolated GVs in 1994. It has been performed most frequently in Asia, especially in Japan. Ethanolamine oleate was the original sclerosant used in the therapy. Since the late 2000s, BRTO using sodium tetradecyl sulfate foam or polidocanol foam as a sclerosant has been performed in many countries other than Japan. Then, early in the 2010s, modified BRTO techniques including vascular plug-assisted retrograde transvenous obliteration and coil-assisted retrograde transvenous obliteration were developed as an alternative treatment for GVs. This article provides a historical overview of BRTO using various sclerosants and modified BRTO techniques, such as plug-assisted retrograde transvenous obliteration and coil-assisted retrograde transvenous obliteration.

Coil-assisted retrograde transvenous obliteration for the treatment of duodenal varix

Duodenal variceal bleeding is a rare but potentially life-threatening complication of portal hypertension. Endoscopic therapy is usually the initial treatment option for bleeding duodenal varices, but it is not always feasible or successful. We present a technique of coil-assisted retrograde transvenous obliteration in a patient with duodenal varices originating from the inferior pancreaticoduodenal vein and draining into the right ovarian vein.

Evolution of Retrograde Transvenous Obliteration Techniques.

Gastric variceal hemorrhage is a life-threatening complication of portal hypertension with a poorer prognosis compared with esophageal variceal hemorrhage. The presence of an infradiaphragmatic portosystemic shunt, often a gastrorenal shunt, allows for treatment with retrograde transvenous obliteration (RTO). RTO is an evolving treatment strategy, which includes balloon-assisted RTO, plug-assisted RTO, and coil-assisted RTO, for both gastric variceal hemorrhage and hepatic encephalopathy. RTO techniques are less invasive than transjugular intrahepatic portosystemic shunt creation, with the benefit of improved hepatic function, but at the expense of increased portal pressure. This article discusses the techniques of RTO, including patient eligibility, as well as technical and clinical outcomes, including adverse events.

Coil-Assisted Retrograde Transvenous Obliteration (CARTO): An Alternative Treatment Option for Refractory Hepatic Encephalopathy.

Overt hepatic encephalopathy (OHE) is a serious complication of liver dysfunction, which is associated with severe morbidity/mortality and healthcare resource utilization. OHE can be medically refractory due to spontaneous portosystemic shunts (SPSSs) and therefore a new treatment option for these SPSSs is critical. This is a retrospective study of 43 patients with medically refractory OHE, who underwent CARTO (Coil-Assisted Retrograde Transvenous Obliteration) procedures between June 2012 and October 2016. The patient demographic characteristics, technical and clinical outcomes with an emphasis on HE improvement, and complications are reviewed and analyzed. The overall clinical success rate was 91% with a significant HE improvement. Eighty-one percent of patients had clinically significant improvement from OHE and 67% of patients had complete resolution of their HE symptoms during our follow-up period of 893 ± 585 days (range 36-1881 days, median 755.0 days). The median WH score improved from 3 (range 2-4) pre-CARTO to 1 (range 0-4) post-CARTO (p < 0.001). The median ammonia level significantly decreased from 134.5 pre-CARTO to 70.0 post-CARTO (p < 0.001) in 3 days. The overall mean survival was 1465.5 days (95% CI of 1243.0 and 1688.0 days). Only three patients had recurrent HE symptoms. There were 39.6% minor complication rate including new or worsened ascites and esophageal varices, and only 2.3% major complication rate requiring additional treatment (one patient with bleeding esophageal varices requiring treatment). No procedure-related death is noted. CARTO appears to be a safe and effective treatment option for refractory overt hepatic encephalopathy (OHE) due to spontaneous portosystemic shunts. CARTO could be an excellent addition to currently available treatment options for these patients.

Modified Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) Techniques for the Treatment of Gastric Varices: Vascular Plug-Assisted Retrograde Transvenous Obliteration (PARTO)/Coil-Assisted Retrograde Transvenous Obliteration (CARTO)/Balloon-Occluded Antegrade Transvenous Obliteration (BATO).

Gastric varices in the setting of portal hypertension occur less frequently than esophageal varices but occur at lower portal pressures and are associated with more massive bleeding events and higher mortality rate. Balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices has been well documented as an effective therapy for portal hypertensive gastric varices. However, BRTO requires lengthy, 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 various modified BRTO techniques.

Coil-Assisted Retrograde Transvenous Obliteration: A Valid Treatment for Gastric Variceal Hemorrhage and Hepatic Encephalopathy

AbstractCoil-assisted retrograde transvenous obliteration (CARTO) has evolved as a simpler and perhaps safer alternative to balloon-occluded retrograde transvenous obliteration (BRTO). The efficacy of BRTO has been established, and early data supports the use of CARTO in similar situations. In a small series of patients with gastric variceal hemorrhage treated with CARTO, complete portosystemic shunt occlusion, complete variceal obliteration, and no rebleeding during the follow-up period were observed in all patients. In a larger, unpublished study, an improvement in hepatic encephalopathy was observed in over 80% of patients treated with CARTO. In addition, overall liver function was markedly improved in 1 month. As for complications, new or worsened ascites and esophageal varices were observed in 24% and 30%, respectively. Overall, CARTO is an effective treatment of gastric variceal hemorrhage and hepatic encephalopathy with high technical and clinical success rates. Compared with plug-assisted retrograde transvenous obliteration (PARTO), CARTO can be used to safely close larger shunts with a comparable efficacy and complication profiles.

Balloon-occluded retrograde transvenous obliteration of varices: focusing on the portal hemodynamics and the recent techniques.

To evaluate the recent topics of Ballloon-occluded retrograde trasnvenous obliteration(B-RTO). We overviewed the recent scientific papers regarding B-RTO. B-RTO is a treatment method for occluding varices retrogradely using a sclerosing agent under balloon occlusion of a major draining vein. It has been recognized as an effective treatment method for gastric varices. Hepatic function reserve is improved and liver volume is increased after B-RTO. In recent years, various technical options, such as plug-assisted retrograde transvenous obliteration, coil-assisted retrograde transvenous obliteration, or foam B-RTO, have also been reported. In performing B-RTO, portal hemodynamics must be thoroughly examined radiologically. Judging the classification of the grade of collateral venous hemodynamics is important to select the appropriate embolization technique of B-RTO and to successfully occlude varices. Finally, the word "portosystemic shunt syndrome" has been proposed and the condition should be considered while selecting a treatment for gastric varices. B-RTO is effective for gastrointestinal varices and portosystemic shunts.