Interventional procedure overview of transvenous obliteration for gastric varices

BRTO

In a systematic review and meta-analysis of 21 studies (847 people), the pooled technical success rate was 96.4% (95% confidence interval [CI] 93.7 to 98.3; I² 99.39). Technical success was defined as complete thrombosis of gastric varices on immediate or short-term follow-up imaging, successful injection of sclerosing agent into gastric varices, and control of actively bleeding gastric varices (Park, 2015).

In a systematic review and meta-analysis of 6 studies (404 people [BRTO], 178 people [TIPS]), there was no difference in the technical success rate between the BRTO and TIPS groups: Odds Ratio (OR)=0.87 (95% CI 0.28 to 2.73, p=0.81, substantial heterogeneity Ι²=50%) (Paleti, 2020).

In a retrospective case series of 183 people, technical success was achieved in 177 people (96.7%). Technical success was defined as the completion of the procedure after the confirmation of sufficient obliteration of gastric varices with sclerosant under retrograde venography, and without re-bleeding at 2 days after BRTO (Jang, 2012).

In a retrospective case series of 100 people, complete obliteration was seen in 97 people (97%) and partial obliteration was seen in 2 people (2%). There was no statistically significant difference in technical success rates between bleeding and prophylactic cases (Naeshiro, 2014).

BATO

In a retrospective case series of 71 people, complete obliteration, with all the gastric varices and their feeding veins obliterated, was achieved in 67 people (94.4%) (Tian, 2011).

CARTO

In a retrospective case series of 36 people, technical success was achieved in 36 people (100%). Technical success was defined as blood flow stagnation on venograms obtained immediately after final balloon deflation (this study used CARTO-II, which involves balloon occlusion) (Yamamoto, 2020).

PARTO

In a retrospective case series of 54 people, technical success was achieved in 54 people (100%) and gastric variceal eradication was seen in 50 people (92.6%). Technical success was defined by the complete occlusion of the efferent shunt and complete filling of gastric varix with a gelfoam slurry (Park, 2020).

In a retrospective cohort study of 95 people (74 BRTO; 21 PARTO) technical and clinical success was achieved in 90 people (94.7%). Technical success was defined as clotting of varices without blood aspiration and no variceal flow on the test injection of contrast media. Clinical success was defined as the absence of residual enhancement within the gastric varices on follow-up computed tomography scan and cessation of gastric bleeding on endoscopic evaluation (Kim, 2016).

BRTO

In the systematic review and meta-analysis of 23 studies (902 people), the pooled clinical success rate was 97.3% (95% CI 95.2 to 98.8; I² 99.29). Clinical success was defined as no recurrence or rebleed of bleeding gastric varices (or in the case of at-risk gastric varices, no future bleed), or alternatively complete obliteration of varices on subsequent imaging (Park, 2015).

CARTO

In a retrospective case series of 36 people, clinical success was achieved in 35 people (97.2%). Clinical success was defined as absence of recurrence (Yamamoto, 2020).

BRTO

In the systematic review and meta-analysis, the reported survival rates were (Park, 2015):

In the systematic review and meta-analysis of 3 studies (126 people [BRTO], 87 people [TIPS]), the mortality rate at 12 months was statistically significantly lower in the BRTO group compared with the TIPS group: OR=0.43 (95% CI 0.21 to 0.87, p=0.02, no heterogeneity Ι²=0%) (Paleti, 2020).

In a systematic review and network meta-analysis, there was no statistically significant difference in mortality between BRTO and beta-blockers, endoscopic techniques, and TIPS (Osman, 2022). BRTO was connected to the network by the Luo, 2021 randomised controlled trial (RCT).

In an RCT of 32 people treated with BRTO versus 32 people treated with endoscopic cyanoacrylate injection, there was no statistically significant difference in mortality rates between the 2 groups, with 4 people dying in each (p=0.719). Cumulative transplantation-free survival rates at 1 and 2 years were not statistically significantly different for cyanoacrylate injection versus BRTO groups – 87.5% versus 84.0% and 93.8% versus 86.2% (p=0.649), respectively. In multivariate analysis, hepatitis B-related cirrhosis (hazard ratio [HR] 0.076; 95% CI 0.014 to 0.412; p=0.003), presence of ascites (HR 5.329; 95% CI 1.055 to 26.915; p=0.043), and MELD score (HR 1.218, 95% CI 1.008 to 1.472; p=0.041) were the prognostic factors associated with mortality (Luo, 2021).

In the retrospective case series of 183 people, the estimated 1-, 3- and 5-year overall survival rates were 86.2%, 71.0%, and 65.8%, respectively. In multivariate analysis, hepatocellular carcinoma (OR=2.897; 95% CI 1.612 to 5.204; p=0.001) and Barcelona Clinic Liver Cancer criteria stage (a score system for grading liver cancer; OR=9.394, 95% CI 4.493 to 19.641; p<0.001) were statistically significantly associated with mortality (Jang, 2012)

In the retrospective case series of 100 people, the overall cumulative survival rate was 50% at 5 years and 26% at 10 years after BRTO. There was no statistically significant difference in survival rates between bleeding and prophylactic cases. In multivariate analysis, Child-Pugh classification (HR 2.371, 95% CI 1.457 to 3.860, p=0.001) and hepatocellular carcinoma development (HR 4.782, 95% CI 2.331 to 9.810, p<0.001) were statistically significant independent factors for overall survival (Naeshiro, 2014).

BATO

In the retrospective case series of 71 people, 13 people (18.3%) died during follow up. The cumulative survival rate at 1 year was 96.9%, at 3 years was 68.9%, and at 5 years was 53.7% (Tian, 2011).

CARTO

In a retrospective case series of 36 people, all survived the mean follow-up period of 207 days (Yamamoto, 2020).

BRTO

In the systematic review and meta-analysis of 4 studies (283 people [BRTO], 106 people [TIPS]), there was no difference in the haemostasis rate in the BRTO and TIPS groups: OR=2.74 (95% CI 0.61 to 12.26, p=0.19, no heterogeneity I²=0%) (Paleti, 2020).

BRTO

In the systematic review and meta-analysis of 7 studies (462 people [BRTO], 214 people [TIPS]), rebleeding rates were statistically significantly lower in the BRTO group compared with the TIPS group: OR=0.30 (95% CI 0.18 to 0.48, p<0.00001, no heterogeneity Ι²=0%) (Paleti, 2020).

In the systematic review and network meta-analysis, BRTO was associated with a statistically significantly lower risk of rebleeding when compared with beta-blockers (relative risk [RR]=0.04; 95% CI 0.01 to 0.26; low certainty) and endoscopic cyanoacrylate injection (RR=0.18; 95% CI 0.04 to 0.77; low certainty) (Osman, 2022). BRTO was connected to the network by the Luo 2021 RCT.

In the RCT of 32 people treated with BRTO versus 32 people treated with endoscopic cyanoacrylate injection, the probability of gastric variceal rebleeding was significantly higher in the cyanoacrylate injection group than in the BRTO group (p=0.024). The 1-and 2-year cumulative probability of remaining free of all-cause rebleeding was statistically significantly higher in the BRTO group than in the cyanoacrylate injection group: the probability after 1 and 2 years was 96.3% and 92.6% in the BRTO group and 77.0% and 65.2% in the cyanoacrylate injection group (p=0.004). In multivariate analysis, BRTO (HR 0.155; 95% CI 0.034 to 0.702; p=0.016) and MELD score (HR 1.24; 95% CI 1.012 to 1.519; p=0.038) were prognostic factors of all-cause rebleeding (Luo, 2021).

In the retrospective case series of 183 people, the estimated 1-, 3- and 5-year rebleeding-free rates were 87.5%, 74.8%, and 68.9%, respectively. In multivariate analysis, Child-Pugh class was statistically significantly associated with rebleeding (OR=2.404; 95% CI 1.013 to 5.704; p=0.047) (Jang, 2012).

BATO

In the retrospective case series of 71 people, rebleeding happened in 7 people (9.9%). The cumulative probability of remaining free of rebleeding at 1 year was 98.4%, at 3 years was 77.7%, and at 5 years was 77.7%. (Tian, 2011).

PARTO

In the retrospective case series of 54 people, there was 1 case of rebleeding (Park, 2020).

BRTO

In the retrospective case series of 183 people, 79 (52.3%) had eradication of gastric varices, 110 (72.8%) had marked shrinkage, and 129 (85.4%) showed a decrease in size of gastric varices at follow up (Jang, 2012).

PARTO

In the retrospective cohort study of 95 people (74 BRTO; 21 PARTO) there were 3 recurrent cases with BRTO and 4 cases with PARTO. People treated with PARTO had a statistically significantly higher rate of recurrence than the BRTO procedures (p<0.05) (Kim, 2016).

PARTO

In the retrospective case series of 54 people, there was a statistically significant increase in hepatic venous pressure gradient before and after PARTO (12.52 ± 3.83 to 14.68 ± 5.03 mmHg, p<0.001) (Park, 2020).