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    The content on this page is not current guidance and is only for the purposes of the consultation process.

    Interventional procedure overview of transvenous obliteration for gastric varices

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    Existing assessments of this procedure

    In 2022, the Baveno VII Faculty published 'Baveno VII – Renewing consensus in portal hypertension', endorsed by the European Association for the Study of the Liver (de Franchis, 2022). The recommendations are based on a review of the literature (methods to identify literature are not reported) and expert opinion. The level of existing evidence was evaluated, and the recommendations were ranked according to the GRADE system, from A (high) to D (very low). The strength of the recommendations was graded 1 (strong) or 2 (weak). The following recommendations relevant to BRTO were made:

    • '5.22: There is no indication at present for balloon-occluded retrograde (antegrade) transvenous obliteration (BRTO or BATO) or TIPS in primary prophylaxis of gastric variceal bleeding in compensated patients. (D.1) (New)'

    • '6.40: In patients with GOV2, IGV1, and ectopic varices, BRTO could be considered as an alternative to endoscopic treatment or TIPS, provided it is feasible (type and diameter of shunt) and local expertise is available, as it has been shown to be safe and effective. (D.2) (New)'

    In 2021, the American Gastroenterological Association published a clinical practice update on the management of bleeding gastric varices (Henry, 2021). The recommendations are based on a review of the literature (methods to identify literature are not reported) and expert opinion. As per the best practice advice:

    • 'Best practice advice 11: When a gastrorenal shunt is present, local expertise is available, and when severe comorbid complications of portal hypertension are absent, BRTO is the optimal endovascular therapy for management of bleeding gastric varices.'

    In 2016, the American Association for the Study of Liver Diseases published practice guidance on the risk stratification, diagnosis, and management of portal hypertensive bleeding in cirrhosis (Garcia-Tsao, 2016). Relevant literature was identified by a literature review (methods are not reported). Statements are based on literature, the outputs of previous consensus conferences, and expert opinion. The following guidance statements relevant to BRTO for gastric varices are made:

    • 'Neither TIPS nor BRTO are recommended to prevent first haemorrhage in patients with fundal varices that have not bled.'

    • 'In patients who have recovered from GOV2 or IGV1 haemorrhage, TIPS or BRTO are first-line treatments in the prevention of rebleeding.'

    In 2015, the British Society of Gastroenterology published UK guidelines on the management of variceal haemorrhage in cirrhotic people (Tripathi, 2015). Relevant literature was identified by an 'exhaustive' literature review (methods are not reported). Recommendations were graded based on the supporting evidence, from level 1 (highest quality evidence; systematic reviews of RCTs) to level 5 (lowest quality evidence; expert opinion) and from grade A (consistent level 1 studies) to grade D (level 5 evidence or inconsistent or inconclusive studies). The guidelines give the following recommendation regarding BRTO:

    • If control of bleeding fails with endoscopic therapy or TIPS:

      • 'B-RTO or surgical shunting can be considered if TIPSS is not possible (for example, portal vein thrombosis present) and depending on local resources (level 3a, grade B).'

    In 2016, the Japanese Society of Gastroenterology published clinical practice guidelines for liver cirrhosis (Fukui, 2016). Literature was identified by a literature search (full methods are not reported). The quality of evidence was graded from A (high) to D (very low). The strength of a recommendation was indicated as either 1 (strong) or 2 (weak). The guidelines give the following recommendations regarding BRTO:

    • 'BRTO is proposed as an elective therapy after haemostasis of initial gastric variceal bleeding using cyanoacrylate and as a prophylactic therapy in the management of high-risk gastric varices (Evidence level C, strength 2).'