Transvenous obliteration for gastric varices

2.1 Varices are dilated veins. Gastric varices form in around 20% of people with portal hypertension. Portal hypertension can happen in cirrhosis or in people without cirrhosis who develop thrombosis of the splanchnic circulation, such as portal vein thrombosis. Gastric varices are prone to bleeding, and this is associated with high mortality and poor prognosis.

2.2 Treatments for gastric varices include non-selective beta-blockers, balloon tamponade, band ligation, endoscopic cyanoacrylate or thrombin injection, transjugular intrahepatic portosystemic shunt and transvenous obliteration.

2.3 Cross-sectional imaging is done to identify and confirm the target shunt (gastrorenal shunt is usually present). Percutaneous venous access of the femoral or jugular vein is done using standard angiographic technique. An occlusion balloon catheter is inserted and navigated into the target shunt under fluoroscopic guidance. The balloon is inflated to block the shunt and venography is then done to define the variceal anatomy and type of varices. Sclerosant is slowly injected into the varices to fill the full extent of the varices, with the embolisation end point being minimal filling of the afferent vein or portal vasculature. The injection of sclerosant can be done with or without using a microcatheter for more selective injection. The occlusion balloon catheter is left in situ until satisfactory embolisation of the varices is achieved. This procedure is called balloon-occluded retrograde transvenous obliteration (BRTO). The aim is to obliterate the varices and manage acutely bleeding gastric varices or those at high risk of bleeding.

2.4 Modified techniques, such as balloon-occluded antegrade transvenous obliteration (BATO, a collective term for portal venous access routes to the varices), vascular plug-assisted retrograde transvenous obliteration (PARTO) and coil-assisted retrograde transvenous obliteration (CARTO), follow a similar procedure to BRTO. However, for PARTO and CARTO, shunt occlusion is achieved by vascular plugging or coiling. These 2 techniques can reduce procedure time and eliminate the risk of balloon rupture.