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Indications / Contraindications
Indications
- Gastric variceal hemorrhage — active or secondary prophylaxis; especially IGV1 (fundal varices, Sarin classification) or GOV2 with gastrorenal shunt
- Gastric varices not controlled by endoscopy (cyanoacrylate) or when TIPS is not feasible or desired
- Ectopic varices with identifiable systemic venous drainage — stomal, rectal, duodenal
- Portal hypertensive gastropathy — selected cases with gastrorenal shunt
- Hepatic encephalopathy — BRTO redirects portal blood flow back to the liver, improving hepatic perfusion; can improve encephalopathy (unlike TIPS)
BRTO vs TIPS for Gastric Varices
- BRTO preferred: isolated gastric varices (IGV1), large gastrorenal shunt present, poor liver reserve, existing or high-risk encephalopathy, Child-Pugh C not eligible for TIPS
- TIPS preferred: esophageal varices predominant, refractory ascites, no gastrorenal shunt, need to treat varices and ascites simultaneously
- Combined BRTO + TIPS: large gastric varices + ascites + gastrorenal shunt (BRTO first, then TIPS if ascites persists)
Contraindications
- Absent gastrorenal shunt (BRTO not feasible without shunt access; consider PARTO via alternate drainage, or transhepatic/transsplenic direct variceal injection)
- Active systemic infection or sepsis
- Uncorrectable coagulopathy (INR >1.5)
- Left-sided portal hypertension from isolated splenic vein thrombosis (BRTO may worsen)
- End-stage liver disease without transplant plan — high sepsis risk from sclerosant-induced splanchnic injury
Variant Distinctions
- BRTO (classic): Balloon occlusion catheter via gastrorenal shunt + sclerosant infusion (3% STS foam or 5% EO); balloon inflated 3–4h or overnight; requires gastrorenal shunt
- PARTO: Amplatzer Vascular Plug instead of balloon; no dwell time required; same-session closure; preferred for high-flow shunts
- CARTO: Coil embolization of shunt then sclerosant injection; alternative when balloon cannot adequately occlude
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Pre-Procedure Checklist
CT with portal venous phase — confirm gastrorenal shunt anatomy, shunt diameter, gastric variceal complex, left renal vein anatomy, absence of competing drainage veins
Endoscopy report — confirm variceal location and Sarin type (GOV1, GOV2, IGV1, IGV2). Rule out esophageal varices requiring separate treatment.
Labs: CBC, INR/PT (target INR <1.5), CMP, type & screen. Check renal function — contrast plus sclerosant nephrotoxicity risk
Informed consent: worsening esophageal varices (15–20% within 6 months), worsening ascites, pulmonary embolism (sclerosant migration), hemoglobinuria (EO), renal injury, incomplete obliteration requiring repeat, liver failure
Cefazolin 1g IV pre-procedure
IV access: 2 large-bore PIVs; IV fluids running
Confirm sclerosant availability — 3% STS foam (preferred in US) or 5% ethanolamine oleate; prepare per institutional pharmacy protocol
ICU/monitoring capability confirmed for post-procedure — hemodynamic monitoring required during balloon dwell (classic BRTO)
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Relevant Anatomy
Gastrorenal Shunt Pathway
- Outflow pathway: left gastric/short gastric veins (feeding gastric varices) → left adrenal or inferior phrenic vein → gastrorenal shunt → left renal vein → IVC. This is the drainage pathway that provides access for retrograde BRTO.
- Left renal vein anatomy: shunt enters left renal vein laterally; must distinguish from adrenal vein and gonadal vein on venogram
- Competing drainage: gastrocaval, gastrorenal, or gastropericardial shunts may require additional coil embolization before sclerosant injection
Sarin Classification of Gastric Varices
- GOV1: extension of esophageal varices along lesser curve — most common; follow esophageal variceal treatment protocol first
- GOV2: extension of esophageal varices along gastric fundus; gastrorenal shunt usually present
- IGV1: isolated fundal varices — highest bleeding risk; large gastrorenal shunt almost always present; ideal BRTO target
- IGV2: isolated ectopic gastric varices elsewhere in stomach
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Technique
Default RadCall approach · share your own below
Supplies
Right femoral vein access kit (5 Fr sheath)
5 Fr multipurpose or Cobra catheter
Amplatz super-stiff wire
Balloon occlusion catheter (10–20 mm)
3% STS foam sclerosant (preferred) or 5% EO
20 mL syringes + contrast medium
Nester or MReye coils (competing outflow)
Amplatzer Vascular Plug II (PARTO variant)
Steps — Classic BRTO
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Femoral Vein Access
Standard right femoral vein puncture, 5 Fr sheath. Advance 5 Fr catheter into IVC.
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Left Renal Vein Catheterization
Advance catheter from IVC into the left renal vein. Perform left renal venogram to identify the gastrorenal shunt origin and left adrenal/inferior phrenic vein anatomy.
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Select Gastrorenal Shunt
Cross into the gastrorenal shunt with a hydrophilic wire. Advance up shunt toward gastric varices. Perform shuntogram (venogram): identify the full gastric variceal complex and any competing outflow vessels.
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Embolize Competing Outflow Veins (Critical)
Coil embolize any accessory drainage vessels (inferior phrenic–gastric veins, gastropericardial shunts) before deploying the occlusion balloon. Failure to close competing outflows is a major technical error that allows sclerosant escape.
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Deploy Occlusion Balloon
Advance balloon catheter to the distal shunt near the left renal vein entry. Inflate balloon to achieve complete occlusion — confirmed by repeat venogram showing stasis of contrast within the variceal complex.
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Sclerosant Injection
Slowly inject 3% STS foam or 5% EO into the gastric variceal complex through the balloon catheter lumen or side arm. Target: complete filling of variceal complex. Inject in small aliquots under fluoroscopic monitoring. Stop immediately if contrast/sclerosant reflux into systemic veins is observed. Typical total volume: 20–40 mL.
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Balloon Dwell Time
For classic BRTO: maintain balloon inflation for 3–4 hours (or overnight per some protocols). Patient remains in monitored setting throughout. For PARTO/CARTO: no dwell required — plug or coils provide permanent mechanical occlusion; procedure completed same session.
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Balloon Removal
Aspirate sclerosant from catheter lumen before deflating balloon to minimize systemic embolization of residual agent. Remove catheter system carefully.
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Femoral Hemostasis
Manual compression for 10–15 minutes at femoral vein puncture site. Closure device optional.
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Troubleshooting
Problem
Cannot identify gastrorenal shunt on initial venogram
Likely cause: Small or absent shunt, variant anatomy, shunt vasospasm, or competing dominant drainage pathway
Next step: Review CT portal venous phase more carefully for shunt course. SMA arterial injection for indirect portography to opacify gastric varices and reveal retrograde drainage. If no gastrorenal shunt present: BRTO is not feasible — consider TIPS, or direct gastric variceal injection via transhepatic or transsplenic approach.
Problem
Sclerosant reflux into systemic circulation
Likely cause: Incomplete balloon occlusion, competing outflow vessel not embolized, or high-flow shunt exceeding balloon capacity
Next step: Stop injection immediately. Re-inflate balloon firmly. Complete coil embolization of ALL competing outflows before resuming. If shunt flow is too high for balloon: convert to PARTO approach using Amplatzer Vascular Plug for definitive mechanical occlusion.
Problem
Incomplete gastric variceal filling with sclerosant
Likely cause: Insufficient volume injected, multiple competing inflow veins, or large variceal complex with high flow
Next step: Inject additional sclerosant volume. Consider coil embolization of variceal complex margins to reduce volume. Incomplete obliteration is associated with higher rebleed rates — complete variceal filling is the technical goal. If unable to achieve complete filling: plan early repeat procedure.
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Complications
Immediate
- Pulmonary embolism from sclerosant migration — hemodynamic monitoring required throughout procedure and balloon dwell
- Hemoglobinuria — EO-specific; rusty/dark urine; aggressive IV fluid resuscitation; monitor renal function
- Contrast nephropathy — minimize contrast load; pre-procedure hydration
- Balloon rupture — rare; may release sclerosant uncontrolled into systemic circulation
Delayed
- Worsening esophageal varices — 15–20% within 6–12 months; loss of competitive gastric variceal drainage increases esophageal variceal pressure; EGD at 1–3 months is mandatory
- Worsening ascites — loss of gastrorenal shunt increases effective portal hypertension; may require diuretic uptitration or paracentesis
- Incomplete obliteration requiring repeat procedure
- Renal failure — rare; associated with EO use and large sclerosant volumes
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Post-Procedure Care
Immediate Monitoring
- 4–6h post-procedure monitoring minimum; overnight admission for classic BRTO with balloon dwell
- Vital signs q1h during balloon dwell period
- Urine monitoring — hemoglobinuria if EO used; dark/rusty urine is expected; monitor for renal function decline
- No hemolysis testing required for STS foam
- CBC at 6h (hemolysis marker)
- CT portal venous phase at 24h — confirm obliteration of variceal complex
Discharge & Outpatient Plan
- EGD at 1–3 months — mandatory to assess esophageal variceal change; initiate banding or non-selective beta-blocker prophylaxis if new or enlarged esophageal varices identified
- Duplex US at 1 month
- Sclerotherapy “top-up” if CT 24h shows incomplete obliteration
- Diuretic adjustment if ascites worsens post-BRTO (loss of gastrorenal shunt drainage)
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Critical Pearls
✶
Know your variant: Classic BRTO requires a gastrorenal shunt and balloon dwell (3–4h or overnight). PARTO uses a vascular plug for same-session closure without dwell — increasingly preferred. CARTO uses coils only and is reserved for specific anatomy where balloon and plug are not feasible.
✶
BRTO improves liver function: Unlike TIPS, BRTO redirects blood back into the portal system, improving hepatic perfusion. MELD scores and LFTs often improve post-BRTO. This makes it the preferred choice in high-MELD patients who cannot tolerate TIPS-induced shunting.
✶
Esophageal varices always worsen — plan for it: Counsel all BRTO patients about this pre-procedure. Loss of competitive gastric variceal drainage invariably increases esophageal variceal pressure. EGD at 1–3 months is non-negotiable. Start prophylaxis (non-selective beta-blocker or banding) for any patient with significant esophageal varices before BRTO.
✶
Sarin IGV1 is the ideal BRTO target: Isolated fundal varices (IGV1) are the single best indication — they almost always have a large gastrorenal shunt, highest bleeding risk, and TIPS carries elevated encephalopathy risk in this anatomic pattern.
✶
Competing outflow embolization is not optional: Failure to coil embolize all competing drainage veins before sclerosant injection is a major technical error. Sclerosant will escape into systemic circulation, causing pulmonary embolism and reducing efficacy.
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STS foam vs EO: In the US, 3% STS foam is standard (EO not widely available). STS foam is effective with lower hemoglobinuria risk. EO requires careful renal monitoring. Both have comparable obliteration efficacy in published series.
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References & Resources
Key Guidelines
- SIR Standards of Practice: BRTO/PARTO
- AASLD Portal Hypertension Guidelines (2021)
Primary References
- Ninoi T, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices. AJR. 2005.
- Saad WE. Balloon-occluded retrograde transvenous obliteration of gastric varices. Semin Intervent Radiol. 2012;29(2):135–147. PMID 23729982.