Transvenous obliteration for gastric varices

Evidence-based recommendations on transvenous obliteration for gastric varices. This involves inserting a tube with a tiny balloon on the end into a vein in the thigh or neck. The tube is then passed into the enlarged vein in the stomach (gastric varix) and the balloon is inflated to stop blood flowing into the vein. The vein is then blocked using one of several techniques. The aim is to reduce the risk of bleeding.

# Recommendations
Evidence on the safety and efficacy of transvenous obliteration of gastric varices is adequate in the short term but limited in the long term. Therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research. Find out what special arrangements mean on the NICE interventional procedures guidance page.
Clinicians wanting to do transvenous obliteration of gastric varices should:
Inform the clinical governance leads in their healthcare organisation.
Give people (and their families and carers as appropriate) clear written information to support shared decision making, including NICE's information for the public.
Ensure that people (and their families and carers as appropriate) understand the procedure's safety and efficacy, and any uncertainties about these. This should include the risk of:
balloon rupture and embolisation of sclerosant or device during the procedure
an increase in portal vein pressure in the long term, which may exacerbate ascites and oesophageal varices.
Audit and review clinical outcomes of everyone having the procedure. The main efficacy and safety outcomes identified in this guidance can be entered into NICE's interventional procedure outcomes audit tool (for use at local discretion).
Enter details about everyone having transvenous obliteration of gastric varices onto suitable registry databases where available and review local clinical outcomes.
Discuss the outcomes of the procedure during their annual appraisal to reflect, learn and improve.
Healthcare organisations should:
Ensure systems are in place that support clinicians to collect and report data on outcomes and safety for everyone having this procedure.
Regularly review data on outcomes and safety for this procedure.
Patient selection should be discussed with a specialist centre that offers all of the standard treatments for portal hypertension and bleeding gastric varices, and that is experienced in managing acute and chronic liver disease.
The procedure should only be done by clinicians with training in and experience of the procedure.# The condition, current treatments and procedure

# The condition
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.

# Current treatments
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.

# The procedure
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.
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.