Balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices
Authors: Alia S. Dadabhai, Jonathan M. Fenkel, Daniel B. Brown, Loren Laine
Journal: Hepatology (2012)

CLINICAL PERSPECTIVES IN HEPATOLOGY aims to engage two experts with opinions supporting differing perspectives on the management of a case. Typically, the case represents an area of debate or evolving practice in clinical hepatology. (A) Baseline axial MRI demonstrates multiple prominent gastric fundal varices (white arrows). (B) Coronal images from the same study demonstrate occlusive thrombus in the main (white arrow), and left and right (arrowheads) portal vein branches. (C) With the balloon inflated (white arrow), the sclerosing agent fills the gastrorenal shunt (white arrowhead) and the gastric varices (black arrow). (D) CT scan obtained 3 months after the procedure demonstrates resolution of the varices with residual sclerosant in the veins (white arrow). The patient presented below gives us the opportunity to discuss balloon-occluded retrograde transvenous obliteration (BRTO) for treatment of gastric varices. Although described since the mid-1990s and accepted as effective therapy, particularly in Japan, BRTO is used sporadically in the United States and Europe. In fact, it is not mentioned in the U.S. (AASLD) or European (EASL/Baveno V) guidelines. Hopefully, increased awareness of and expertise in this modality will generate the evidence-based data needed to establish the role and safety of BRTO in patients with gastric varices. BCA, N-butyl-cyanoacrylate; BRTO, balloon-occluded retrograde transvenous obliteration; CT, computed tomography; GOV2, type 2 gastroesophageal varices; IGV1, isolated gastric varices in the fundus; IGV2, isolated gastric varices in the antrum; MELD, model for endstage liver disease; MRI, magnetic resonance imaging; TIPS, transjugular intrahepatic portosystemic shunt. A 50-year-old male with hepatitis C and alcohol-related cirrhosis was hospitalized with his first upper gastrointestinal bleed secondary to isolated large gastric fundal varices, as confirmed by endoscopy. The patient was stabilized with conservative treatment. Magnetic resonance imaging (MRI) revealed thrombosis of the main, left, and right portal veins, with patency of the splenic vein and a spontaneous splenorenal shunt (Panels A and B). As endoscopic N-butyl-2-cyanoacrylate injection was not available, and given the presence of portal vein thrombosis and a spontaneous splenorenal shunt, an elective balloon-occluded retrograde transvenous obliteration (BRTO) procedure was selected over a transjugular intrahepatic portosystemic shunt (TIPS). Using a right groin approach, the splenorenal shunt was catheterized and an 11-mm occlusion balloon (Python, Applied Medical, Rancho Santa Margarita, CA) inflated in the venous outflow. The varix was selectively catheterized back to the point of communication with the portal venous system. Foam sclerosant consisting of 3 parts air, 2 parts 3% Sotradecol (Angiodynamics, Queensbury, NY) and 1 part Ethiodol (Guerbet, Roissy, France) was mixed and approximately 13 mL injected during catheter withdrawal, filling the varix and outflow vein back to the level of the balloon (panel C). Balloon inflation was maintained for 3 hours at which point the patient was restudied and satisfactory occlusion was confirmed. The patient was discharged without further bleeding and 3-month follow-up computed tomography (CT) confirmed collapse of the varices (panel D). Endoscopic therapy with tissue adhesive (e.g., N-butyl-cyanoacrylate [BCA]) is recommended for acute treatment of bleeding from isolated gastric varices in the fundus (IGV1), present in the patient described, and antrum (IGV2), and from type 2 gastroesophageal varices (GOV2), which extend from the esophagus into the fundus and tend to be long and tortuous.1, 2 Following the acute episode, either BCA or TIPS is recommended for prevention of recurrent bleeding from IGV or GOV2. Data assessing tissue adhesives come primarily from observational studies, with a limited number of randomized trials available. BCA is the most widely used tissue adhesive. In the U.S., BCA is approved for cerebral arteriovenous malformations but not for gastric varices. 2-Octyl-cyanoacrylate, approved for cutaneous wound closure in the U.S., has also been used. Case series indicate initial hemostasis of actively bleeding gastric varices with BCA from 82%-100%, with rebleeding in large series generally ≤15%.3, 4 Complications range from 0%-8% in most series and include bleeding due to early glue cast extrusion, distant embolism (e.g., brain, lung, spleen, heart), and sepsis.3, 5 A majority of patients in most series have GOV rather than IGV but multivariate analysis in a recent large series found no significant association of gastric variceal type and rebleeding4 after BCA therapy. BCA had significantly better control of actively bleeding gastric varices in one randomized trial (87% versus 45%),6 but not another (93% versus 93%).7 Both studies showed significantly lower rates of long-term rebleeding with BCA (31% versus 54% and 22% versus 44%).6, 7 The greatest benefit of BCA appeared to be in patients with IGV1.7 Ligation had more complications (primarily treatment-induced ulcer bleeding) and a strong trend to decreased survival (29% versus 48%; P = 0.05) in one study.6 A third randomized trial, restricted to GOV1, found significantly lower rates of persistent or recurrent bleeding (16% versus 35%) with BCA.8 BCA had significantly lower rates of gastric variceal rebleeding (15% versus 55%) and mortality (3% versus 25%) over a median of 26 months in a randomized trial.9 BCA had significantly more gastric variceal rebleeding (38% versus 11%) in a randomized trial.10 No significant difference was seen in survival or complications, although encephalopathy was more common with TIPS (26% versus 3%). Observational studies from the U.S. and U.K. raise the possibility that healthcare resource utilization may be higher with TIPS in the first 6-12 months, with more days in hospital due to TIPS complications.11, 12 Endoscopic BCA is first-line therapy for acute treatment of bleeding gastric varices. If BCA is unsuccessful or unavailable, TIPS is recommended. TIPS is more effective than BCA in preventing recurrent bleeding, but has a higher rate of encephalopathy. In patients in whom TIPS is technically difficult or impossible, BRTO, as in the case presented, appears to be a very reasonable option. TIPS is the standard approach for variceal bleeding that fails endoscopic management. BRTO can be performed when TIPS has a higher risk, such as portal vein thrombosis, high Model for Endstage Liver Disease (MELD) score, or encephalopathy. Our sclerosant preference is a mixture, as used in this case, which damages vascular endothelium within 2 minutes of contact and results in complete vascular thrombosis within 30 minutes. The minimum balloon inflation time is unknown—some authors use only 30 minutes,13 but we leave the balloon in place for 3 hours, similar to others using Sotradecol.14 Patient selection is important to achieve procedural success, as BRTO is not feasible in all patients. A patent shunt connecting the varices/portal system to the renal vein must be present. Once the varix is catheterized, outflow veins with systemic communication must be embolized to prevent unintentional infusion of the sclerosant into the systemic circulation. Embolization of these systemic communicators is necessary in approximately 50% of cases and is relatively straightforward.14 When evaluating outcomes over multiple studies, Sabri et al.14 described rebleeding rates following BRTO ranging from 0%-9%. Varices were completely obliterated in 87%-100% of patients at follow-up endoscopy. Long term, freedom from recurrent gastric variceal hemorrhage of 90% at 8 years follow-up has been described.13 In this long-term follow-up study, the gastric varices were completely eradicated at endoscopy in 61 of 63 patients. Technical failure due to anatomic unsuitability ranges from 7%-12%.13, 15 Potential adverse effects of BRTO include development of esophageal varices and/or ascites resulting from elevation in portal pressure due to occlusion of a large gastrorenal shunt. In one series of 78 patients,16 worsening of esophageal varices was observed in 29 patients, with incidences at 1, 3, and 5 years of 27%, 58%, and 66%, respectively. On the other hand, encephalopathy and synthetic function have been shown not to worsen following BRTO as portal perfusion increases.17, 18 Surveillance endoscopy after BRTO and appropriate use of nonselective beta-blockade and/or banding are required to prevent the possibility of esophageal variceal bleeding. BRTO data, although largely uncontrolled, demonstrates excellent control of bleeding with durable obliteration of treated varices. The presence of a splenorenal shunt in the setting of factors increasing the risk for TIPS, such as portal vein thrombosis in the case presented, represents the ideal clinical application for BRTO. Expansion of use of this technique in the U.S. is likely over the next several years.