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Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Technique and Intraprocedural Imaging.

ABSTRACT: Balloon-occluded retrograde transvenous obliteration (BRTO) is an endovascular technique used as a therapeutic adjunct or alternative to transjugular intrahepatic shunts (TIPS) in the management of gastric varices. Occlusion balloons are strategically placed to modulate flow within the gastrorenal or gastrocaval shunt to allow stagnation of the sclerosant material within the gastric varix. The approach and complexity of the procedure depends on the anatomic classification of inflow and outflow veins of the varix. Ethanolamine oleate has been described as the main sclerosant used in this procedure. Recently, foam sclerosants have gained popularity as alternative embolization agents, which provide the advantage of better variceal wall contact and potentially less dose of sclerosant.

SUBMITTER: Sabri SS

PROVIDER: S-EPMC3312158 | biostudies-other | 2011 Sep

REPOSITORIES: biostudies-other

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Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Preprocedural Evaluation and Imaging.

Project description:Patients undergoing balloon retrograde transvenous obliteration (BRTO) are mostly decompensated cirrhotic with either bleeding gastric varices (GV) or hepatic encephalopathy. It is crucial that clinicians are up-to-date with the assessments needed prior to BRTO to anticipate and prevent complications, and to deliver critical quality care. These patients will require preprocedural assessments and management, including endoscopic, clinical, laboratory, and imaging evaluation. Endoscopic evaluation is mandatory prior to BRTO, and it is highly recommended that it be performed at the same institution where BRTO will be performed. It is essential that clinicians are aware of the potential benefits and complications that may result from BRTO. These complications should be anticipated and prevented when possible. For GV bleeders, there should be consideration of a transvenous intrahepatic portosystemic shunt (TIPS) during or before BRTO in patients with refractory ascites or pleural effusion, as well as endoscopic banding or a TIPS in patients with high-risk esophageal varices. Patients undergoing BRTO are usually complicated and require a team approach. In this article, the authors address these assessment and preparatory management and planning procedures prior to the BRTO procedure as well as expected outcomes and potential complications.

| S-EPMC3312157 | biostudies-other

Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Follow-Up and Postprocedural Imaging.

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| S-EPMC3312166 | biostudies-other

Variations of Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Balloon-occluded Antegrade Transvenous Obliteration (BATO) and Alternative/Adjunctive Routes for BRTO.

Project description:Alternative routes for transvenous obliteration are often sought in the management of gastric varices, as well as in the management of other nongastric varices (ectopic varices) such as duodenal and mesenteric varices. These alternative routes can be classified into A-portal venous access routes and B-systemic venous access routes. Anecdotally, alternative routes are more commonly required with duodenal and mesenteric varices compared with gastric varices. Twelve percent (2-19%) of patients with gastric varices require alternative/adjunctive variceal access routes. The most common alternative route described for transvenous obliteration of gastric varices is the percutaneous transhepatic route, which is commonly referred to in the Japanese literature as percutaneous transhepatic obliteration (PTO). The percutaneous transhepatic obliteration route can be performed alone or in combination with the more traditional balloon-occluded retrograde transvenous obliteration (BRTO) transrenal route. Percutaneous transhepatic obliteration by itself is successful in 44-100% of cases for obliterating gastric varices and is rarely unsuccessful when it is combined with BRTO. Other alternative routes are less commonly described and as a result, their clinical outcomes are relatively anecdotal. However, they are technically more challenging and are less commonly successful. These routes include, but are not confined to transphrenic, transileocolic, trans-TIPS (transvenous intrahepatic portosystemic shunt), transgonadal, transazygous, and transrenal capsular vein approaches.

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Balloon-occluded retrograde transvenous obliteration of gastric varices: concept, basic techniques, and outcomes.

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Treatment outcomes after splenectomy with gastric devascularization or balloon-occluded retrograde transvenous obliteration for gastric varices: a propensity score-weighted analysis from a single institution.

Project description:BACKGROUND:Although balloon-occluded retrograde transvenous obliteration (BRTO) is often selected to treat gastric varices caused by portal hypertension, data comparing BRTO and splenectomy with gastric devascularization (Sp?+?Dev) are limited. METHODS:From January 2009 to February 2018, 100 patients with gastric varices caused by portal hypertension who underwent Sp?+?Dev (n?=?45) or BRTO (n?=?55) were included. Overall survival (OS) and the rebleeding rate were calculated using the inverse probability of a treatment weighting-adjusted log-rank test. Independent risk factors were identified by Cox regression analysis. Changes in liver function and adverse events after the procedures were analyzed. RESULTS:Patients in the Sp?+?Dev group tended to have lower platelet counts than those in the BRTO group, but liver function did not differ between these groups. The 5-year OS rates for the Sp?+?Dev and BRTO groups were 73.4 and 50.0% (p?=?0.005), respectively. There were no significant differences in rebleeding rates between the two groups. Multivariate analysis showed that serum albumin level ?3.6 g/dL, prothrombin time% activity (PT%) ?80%, and serum creatinine level ?0.84 mg/dL were poor prognostic factors. Although the Sp?+?Dev group had more short-term complications after procedures, Sp?+?Dev tended to be more effective in improving liver function than BRTO. CONCLUSIONS:Sp?+?Dev showed better OS and improvement of liver function compared with BRTO for the treatment of gastric varices caused by portal hypertension.

| S-EPMC7289714 | biostudies-literature

Successful Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Varices Using Foam Sclerosant Followed by Glue Embolization of Gastrorenal Shunt via the Brachial Vein Approach in a Severely Obese Patient.

Project description:Balloon-occluded retrograde transvenous obliteration is an effective treatment for gastric varices. In this report, we illustrate a consecutive treatment strategy via brachial vein approach and n-butyl cyanoacrylate (NBCA) packing of the gastrorenal shunt (GRS) after injecting sclerosing agent in a severely obese patient. The brachial vein approach reduced the burden on the patient, and the closure of the GRS using NBCA shortened the procedure time. These techniques may improve patient comfort as well as reduce medical costs and the risks of several complications.

| S-EPMC6957899 | biostudies-literature

Combined Balloon-, Plug- and Coil-assisted Retrograde Transvenous Obliteration of Multiple Portosystemic Shunts to Treat Recurrent Hepatic Encephalopathy: A Case Report.

Project description:Balloon- or plug-assisted retrograde transvenous obliteration of portosystemic shunts is an effective endovascular technique for the treatment of type B bypass hepatic encephalopathy. We describe a patient who underwent balloon- and plug-assisted obliteration for a lienorenal and lienogonadal shunt, respectively. He returned with symptoms of recurrent hepatic encephalopathy two years later due to reformation of new lienorenal and lienogonadal shunts. Repeat obliteration of these new shunts was now performed using balloon and coil assistance. We describe the treatment for multiple portosystemic shunts with combined usage of vascular plug, balloon and coils depending on anatomical and technically factors. Our case also highlights that after shunt obliteration increased portal pressure may form new portosystemic collateral pathways which leads to clinical failure and may require repeat treatment.

| S-EPMC7335714 | biostudies-literature

Endoscopic variceal obturation and retrograde transvenous obliteration for acute gastric cardiofundal variceal bleeding in liver cirrhosis

Project description:Background/Aims We retrospectively compared the effect of endoscopic variceal obturation (EVO) and retrograde transvenous obliteration (RTO) in acute cardiofundal variceal bleeding. Methods Patients with acute cardiofundal variceal bleeding treated with EVO or RTO at two hospitals were included. Results Ninety patients treated with EVO and 86 treated with RTO were analyzed. The mean model for end-stage liver disease score was significantly higher in EVO group than in RTO group (13.5 vs. 11.7, P = 0.016). The bleeding control rates were high (97.8% vs. 96.5%), and the treatment-related complication rates were low in both EVO and RTO groups (2.2% vs. 3.5%). During the median follow-up of 18.0 months, gastric variceal (GV) and esophageal variceal rebleeding occurred in 34 (19.3%) and 7 (4.0%) patients, respectively. The all-variceal rebleeding rates were comparable between EVO and RTO groups (32.4% vs. 20.8% at 2-year, P = 0.150), while the GV rebleeding rate was significantly higher in EVO group than in RTO group (32.4% vs. 12.8% at 2-year, P = 0.003). On propensity score-matched analysis (71 patients in EVO vs. 71 patients in RTO group), both all-variceal and GV rebleeding rates were significantly higher in EVO group than in RTO group (all P < 0.05). In Cox regression analysis, EVO (vs. RTO) was the only significant predictor of higher GV rebleeding risk (hazard ratio 3.132, P = 0.005). The mortality rates were similar between two groups (P = 0.597). Conclusions Both EVO and RTO effectively controlled acute cardiofundal variceal bleeding. RTO was superior to EVO in preventing all-variceal and GV rebleeding after treatment, with similar survival outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02428-1.

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Successful percutaneous transvenous removal of a fractured port catheter via novel technique: Balloon-supported retrieval.

Project description: Not available

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The balloon impasse sign in percutaneous transvenous mitral valvuloplasty.

Project description:Percutaneous transvenous mitral valvuloplasty (PTMV) is an established therapy for rheumatic mitral stenosis (MS). While the Wilkins score standardizes the description of valve anatomy and predicts successful PTMV, echocardiographic assessment has some limitations. The 'balloon impasse' sign is the inability to cross a stenotic valve with a deflated Inoue balloon. This sign was described in the 1990s as an indicator of severe subvalvular thickening (regardless of the echocardiographic findings), portending an increased risk of severe mitral regurgitation (MR) post-PTMV. Despite its implications for management, it has been seldom reported. A 57-year-old woman with symptomatic, severe MS and a Wilkins score of 7 underwent PTMV. The 'balloon impasse' sign was observed when attempting to cross the stenotic valve. When the balloon was fully inflated, severe MR was noted, and the patient required mitral valve replacement. This case demonstrates the continued importance of the 'balloon impasse' sign and its implications for the therapeutic efficacy of PTMV.

| S-EPMC7416822 | biostudies-literature

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