Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) of gastric varices: A case report

V. Senthilvelmurugana,*, P. Santhosh Kumarb, N. Raam Prasanthc, K. Arivarasand

aHOD, Department of Radiology, Kauvery Hospital, Trichy

bConsultant Radiologist, Kauvery Hospital, Salem

cResident Radiology, Kauvery Hospital, Trichy

dConsultant Gastroenterologist, Kauvery Hospital, Trichy

*Correspondence: [email protected]

Abstract

Background:

Upper gastrointestinal endoscopy is the first-line diagnostic and management tool for bleeding gastric varices when confronting failure in controlling gastric variceal bleeding. A transjugular intrahepatic portosystemic shunt (TIPS) is performed traditionally but Balloon-Occluded Retrograde Transvenous Obliteration is more effective than TIPS in controlling bleeding gastric varices.

Clinical Presentation:

A 42-years-aged male patient who is known to have chronic parenchymal liver disease, with portal hypertension, and multiple portosystemic shunts present with sudden hematemesis after initial stabilization with endoscopic ligation of esophageal varices, he was further managed with balloon occluded retrograde transvenous obliteration of gastric varices by interventional radiology team.

Conclusion:

BRTO has many advantages over TIPS for managing Gastric varices as it preserves hepatic function and reduces the risk of hepatic encephalopathy.

Keywords:

Gastric varices, BRTO, TIPS, Chronic liver disease, Portal Hypertension, Gastrorenal shunts, Sclerosants

 

Background

Patients with gastric variceal bleeding require a multidisciplinary team approach including, medical gastroenterologists, diagnostic radiologists and interventional radiologists. Upper gastrointestinal endoscopy is the first-line diagnostic and management tool for bleeding gastric varices, as it is in all upper gastrointestinal bleeding scenarios. Traditionally when endoscopy fails to control gastric variceal bleeding, a transjugular intrahepatic portosystemic shunt (TIPS) is performed along with decompression of portal circulation. However, TIPS has not shown the same effectiveness in controlling gastric variceal bleeding that it has with oesophageal variceal bleeding. BRTO has many advantages over TIPS in that it is less invasive and can be performed on patients with a poor hepatic reserve and those with encephalopathy (and may even improve both).

Case Presentation

A 42-years-aged male patient came with complaints of hematemesis and malena for the past 3 days. He was known to have chronic liver disease. and diabetic mellitus on medications. Patient’s general examination was normal and vitals were initially stable. Upper gastrointestinal endoscopy revealed large esophageal and fundal varices with features of portal hypertension for which Emergency Endoscopic Variceal Ligation was done. On the next day, there was a drop in haemoglobin level for which blood transfusion started. He was planned for contrast-enhanced CT abdomen.

Balloon1

Fig. 1.

Contrast CT shows features of Chronic Liver Disease with multiple collaterals, and paraesophageal and gastric varices with large gastrorenal shunts. The collaterals around the gastric region were also grossly dilated and intraluminal projection was seen.

With Contrast CT we confirmed the portal vein’s patency as well as the size of gastrorenal shunts (for conventional BRTO) and the presence of alternative portosystemic shunts.

In presence of a thrombosed main portal vein, occlusion of the gastrorenal shunt a by-product of the BRTO procedure, would potentially cause mesenteric venous hypertension, mesenteric ischemia, and possibly thrombosis of the entire splanchnic portal venous circulation.

BRTO Procedure

The BRTO procedure is an endovascular technique that causes occlusion of outflow portosystemic shunt, such as a gastro-renal shunt, using an occlusion balloon followed by the endovascular injection of a sclerosing agent directly into the gastro-variceal system/complex.

Vascular access

Percutaneous venous access of the right internal jugular vein using standard Seldinger technique was performed with placement of a 8-french sheath. Careful review of pre-procedure cross-sectional imaging helped decide the approach that provided the best angle for selecting the target gastrorenal shunt.

Shunt catheterisation

Catheterisation of the gastrorenal shunt via the left renal vein is typically accomplished using catheters with mounted occlusion balloons that are specifically designed for the BRTO procedure. We chose 8-french reliant balloon occlusion catheter and placed across the splenorenal shunt after that balloon was inflated across the junction of gastrorenal shunt with left renal vein. Balloon occlusion was used for two technical reasons:

  1. Occlusion of the gastrorenal shunt so that retrograde (upstream) venography could be performed to visualize the gastric-variceal system/complex.
  2. To modulate flow and cause stagnation of the sclerosant within the gastric-variceal system without reflux of the sclerosant into either the portal or systemic vasculature.

Stagnation in the flow was helpful to maximize sclerosant dwell time to achieve maximal effect of the sclerosant on the gastro-variceal system endothelial lining, leading to thrombosis and subsequent scarring of the system.

Balloon2

Fig. 2.

Image showing 8 French reliant balloon occlusion catheter.

Balloon3

Fig. 3.

Image showing balloon was inflated and occlusion at confluence of left renal vein with Gastro renal shunt.

Sclerosant Injection

The aim during sclerosant injection was to fill the entire gastric-variceal system so that no varices remain and no dispensable portosystemic connections were left for the system to revascularize.

Numerous sclerosing agents can be used. These agents include 5 to 10% EO (Ethanolamine oleate), 3% STS (sodium tetra decayl sulphate), and Polidocanol. All agents can be used in foam, froth, or liquid form. In addition, liquid sclerosants such as N-butyl- cyanoacrylate and absolute (97 to 99%) ethanol have also been used. EO is the traditional agent used for BRTO but EO causes haemolysis in the blood vessels; as a result, free haemoglobin is released, which may cause renal tubular disturbances and acute renal failure. To prevent renal insufficiency, 2000 U to 4000 U of haptoglobin is routinely administered intravenously during the BRTO to chelate the circulating free haemoglobin to minimise its nephrotoxic effects. After Quantification of maximum volume of dilated varices done and respective sclerosant mixture calculated. With balloon occlusion we use mixture of sclerosants (3% STS, LIPIDOL, AIR) injected into bed of gastric varices.

Balloon4

Fig. 4.

Image showing complete distribution of sclerosant into the variceal system with balloon occlusion.

Sclerosant Dwell Time (Balloon Dwell Time)

The balloon-occlusion catheters are left inflated for 4 to 24 h. Over time, the dwell time has been reduced safely to 4 to 6 h. In this case, we preferred 6 h as dwell time. This protocol was adopted for logistical reasons, such as cost concerns (patients stay overnight in monitored beds), patient comfort, and reducing the infection risk of indwelling catheters tethered at skin sites. The fluoroscopy did after 6 h showed good stasis of sclerosant in gastric variceal bed. Balloon was deflated and removed and there was no dislodgement of sclerosant.

Balloon5

Fig. 5.

Image showing balloon was deflated and removed along with catheter. There is stasis of sclerosant with completely thrombosed variceal system seen.

Balloon6

Fig. 6.

Post-procedure Plain CT shows Complete distribution of sclerosant within the gastrorenal shunt.

Clinical Outcomes of BRTO

The primary indications for BRTO are gastric variceal bleeding (or potential bleeding) and refractory encephalopathy in the presence of a gastrorenal shunt. The aggravation of non-gastric (oesophageal or duodenal) varices appears to be a major problem following BRTO and reflects post-procedural increased portal hypertension. This effect varies widely, probably depending on the degree of vigilance, documentation, and thoroughness of follow-up endoscopy. The major procedural complications include gross hematuria, pulmonary embolism, cardiac arrhythmia, anaphylaxis, renal failure and long-term complications include portal hypertensive gastropathy, aggravation of oesophageal varices, duodenal varices, ascites, bacterial peritonitis, renal vein thrombosis.

Balloon7

Fig. 7.

One year follow up CT Images shows Complete Obliteration of gastrorenal shunt.

Conclusion

Patients with gastric variceal bleeding require upper gastrointestinal endoscopy as the first-line diagnostic and management tool for bleeding gastric varices. When endoscopy fails to control gastric variceal bleeding, a transjugular intrahepatic portosystemic shunt (TIPS) traditionally is performed. However, TIPS has not shown the same effectiveness in controlling gastric variceal bleeding as that it has with esophageal variceal bleeding. BRTO has been shown to be effective in controlling gastric variceal bleeding with low rebleed rates. The greatest advantages of BRTO are its preservation of hepatic function and its reduction in the risk of hepatic encephalopathy. In fact, one of the indications for BRTO is encephalopathy with the presence of a gastrorenal or gastro-splenorenal shunt. BRTO has many advantages over TIPS in that it is less invasive and can be performed on patients with poor hepatic reserve and those with encephalopathy (and often improve both).

References

  1. Saad WE. Balloon-occluded retrograde transvenous obliteration of gastric varices: concept, basic techniques, and outcomes. Semin Intervent Radiol. 2012;29(2):118-28.
  2. Hiro Kiyosue, et al, Transcatheter Obliteration of Gastric Varices, Jul 1 2003;.
  3. Pushpinder SK, et al., Retrograde transvenous obliteration of gastric varices using sodium tetradecyl sulphate: technical considerations and results from a single institution retrospective study. J Clin Interv Radiol. 2021;6:10-17.
  4. Lewandowski R, et al., Handbook of Interventional Radiology, 6th

    edition.

  5. Brandt C. Wible. Diagnostic Imaging: Interventional Radiology, 3rd Edition.
Senthilvelmurugan

Dr. V. Senthilvelmurugan

HOD, Radiology

Santhosh Kumar

Dr. P. Santhosh Kumar

Radiologist

Raam Prasanth

Dr. N. Raam Prasanth

Resident Radiology

Arivarasan

Dr. K. Arivarasan

Gastroenterologist

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