Procedure Guide

BRTO Procedure

A BRTO procedure (balloon-occluded retrograde transvenous obliteration) is for treatment of gastric varices. BRTO remains a staple in the armortarium for the treatment of portal hypertension patients. Understanding of the hemodynamics involved with gastric varices is critical for successfully completing a BRTO procedure and reducing the risk of BRTO complications such as non-target embolization. There are variations of techniques for a BRTO procedure, which can layer complexity onto this topic and expand the treatment options for variceal treatment.

Step-by-step guidance on how to perform Balloon-Occluded Retrograde Transvenous Obliteration. Review tools, techniques, pearls, and pitfalls on the BackTable Web App.

Pre BRTO Procedure Prep

BRTO Indications

• Gastric varices: actively bleeding, high risk for rupture or previously ruptured
• Refractory hepatic encephalopathy

BRTO Contraindications

• Portal vein thrombosis
• Splenic vein thrombosis
• Ascites refractory to medical management
• Uncontrolled or high risk esophageal varices

Pre-Procedural Evaluation

• H&P
• Allergies
• Medications
• Renal function
• Coagulation status: ideally, platelets above 50,000 and INR < 2.0
• Transfusion requirements

Pre-Procedure Imaging

• Computed tomography angiography (CTA)/magnetic resonance angiography (MRA)
• Evaluate anatomy, varices and size of shunt
• Patency of portal vein

BRTO Podcasts

Ep. 47

BRTO vs. PARTO in Gastric Variceal Bleeding

Special Guest Dr. Luke Wilkins of University of Virginia VIR discusses BRTO and PARTO techniques for treatment of gastric variceal bleeding.


BRTO Procedure Steps

Antibiotic Prophylaxis

• No consensus


• Obtain venous access: right femoral or internal jugular vein
• Choose access to give best angle to cannulate the gastrorenal shunt (GRS)

Advance vascular sheath into IVC; length and diameter of sheath based on preprocedure image review
Catheterize left renal vein using angled catheter (e.g., Cobra) and 0.035" wire (e.g., Glidewire or Rosen)
Advance sheath into proximal left renal vein
• Catheterize GRS with "pull back venogram"
• Rotate Cobra catheter superiorly and pull back, catheter should fall into shunt - inject contrast to confirm location
• Alternatively, exchange for angle-tipped catheter to select shunt
2nd option for cannulation of GRS - Advance 10-Fr TIPS sheath over 0.035" guidewire into left renal vein
• remove sheath inner dilator
• pull back sheath over 0.035" wire until sheath falls into shunt - inject contrast to confirm

Advance Glidewire and 5-Fr catheter into shunt - injection to confirm location and shunt diameter
Advance vascular sheath into shunt
• May need to exchange for stiff guidewire
• May need to remove catheter and use inner dilator of the sheath

Advance occlusion balloon into shunt
• Size balloon to shunt
• Examples: Python occlusion balloon (Applied Medical) or Coda (Cook)
Perform balloon-occlusion digitally subtracted venography (DSV)
• Consider Cone-Beam CT
• Define type of variceal system
• Opacify the entire gastric-variceal system
• Delineate anatomy: afferent vessels - portal venous supply; efferent vessels - Identify systemic draining veins that preclude filling the varix and may need embolization
• Measure volume required to fill varix

Embolization of Collaterals

Potential embolization of afferent (portal) and efferent (systemic draining) veins prior to variceal sclerosis
• Not all collaterals will require embolization
• Look for efferent vessels: inferior phrenic, pericardiophrenic, duplicated GRS
• Look for afferent vessels: Left gastric, posterior gastric, short gastric and gastroepiploic vein
• Embolize potential efferent vessels with coils, amplatzer plug or liquid embolic

Following embolization, repeat DSV to evaluate for change in flow vs new collateral opacification
If unable to access collaterals for embolization:
• Gelfoam embolization may reduce flow into efferent collaterals. Need to repeat DSV after embolization
Many other options to deal with significant collaterals (both afferent and efferent)
• Advance occlusion balloon further into shunt, beyond collaterals, and sclerosis for deeper position
• Antegrade access collaterals from the portal venous system. Potentially via TIPS or transhepatic access
• Non-selective Gelfoam embolization may reduce flow to efferent collaterals
Need to repeat DSV after embolization


Estimate volume based on final DSV used to opacify shunt - approximately 30-40 ml but can be more
Sclerosant - many options
• 3% Sotradecol (STS) -Air:STS:Lipiodol in 3:2:1 mixture
• Example: 30 ml air, 20 ml 3% STS and 10 ml Lipiodol
• Ethanolamine oleate is traditional agent
Administer sclerosant agent with fluoroscopy or DSA - balloon should be inflated
Fill entire gastric-variceal system
• Slow, steady injection
• Endpoint - minimal flow into afferent portal vasculature
• Can use microcatheter alongside occlusion balloon for more even distribution of sclerosant
Dwell time: 4-24 hours suggested
• Patient to ICU or telemetry holding area
• Bedrest while balloon is inflated and sclerosant is indwelling

Removal of Sclerosant

• Return to cath lab
• Aspirate sclerosant via balloon occlusion catheter - record output
• Deflate and remove occlusion balloon
• DSV of left renal vein through sheath to confirm patency
Sheath removal


BRTO Complications

• Major complications: 3% (portal/splenic and IVC/iliac venous thrombus, pulmonary emboli, sclerosant extravasation)
• Immediate/periprocedural complication(s): Sclerosant EO may induce renal failure due to hemolytic effect
• Hematuria expected with ethanolamine oleate sclerosant
• Systemic venous thrombosis (as high as 15%)
• Low-grade fevers (51%) - treat conservatively
• Abdominal and back pain common - treat conservatively

Delayed BRTO Complication(s)

• Increased portal pressures
• Worsening of existing esophageal varices (EV)
• Year 1 (27-35%)
• Year 2 (45-66%)
• Year 3 (45-91%)
• New EV in patient who had none (> 50%)
• Hepatic hydrothorax and ascites (9-33%)

Follow-up CTA, MRA, or Endoscopic US to Confirm Obliteration of Varices

• About 2 weeks post-procedure
• Can predict long-term efficacy of BRTO
• Periodic endoscopy to evaluate for recurrence or new varices; band ligate new esophageal varices
• Partial obliteration can undergo repeat BRTO
• Regrowth or persistent varices at 3 months should undergo repeat treatment
• May embolize spleen prior to repeat treatment

BRTO Demos

BRTO for Large Bleeding Gastric Varices

Dr. Sandeep Sharma demonstrates balloon-occluded retrograde transvenous obliteration (BRTO) therapy for gastric varices that are untreatable endoscopically.

BRTO Music Video

This demo shows a Balloon-Occluded Retrograde Transvenous Obliteration (BRTO).

MELD Calculator
Model for End-Stage Liver Disease. Stratifies severity of end-stage liver disease, for transplant planning.
MELD Calculator on BackTable

BRTO Literature

American Journal of Roentgenology (Oct 2012)

Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices

The purpose of this review is to describe the clinical factors related to balloon-occluded retrograde transvenous obliteration, including the preparation needed, the technique and challenges, and the outcomes.

Seminars in Interventional Radiology (Feb 2012)

Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices: Concept, Basic Techniques, and Outcomes

This article discusses the concept, technique, and outcomes of BRTO within the broader management of gastric varices.

Clinical and Translational Gastroenterology (Aug 2018)

Coil-Assisted Retrograde Transvenous Obliteration (CARTO) for the Treatment of Portal Hypertensive Variceal Bleeding: Preliminary Results

CARTO appears to be a technically feasible and safe alternative to traditional balloon-occluded retrograde transvenous obliteration or transjugular intrahepatic portosystemic shunt, with excellent clinical outcomes in treating portal hypertensive non-esophageal variceal bleeding.

Related Content

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BRTO vs. PARTO in Gastric Variceal Bleeding

BRTO vs. PARTO in Gastric Variceal Bleeding Podcast with Dr. Luke Wilkins

Practice Tool

MELD Calculator

MELD Calculator on BackTable

Demo Video

BRTO for Large Bleeding Gastric Varices

Join The Discussion


[1] Park JK, Saab S, Kee ST, et al. Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) for Treatment of Gastric Varices: Review and Meta-Analysis. Dig Dis Sci. 2015;60(6):1543‐1553. doi:10.1007/s10620-014-3485-8
[2] Saad WE, Simon PO Jr, Rose SC. Balloon-occluded retrograde transvenous obliteration of gastric varices. Cardiovasc Intervent Radiol. 2014;37(2):299‐315. doi:10.1007/s00270-013-0715-y
[3] Saad WE, Kitanosono T, Koizumi J, Hirota S. The conventional balloon-occluded retrograde transvenous obliteration procedure: indications, contraindications, and technical applications. Tech Vasc Interv Radiol. 2013;16(2):101‐151. doi:10.1053/j.tvir.2013.02.003
[4] Patel A, Fischman AM, Saad WE. Balloon-occluded retrograde transvenous obliteration of gastric varices. AJR Am J Roentgenol. 2012;199(4):721‐729. doi:10.2214/AJR.12.9052

Disclaimer: The Materials available on are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients.