Balloon-Occluded Retrograde Transvenous Obliteration

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Overview

Overview content for Balloon-Occluded Retrograde Transvenous Obliteration is not yet available.

Pre-Procedure

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

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

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

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

Procedure

Antibiotic prophylaxis:
• No consensus

Access:
• 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

Sclerosis
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

Post-Procedure

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 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 in ~ 2 weeks
• 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

Related Procedures

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References

[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

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