BRTO: Beyond the Basics

In this episode, Dr. Saher Sabri and our host Dr. Aparna Baheti discuss PARTO, BRTO, and combined TIPS and BRTO procedures.

First, they discuss differences between PARTO (Plug-Assisted Retrograde Transvenous Obliteration) and BRTO (Balloon-Occluded Retrograde Transvenous Obliteration). Dr. Sabri walks us through the steps of both, noting that it is important to study the shunt before the procedure to identify its narrowest part. He also emphasizes the need to confirm successful balloon occlusion before starting embolization. This can require minor adjustments to balloon size and positioning.

To identify the endpoint for injection, Dr. Sabri tracks sclerosant movement up to the diaphragm and then down to the gastric varix. He confirms that the shunt has been obliterated and prevented from recruiting other outflows in the future.

When considering combined TIPS and BRTO procedure, Dr. Sabri focuses on key indications such as bleeding gastric varices, high-risk esophageal varices, and ascites. He prefers to do the TIPS procedure first, then the BRTO, then re-measuring the gradient and deciding if more ballooning of the TIPS is needed.

Finally, the doctors discuss post-procedural follow up and imaging. Dr. Sabri aims to have CT imaging within 2-4 weeks after BRTO and an ultrasound within 2 weeks after TIPS.