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Balloon-Occluded Retrograde Transvenous Obliteration

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.

Balloon-Occluded Retrograde Transvenous Obliteration Procedure Prep

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Ep 179 Happiness is a Warm Coil: Treating GI Bleeds with Dr. Donald Garbett
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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

Balloon-Occluded Retrograde Transvenous Obliteration Podcasts

Listen to leading physicians discuss balloon-occluded retrograde transvenous obliteration on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.

Episode #179

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Interventional Radiologist Donald Garbett and our host Sabeen Dhand discuss their standard workups and procedural decision making for GI bleeds, including radial vs. femoral approach and preferred embolics.

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Episode #160

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Dr. Aparna Baheti talks with Dr. Saher Sabri from MedStar Georgetown University Hospital about his approach to Balloon-occluded retrograde transvenous obliteration (BRTO) for portal hypertension, including advanced tips and tricks.

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Episode #87

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Interventional Radiologist Rajeev Suri from UT Health San Antonio tells us about his clinical approach to the high-volume ascites patient, including paracentesis technique and tips, albumin regimen, and discussing the need for TIPS in some patients.

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Episode #47

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

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BRTO Procedure Steps

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

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

• 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%)

Balloon-Occluded Retrograde Transvenous Obliteration Demos

Watch video walkthroughs of balloon-occluded retrograde transvenous obliteration on the BackTable VI expanded content network.

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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Podcasts

Happiness is a Warm Coil: Treating GI Bleeds with Dr. Donald Garbett on the BackTable VI Podcast)
BRTO: Beyond the Basics with Dr. Saher Sabri and Dr. Aparna Baheti on the BackTable VI Podcast)
Deep Dive Into Ascites with Dr. Rajeev Suri on the BackTable VI Podcast)
BRTO vs. PARTO in Gastric Variceal Bleeding with Dr. Luke Wilkins on the BackTable VI Podcast)
New Tools to Treat Severe Distal Femoropopliteal Disease with Dr. John Rundback on the BackTable VI Podcast)

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