Balloon-Occluded Retrograde Transvenous Obliteration (BRTO): A Novel Method of Control of Bleeding from Post-Glue Ulcer over Gastric Varices. Report of Two Cases and Review of Literature

Abstract

Bleeding gastric varices (GV) are managed by cyanoacrylate glue injection with transjugular intrahepatic portosystemic shunt (TIPSS) as modality for treatment failure. Ulcer can form at the site of glue injection over GV and it can cause bleeding. Treatment approach for such bleed is not well described. Balloon-occluded retrograde transvenous obliteration (BRTO), TIPSS, and devascularization remain the treatment options in this scenario. BRTO is an endovascular procedure where a balloon catheter is inserted into a draining vein of GV, and the sclerosant can be injected into the varices through the catheter during balloon occlusion. BRTO has the benefit of increasing portal hepatic blood flow and can also be useful in patients who may not tolerate TIPSS. We report two cases where BRTO was done for control of bleeding from ulcers formed over previously injected GV. 1 Treatment modalities for bleeding GV are cyanoacrylate glue injection and transjugular intrahepatic portosystemic shunt (TIPSS). Balloon-occluded retrograde transvenous obliteration (BRTO) has been used as a primary treatment for acute bleeding GV. Ulcer can form at the site of glue injection over GV and it can cause bleeding. The exact prevalence of such bleeding and treatment options is not well established. BRTO has been proposed as a possible treatment option in such situation. TIPSS and devascularization remain other therapeutic options in this scenario.BRTO is an endovascular procedure where a balloon catheter is inserted into a draining vein of GV, and the sclerosant can be injected into the varices through the catheter during balloon occlusion. BRTO has been used for active GV hemorrhage, which was transiently treated by either endoscopic sclerotherapy or Sengstaken-Blakemore tubes, recent bleeding, and preventive GV obliteration in patients who had never bled.2 Reports of refractory variceal bleed treated with BRTO are rare. 2 We report two cases where BRTO was done for control of bleeding from ulcers formed over previously injected GV. CASE 1A 44-year-old male with Child-Pugh class B cirrhosis presented with UGI bleed. He had past history of glue injection for gastric variceal bleeding one month ago. At admission, the patient had tachycardia (pulse 116/min) and hypotension (BP 86/50 mmHg) pallor. He was resuscitated with crystalloid infusion and blood transfusion and terlipressin infusion was started. After hemodynamic stabilization, he underwent emergent UGI endoscopy which showed small esophageal varices with no stigmata of bleed with large deep white based ulcer over GV at the site of previous glue injection (Figure 1). There was no unsolidified area in the varices for further glue injection. There was ongoing bleeding as indicated by persistent tachycardia and requirement of blood transfusion. Options of TIPSS or BRTO were considered and CT angiography abdomen was done to assess patency of portal vein, hepatic veins, splenic vein, and presence of gastrorenal shunt. CT showed patent portal and splenic veins and a large gastrorenal shunt d...

Retrograde Transvenous Obliteration of Gastric Varices using Sodium Tetradecyl Sulphate: Technical Considerations and Results from a Single Institution Retrospective Study

“…6). 3,[22][23][24][25] Pooled analysis of the published Indian studies revealed survival rate at 1 year among patients undergoing BRTO of 97% (95% CI: 0.91 to 1.0) and 98% (95% CI:0.89 to 1.0) by fixed and random effect models, respectively (►Fig. 7).…”

“…7). 3,[22][23][24][25] To our knowledge, there are two other large studies from the Indian subcontinent, describing the role of BRTO in patients with bleeding GVs or HE. 3,25 The sclerosant used by authors in both these studies was a mixture of air, STS, and lipiodol in a ratio 3:2:1.…”