Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) Versus Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Treatment of Gastric Varices Because of Portal Hypertension

Abstract

Background: Although gastric variceal (GV) bleeding is less common than esophageal variceal bleeding, the severity of GV bleeding is often greater with higher morbidity and mortality rates. Minimally invasive endovascular treatments such as balloon-occluded retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunt (TIPS) have been used for the management of GVs with varying results, and individual and institutional differences exist in the use of BRTO and TIPS. We performed a systematic review and meta-analysis to compare the feasibility, efficacy, and safety of BRTO and TIPS for the treatment of GVs because of portal hypertension. Methods: Searches of PubMed, EMBASE, Google Scholar, and Cochrane Library databases were performed from inception through March 2019. Summary odds ratio (OR) with 95% confidence intervals (CI) was estimated for technical success, hemostasis rate, postprocedural complications, rebleeding rate, incidence of hepatic encephalopathy, and mortality rate at 1 year utilizing a random-effects model. Results: Seven studies with a total of 676 patients (BRTO: 462 and TIPS: 214) were included. There was no difference in pooled technical success rate (OR, 0.87; 95% CI, 0.28-2.73; P=0.81), hemostasis rate (OR, 2.74; 95% CI, 0.61-12.26; P=0.19), and postoperative procedure-related complications (OR, 1.95; 95% CI, 0.44-8.72; P=0.38). However, treatment with BRTO was associated with lower rates of postoperative rebleeding (OR, 0.30; 95% CI, 0.18-0.48; P<0.00001), postoperative encephalopathy (OR, 0.06; 95% CI, 0.02-0.15; P < 0.00001), and mortality at 1 year (OR, 0.43; 95% CI, 0.21-0.87; P=0.02). Conclusions: BRTO was associated with lower rates of rebleeding, postprocedure hepatic encephalopathy, and mortality at 1 year. BRTO should be considered first-line modality for the treatment of GVs because of portal hypertension.

Friend or Foe? Spontaneous Portosystemic Shunts in Cirrhosis—Current Understanding and Future Prospects

“…ese therapies are aimed at controlling both inflow and the outflow of the variceal complex using balloon, coils, or plug. Various studies and subsequent meta-analyses (Table 2) have reported technical and clinical success rates in excess of 95% for BRTO [71][72][73][74][75][76][77][78][79][80][81][82]. Also, gastric variceal rebleed rates among those undergoing successful BRTO procedure range between 0% and 20% [71][72][73][74][75][79][80][81][82].…”

“…Various studies and subsequent meta-analyses (Table 2) have reported technical and clinical success rates in excess of 95% for BRTO [71][72][73][74][75][76][77][78][79][80][81][82]. Also, gastric variceal rebleed rates among those undergoing successful BRTO procedure range between 0% and 20% [71][72][73][74][75][79][80][81][82]. Compared to TIPS, shunt embolization results in diversion of blood towards the liver, thereby preserving or improving liver functions, during the initial 6 to 9 months [71,73,75].…”

Combined Transjugular Intrahepatic Portosystemic Shunt Plus Variceal Obliteration versus Transjugular Intrahepatic Portosystemic Shunt Alone for the Management of Gastric Varices: Comparative Single-Center Clinical Outcomes

“…Compared to combined therapy, isolated BRTO occludes a naturally occurring portosystemic shunt and is therefore, often associated with worsening portal hypertensive complications. Some studies have reported ascites in up to 44% of patients and EV aggravation in up to 30% of patients who underwent BRTO (4,40,41). Because combined therapy trades a physiologic shunt for a manmade one, additional sequelae of portal hypertension may be circumvented, as seen in this study.…”

North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension

“…60,61 Studies have shown the efficacy of these measurements when assessing clinical response after TIPS creation. [62][63][64] These studies also have shown a statistically significant difference between the hepatic venous or IVC pressure compared with the RAP owing to the effect of intraabdominal pressure. This difference decreases the prognostic value of the PSG when the RAP is used and potentially could lead to underdilation or overdilation of the TIPS stent to achieve a target gradient.…”