Evolution of Retrograde Transvenous Obliteration Techniques

Abstract

Gastric variceal hemorrhage is a life-threatening complication of portal hypertension with a poorer prognosis compared with esophageal variceal hemorrhage. The presence of an infradiaphragmatic portosystemic shunt, often a gastrorenal shunt, allows for treatment with retrograde transvenous obliteration (RTO). RTO is an evolving treatment strategy, which includes balloon-assisted RTO, plug-assisted RTO, and coil-assisted RTO, for both gastric variceal hemorrhage and hepatic encephalopathy. RTO techniques are less invasive than transjugular intrahepatic portosystemic shunt creation, with the benefit of improved hepatic function, but at the expense of increased portal pressure. This article discusses the techniques of RTO, including patient eligibility, as well as technical and clinical outcomes, including adverse events.

AASLD Practice Guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage

“…Additionally, because RTO does not have any effect on portal venous resistance, the redirection of flow to the liver may increase portal pressure and PSPG, 70 which can lead to the development of new collateral pathways to the often coexisting esophageal varices in up to 60% of cases 50,71,72 . Ascites and hepatic hydrothorax may also worsen in up to 10% after the procedure, which may necessitate subsequent TIPS placement 73 . As a result, patients with esophageal bleeding and/or refractory ascites/hydrothorax following RTOs may require treatment with TIPS placement 74 .…”

“…Instead, a vascular plug (typically the Amplatzer plug) and Gelfoam slurry are used to obliterate the gastric varices 77 . The use of Gelfoam instead of sclerosing agents obviates the need for embolization of small collateral vessels, which is an essential part of BRTOs to prevent leakage of sclerosing agents 73 . The PARTO procedure is performed by accessing the GRS with a catheter, which is then upsized to a large sheath to deploy the vascular plug within the most narrow portion of the shunt (choke point).…”

“…[50,71,72] Ascites and hepatic hydrothorax may also worsen in up to 10% after the procedure, which may necessitate subsequent TIPS placement. [73] As a result, patients with esophageal bleeding and/or refractory ascites/hydrothorax following RTOs may require treatment with TIPS placement. [74] On the other hand, the increased portal flow following RTOs may help improve hepatic function, leading to improved MELD and Child-Pugh scores.…”

“…[77] The use of Gelfoam instead of sclerosing agents obviates the need for embolization of small collateral vessels, which is an essential part of BRTOs to prevent leakage of sclerosing agents. [73] The PARTO procedure is performed by accessing the GRS with a catheter, which is then upsized to a large sheath to deploy the vascular plug within the most narrow portion of the shunt (choke point). After plug deployment, additional embolization of the entire gastric variceal complex is performed using Gelfoam.…”

“…The presence of difficult-tocontrol ascites is a relative contraindication that can worsen with RTO and can be mitigated by TIPS placement after RTO. [71,73] In addition, several anatomical factors must be considered. There must be an efferent shunt (e.g., GRS) amenable to catheterization and occlusion.…”