The History and Evolution of Balloon-occluded Retrograde Transvenous Obliteration (BRTO): From the United States to Japan and Back

Abstract

The concept of obliterating varices that complicate portal hypertension dates back to the 1970s, but its minimally invasive clinical utilization was probably lost with the advent of the transjugular intrahepatic portosystemic shunt (TIPS). The conception of retrograde obliteration of a gastrorenal shunt via the left renal vein was reported by Olson et al from the University of Indiana. However, the definition, development, technical perfection, and clinical implementation of the balloon-occluded retrograde transvenous obliteration (BRTO) occurred in Japan (by Kanagawa et al and others). The BRTO-procedure is currently undergoing a renaissance in the United States particularly for patients who are not TIPS candidates.

Comparison of patients with hepatic encephalopathy and those with gastric varices before and after balloon‐occluded retrograde transvenous obliteration

“…There are two forms of HE, namely, the synthetic type, which is related to hepatic failure, and the bypass type, which is associated with portosystemic shunts (PSSs) . Over 80% of patients with gastric fundal varices have gastrorenal shunts (GRSs), and radiological findings indicate that large spontaneous PSSs are present in 46–71% of patients with refractory encephalopathy who are resistant to dietary restrictions and drugs . Therefore, the presence of major shunts explains the persistence or recurrence of HE, despite a patient's liver function being acceptable, and the PSSs might represent therapeutic targets.…”

Nonendoscopic Management Strategies for Acute Esophagogastric Variceal Bleeding

“…108,109,100,111, 112 For the conventional BRTO procedure, a large infradiaphragmatic “left-sided” portosystemic collateral is required. 113,114, 115 The most common shunt to be occluded during a conventional BRTO procedure is a gastrorenal shunt, which provides venous outflow in 90% of gastric varices cases. The remaining 10% of gastric varices drain through a gastrocaval shunt (infra-diaphragmatically) or other less common transdiaphragmatic veins.…”

Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices: Concept, Basic Techniques, and Outcomes

“…6 They utilized 5% ethanolamine oleate (EO) (Oldamin; Grelan Pharmaceutical, Tokyo, Japan) as an endovascular sclerosant, with which European and American interventional radiologists were not familiar. 5,6 EO is an established upper endoscopy variceal sclerosant. However, when used during endovascular procedures, there is a risk for hemolysis, hemoglobinuria, and potentially hemoglobin-induced renal tubular dysfunction.…”

“…Subsequently, in 2006-2007, American interventionalists introduced a different sclerosant: 3% sodium tetradecyl sulfate (3% STS) (Sotradecol, AngioDynamics, Inc. Queensbury, NY) to perform the BRTO procedure. 5 It was developed out of necessity due to the lack of an antidote for hemolysis (haptoglobin) in the United States, as well as the unfamiliarity with EO as an endovascular sclerosant. The first two institutions to use 3% STS were Mount Sinai (New York) and the Dotter Institute (Oregon), 5 subsequently and independently followed by the University of Virginia.…”