Treatment of gastric fundal varices by balloon‐occluded retrograde transvenous obliteration

Abstract

Although less common than oesophageal varices in portal hypertension, gastric fundal varices carry a higher mortality rate when they rupture. They are less amenable to sclerotherapy. We have developed a minimally invasive balloon-occluded retrograde transverse obliteration (B-RTO) procedure to treat gastric fundal varices. B-RTO involves inserting a balloon catheter into an outflow shunt (gastric-renal or gastric-vena caval inferior) via the femoral or internal jugular vein. Blood flow is then blocked by inflating the balloon, and 5% ethanolamine oleate iopamidol is injected in a retrograde manner. The embolized gastric varix subsequently disappears. B-RTO was performed in 32 patients with gastric varices. Follow-up endoscopies were performed at intervals of 2-4 months for an average observation period of 14 months. Eradication of the varices has been confirmed in 31 of 32 patients. No recurrence occurred in any patients in the follow-up period. There were no significant changes in liver function after the procedure. We conclude that B-RTO is a safe and effective procedure for the treatment of gastric fundal varices.

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

“…[1][2][3]39 Most authors refer to Kanagawa et al (1991Kanagawa et al ( -1993 as the originator of the BRTO procedure 1 However, the first published document of an attempt at balloon-occluded sclerotherapy of the gastrorenal shunt for the management of gastric varices was authored by Olson et al in 1984. 39 This is clearly 5 and 7 years prior to the practice and publications, respectively, of Kanagawa et al (1991Kanagawa et al ( -1993, respectively).…”

“…39 This is clearly 5 and 7 years prior to the practice and publications, respectively, of Kanagawa et al (1991Kanagawa et al ( -1993, respectively). 1 Olson et al utilized a transfemoral balloon occlusion catheter and absolute alcohol for the successful sclerosis attempt. 39 Embolic coils were also placed in the outflow gastrorenal shunt.…”

“…39 Subsequently, Kanagawa et al revived the BRTO concept and developed the BRTO procedure in the early 1990s, coining the term ''balloon-occluded retrograde transvenous obliteration'' (B-RTO). 1 They utilized ethanolamine-oleate, an established upper endoscopic variceal sclerosant, which was unfamiliar to Western (European and American) interventional radiologists. Risks of this agent endovascularly include hemolysis, hemoglobinuria, and potentially hemoglobin-induced renal tubular dysfunction.…”

Primary prophylaxis of gastroesophageal variceal bleeding: consensus recommendations of the Asian Pacific Association for the Study of the Liver

“…Balloon-occluded retrograde transvenous obliteration (B-RTO) has been shown to be effective and safe in obliterating gastric fundal varices, with a success rate in about 90% of cases and a variceal recurrence rate of less than 7% [89][90][91][92]. B-RTO is also effective for duodenal varices with lienorenal shunt.…”

Efficacy and Safety of Transcatheter Embolization for Hepatic Encephalopathy Caused by Spontaneous Portosystemic Shunts

“…BRTO is a technique popularized in Japan since it was first reported by Kanagawa et al [15] in 1991 for the treatment of gastric varices. BRTO is less invasive than TIO and PTO, and it can be performed with local anesthesia in almost all patients.…”