BALLOON-OCCLUDED

R ETROGRADE
TRANSVENOUS O BLITERATION ( BRTO) O F
GASTRIC VARICES
Resident(s): Ashish R. Vyas M.D., Dominic T. Semaan M.D.,
J.D.
Attending(s): Dr. Laurie Vance
Program/Dept(s): Providence Hospital and Medical Center,
Department of Radiology , Southeld, Michigan

CHIEF COMPLAINT & HPI

Chief Complaint and/or reason for consultation
77-year-old male with acute hematemesis secondary to bleeding gastric varices despite
endoscopic banding

History of Present Illness

1 day history of hematemesis
No history of prior upper or lower GI bleed
Patient recalls blacking-out last afternoon and waking up with bright red
blood on oor and all over his clothes with another episode prior to bed
Underwent endoscopic banding of actively bleeding gastric varices upon
admission
VIR consulted by GI after failed endoscopic banding and multiple friable and
bleeding gastric varices

RELEVANT HISTORY
Past Medical History

Prior CVA
Diabetes mellitus, type II
Hypertension
Nephrolithiasis
Diverticulitis

Past Surgical History

Partial colectomy for diverticulitis

Left carotid endarterectomy

Family & Social History

Alcohol abuse (at least 3-4 shots of whiskey/day for 20 years)

Review of Systems

Pertinent for those mentioned in HPI, PSH, PMH

RELEVANT HISTORY
Medications
Losartan 50 mg, PO, Qday
Ezetimibe 40 mg, PO, Qday
Metformin 500 mg, PO, Qid
Multivitamin
Aspirin 81 mg, PO, Qday

Allergies
Penicillin
Donnatal

DIAGNOSTIC WORKUP
Physical Exam
Vital signs stable, no acute distress
No active hematemesis at bedside
Lungs clear, no gynecomastia
Normal rate and cardiac rhythm
Bowel signs present, no evidence of distension to suggest ascites; no signs of caput
medusa, hepatosplenomegaly,
No jaundice, asterixis, scleral icterus

Laboratory Data
Pertinent positive/negative diagnostic studies.

DIAGNOSTIC WORKUP
Laboratory Data

9.8

4.0

89

28.1%

AST/ALT: 39/55

Alkaline phosphatase: 48
Total bilirubin: 0.6

139

105

61

5.0

20

1.3

Hepatitis panel: Negative

109

DIAGNOSTIC WORKUP
Non-invasive imaging
CT-angiography of the abdomen and pelvis

DIAGNOSTIC WORKUP CT-ANGIOGRAPHY

Axial CTA shows multiple large gastric varices, some thrombosed. Findings of nodular liver contour and caudate lobe hypertrophy
suggestive of cirrhosis are also present.

DIAGNOSTIC WORKUP CT-ANGIOGRAPHY

Coronal MIP image demonstrates gastric varices draining via a gastrorenal shunt.

DIAGNOSIS
Diagnosis
Bleeding gastric varices draining via a gastrorenal shunt
Hepatic cirrhosis

INTERVENTION
Patient underwent endoscopic banding of gastric varices
Active variceal bleeding and multiple friable varices were seen despite multiple band
placements

General surgery consulted for possible gastrectomy for bleeding refractory to

treatment
CTA ordered by surgery was reviewed by IR

Detailed discussion was had among patient, surgery, GI and IR regarding surgical
and minimally invasive options
Patient was emergently brought down to IR for Balloon-Occluded Retrograde
Transvenous Obliteration (BRTO) of gastric varices

INTERVENTION - BRTO
After sheath upsizing, the inferior
cardiophrenic vein was coil
embolized with 0.018 Nester coils
to prevent sclerosant from
central venous drainage.
Contrast injection demonstrated
no residual ow in the coiled
pericardiophrenic vein with the
occlusion ballooon inated.
Active hemorrhage is evident.

Inferior phrenic venogram conrms gastric varices draining

via a gastrorenal shunt. Inferior pericardiophrenic vein also
opacies. The left adrenal vein is excluded.

INTERVENTION - BRTO

An 11.5 mm occlusion balloon was advanced

into the distal inferior phrenic vein and inated
to occlude the eerent draining vein. Foam
sclerotherapy was performed with 3%
Sotradecol for a total dwell time of 30 minutes.

Sclerotherapy was also

augmented by 0.018 coil
embolization. Repeat injection
showed stagnation of ow in the
gastric varices.

The eerent draining vein was

coil embolized with 0.035 coils.

The left adrenal vein remained

preserved and patent.

QUESTION SLIDE
In the traditional method of BRTO, 5-10% ethanolamine oleate is utilized as the
sclerosant of choice. What is a well-known potential side eect described in the
literature in utilizing this agent and its treatment/prevention?
A. Bleeding; supportive measures including blood transfusion
B. Hemolysis and acute renal failure: intravenous haptoglobin administration and
IV hydration
C. Mental status changes: immediate lactulose administration
D. Alcohol poisoning: aggressive IV resuscitation

CLINICAL FOLLOW UP
Post-embolization, no additional episodes of hematemesis were noted and the
patient was discharged on POD#1
The patient was seen in IR clinic in 2 weeks for follow-up and evaluation for
transvenous intrahepatic portosystemic shunt (TIPS) placement

SUMMARY & TEACHING POINTS

Classically, when endoscopic management of gastric variceal bleeding fails, TIPS
has been performed to decompress the portal system
BRTO, however, oers a minimally invasive option for the treatment of gastric
variceal bleeding as it is:
Minimally invasive
Performed in patients with poor hepatic reserve
Lower rebleeding rates than TIPS

Management of gastric varices requires a multidisciplinary approach

The interventional radiologist plays a key role in identifying and selecting patients
who would benet from BRTO

REFERENCES & FURTHER READING

Kiyosue H, Mori H, Shunro M, Yamada Y, Hori Y, Okino Y. Transcatheter
obliteration of gastric varices. Radiographics. 2003 Jul-Aug; 23(4): 911-20.
Saad, W. Balloon-occluded retrograde transvenous obliteration of gastric varices:
concept, basic techniques and outcomes. Semin Intervent Radiol. Jun 2012; 29(2):
118-128.
Darcy M, Saad W. Transjugular intrahepatic portosystemic shunt (TIPS) versus
balloon-occluded retrograde transvenous obliteration (BRTO) for the
management of gastric varices. Semin Intervent Radiol. Sept 2011; 28(3): 339-349.