Beruflich Dokumente
Kultur Dokumente
Patel et al.
Transvenous Obliteration of Gastric Varices
Balloon-Occluded Retrograde
FOCUS ON:
Transvenous Obliteration of
Gastric Varices
Amish Patel1 OBJECTIVE. The purpose of this review is to describe the clinical factors related to
Aaron M. Fischman1 balloon-occluded retrograde transvenous obliteration, including the preparation needed, the
Wael E. Saad2 technique and challenges, and the outcomes.
CONCLUSION. Although the procedure can be performed when transjugular intrahe-
Patel A, Fischman AM, Saad WE patic portosystemic shunt is contraindicated or when endoscopic management fails, balloon-
occluded retrograde transvenous obliteration is successful as a first-line or second-line thera-
py. Gastric variceal rebleeding rates are low and serious complications are rare. Randomized
controlled trials are required to evaluate the superiority of this procedure over other methods
of treating gastric varices and to determine which sclerosant should be used. In the near fu-
ture, this procedure may play a larger role in emergency care and in the management of non-
gastric varices.
the procedure, key features in patient eval- lines [31]. For this reason, indications to treat ized controlled trials comparing its efficacy
uation, the importance of preprocedure im- gastric varices with this technique are not well with that of other therapies, patients should be
aging, and the relevant anatomy of gastric established in the United States. Although it carefully evaluated to determine which ther-
varices. We also describe the technical fea- has been described for the management of ac- apy is best in the clinical situation. Although
tures of the procedure, including equipment, tively bleeding gastric varices [32] and for he- exact protocols differ between institutions,
choice of embolic agent, and technical chal- patic encephalopathy [17, 19], the procedure evaluation should include preprocedure lab-
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lenges and considerations. Finally, we review appears most useful for preventing gastric oratory studies (serum electrolytes, complete
the literature on outcomes and comparison variceal rebleeding after endoscopic ther- blood cell count, coagulation panel, and liver
with other therapies and propose future di- apy or when management with endoscopy and kidney function tests) and cross-sectional
rections for the procedure. fails [15, 21, 24, 33]. This is particularly true imaging (CT or MRI with coronal reformation
when patients are not good candidates for and acquisition) [1, 2]. Cross-sectional imag-
Pathophysiology of Portal TIPS (see later) [2]. Reasons for utilizing bal- ing is required to determine the candidacy of
Hypertension loon-occluded retrograde transvenous oblit- the patient for the procedure and the patency of
Venous blood draining from the stomach, eration over TIPS include coagulopathy, high the splenic and portal veins [1, 2] (Fig. 1). The
pancreas, spleen, and intestines enters the Model for End-stage Liver Disease (MELD) traditional balloon-occluded retrograde trans-
liver via the portal vein, which is formed by score, and hepatic encephalopathy [5, 7, 17– venous obliteration procedure requires a por-
the confluence of the splenic and mesenteric 19, 24, 33]. Several reports from Asia have tosystemic shunt, usually a gastrorenal shunt
veins. Intrahepatically, blood passes through described the use of the technique for both (Fig. 2). Preprocedure imaging should be ob-
the hepatic sinusoids and into the hepat- emergency treatment and as prophylaxis of tained immediately before balloon-occluded
ic veins and subsequently the inferior vena bleeding from high-risk gastric varices [14, transvenous obliteration so that the anatomy
cava. In liver disease such as cirrhosis, blood 17–19, 21, 24, 25], yet medical and endoscop- of the shunt can be delineated and an approach
flow through the hepatic sinusoids is limited, ic therapies predominate in the United States, formulated. Any clinically significant coagu-
and portal pressure increases. This increased where reports of endovascular obliteration are lation laboratory abnormality should be cor-
portal pressure, normally 2–5 mm Hg, de- few [13]. Although endoscopic therapy has re- rected before the procedure. In addition, the
fines portal hypertension, the complications sulted in good initial hemostasis, reported re- MELD score should be calculated for each pa-
of which typically develop at greater than bleeding rates are high, ranging from 34% to tient to identify patients whose liver-related
12 mm Hg [7, 13]. In addition to gastric and 53% [10, 13, 34, 35]. Furthermore, mortality mortality after TIPS would be high, perhaps
esophageal varices, the stigmata of portal from each episode of rebleeding is also high, making balloon-occluded transvenous obliter-
hypertension include transudative complica- approximately 20% [35]. ation more suitable [2, 30].
tions (ascites and hepatic hydrothorax) and
splenomegaly that can result in sequestration Patient Evaluation and Anatomy of Gastric Varices
and pancytopenia. Little is known about why Preprocedure Imaging Eighty-five percent of gastric varices have
gastric varices occur in some patients and Patients with cirrhosis and upper gastro- gastrorenal shunts, 10% have gastrocaval shunts,
esophageal varices in others [4]. The vari- intestinal bleeding should be in stable condi- and 5% have gastrocardiophrenic shunts [36].
ous causes of portal hypertension are classi- tion and undergo upper endoscopy for first- A minority of patients with gastric varices have
fied by location, as follows [7]: extrahepatic line diagnostic and therapeutic purposes [1]. a portosystemic communication along the
postsinusoidal (Budd–Chiari syndrome), in- Aggressive volume resuscitation should be left gastric azygohemiazygous axis [37, 38].
trahepatic postsinusoidal (hepatic venooc- avoided because variceal bleeding is pressure Although balloon-occluded retrograde trans-
clusive disease), sinusoidal (cirrhosis, cystic driven, and overzealous fluid resuscitation can venous obliteration of gastropericardiophrenic
liver disease, partial nodular transformation increase bleeding [1]. With the indications for shunts and gastroazygous shunts is more chal-
of the liver, metastatic malignant disease), balloon-occluded transvenous obliteration be- lenging than that of gastrorenal and gastroca-
intrahepatic presinusoidal (schistosomiasis, ing poorly defined in the absence of random- val shunts, success has been achieved, albeit in
sarcoidosis, congenital hepatic fibrosis, vi-
nyl chloride, drugs), and extrahepatic presi-
nusoidal (portal vein thrombosis, malignant
disease of pancreas, pancreatitis, congenital
extrahepatic portal vein occlusion). In a mi-
nority of cases in the United States (< 10%),
gastric varices occur with sentinel portal hy-
pertension (splenic vein thrombosis) and not
global portal hypertension [1, 2].
Fig. 1—47-year-old man
Indications with portal hypertension
Despite being widely used in Asia, balloon- and recent gastric
occluded retrograde transvenous obliteration bleeding. Contrast-
is uncommon in the United States and is not enhanced CT venogram
shows prominent gastric
mentioned in the American Association for varices (arrow) protruding
the Study of Liver Diseases practice guide- into gastric lumen.
embolization procedure.
oleate is hemolytic, and the resultant free hemo- oleate, STS (STS 1% and 3% Sotradecol,
globin can cause renal failure [47]. Therefore, AngioDynamics) is a detergent, and U.S. op-
patients are typically pretreated with 4000 erators are experienced with its use throughout
Fig. 4—47-year-old man with gastric varices. Coronal units of haptoglobin [19, 47]. In addition to the the body [5]. Sabri et al. [5] found that com-
reformatted image from CT venogram reveals lack of ready availability of haptoglobin in the pared with obliteration with ethanolamine ole-
angulation of left renal vein (arrow) in relation to
gastrorenal shunt. Acute angle suggests jugular United States, lack of experience with ethanol- ate, performing the procedure with STS re-
access is more appropriate for balloon-occluded amine oleate has made its use infrequent in the quired a smaller volume of sclerosant. They
retrograde transvenous obliteration procedure. United States [5]. Some authors [17, 48–50] suggested that the smaller volume of sclerosant
attempt to minimize the renal risk by using a can yield fewer systemic effects, and its prepa-
Choice of Sclerosant reserved approach and injecting less ethanol- ration as a foam can make it a more effective
Sclerosants are harsh chemical agents that amine oleate but accepting the probable need sclerosant [5, 29]. STS foam is typically pre-
act by denaturing biologic tissue. When in- for additional obliteration sessions. pared with the use of a three-way stopcock to
jected into a vein, they incite complete en- combine a 3:2:1 ratio of gas (air or carbon di-
dothelial destruction and fibrosis [44]. The Sodium Tetradecyl Sulfate oxide) to 3% STS to lipiodol (Ethiodol, Savage
balance is delicate between chemical toxic- Sodium tetradecyl sulfate (STS) is the pre- Laboratories). Other proportions of gas to STS
ity and clinical efficacy. Agents such as etha- dominant sclerosant agent used in the bal- to lipiodol (less gas and more STS, producing a
nolamine oleate (Ethamolin, QOL Medical) loon-occluded retrograde transvenous oblit- froth and not a foam) have been used success-
have been cited as being too prone to com- eration procedure in the United States (Saad fully in the United States [29].
plication and are rarely used in the United WE, unpublished data). Unlike ethanolamine
States [44]. Detergent sclerosants have saf- Polidocanol (Hydroxy Polyethoxydodecane)
er profiles. Most sclerosants (including eth- Also a detergent and used in foam form
anolamine oleate and detergent sclerosants) for varicose vein sclerotherapy [51], poli-
can be made into foam or froth by agitating docanol (0.5% polidocanol; 1% Asclera,
them with gas (carbon dioxide or air). This Merz Aesthetics) is widely used in the United
process increases the volume-to-sclerosant States [44] and has been studied as a sclerosant
ratio, markedly increasing potency and safe- for balloon-occluded retrograde transvenous
ty [9, 44]. Because balloon-occluded retro- obliteration [9]. Choi et al. found that relative-
grade transvenous obliteration is becoming ly small volumes of polidocanol were required
more popular outside Asia, use of detergent for this procedure, decreasing the risk of com-
sclerosants is being studied and has had good plication and avoiding the use of haptoglobin
preliminary results [5, 9]. to protect against renal failure. This complica-
tion was not observed in any of the 16 patients
Ethanolamine Oleate in the study. The technical success, oblitera-
Ethanolamine oleate is the predominant and tion, and rebleeding rates with polidocanol
traditional sclerosant agent used in the balloon- were similar to those with other sclerosants.
occluded retrograde transvenous obliteration Polidocanol is relatively new to the U.S. mar-
procedure, particularly in Asia [14–17, 19–21, ket and is not available in the United States in
24, 32, 42, 43, 45, 46]. Ten percent ethanol- the high concentrations it is elsewhere.
amine oleate is typically mixed with an equal
volume of contrast medium, typically iopami- Foam Versus Liquid Sclerosant
Fig. 6—51-year-old man with gastric varices.
dol, resulting in a 5% ethanolamine oleate– Fluoroscopic image shows sclerosant mixture inside The use of sclerosant in a foam or froth start-
iopamidol mixture. However, ethanolamine gastric varices. ed in 2005–2006 in both Japan (polidocanol)
oleate–iopamidol 35.5 mo
Choi et al. [9] 2011 Polidocanol 16 7 8 1 14 2 94 1h 91 Median 7 50
273 d
Sabri et al. [5] 2011 Sodium tetradecyl 22 22 91 4h 89a Mean 0 41
sulfate 130 d
aProcedure repeated multiple times.
on the portal system [5] but also tend to bleed as a first- or second-line therapy. Gastric vari- 12. Trudeau W, Prindiville T. Endoscopic injection
at lower pressures compared with esophageal ceal rebleeding rates are low, and serious com- sclerosis in bleeding gastric varices. Gastrointest
varices [10, 11]. In the series reported by Sabri plications are rare. Aggravation of esophageal Endosc 1986; 32:264–268
et al. [5], two patients underwent balloon-oc- varices and transudative complications may be 13. Jalan R, Hayes PC. UK guidelines on the manage-
cluded retrograde transvenous obliteration for an issue, but their exact clinical importance is ment of variceal haemorrhage in cirrhotic pa-
bleeding gastric varices despite having a func- unknown. Randomized controlled trials are re- tients. British Society of Gastroenterology. Gut
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tioning TIPS (Fig. 10). Saad and Darcy [30] quired to determine the superiority of balloon- 2000; 46(suppl 3-4):III1–III15
speculated on combining balloon-occluded occluded retrograde transvenous obliteration 14. Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida
retrograde transvenous obliteration and TIPS over other methods of treating gastric varices T, Okuda K. Treatment of gastric fundal varices by
for patients with baseline substantial ascites and to better define the role of the technique in balloon-occluded retrograde transvenous obliteration.
or hydrothorax or uncontrolled concomitant managing gastric varices. In the near future, J Gastroenterol Hepatol 1996; 11:51–58
esophageal varices who have reasonable he- this procedure may play an even larger role in 15. Arai H, Abe T, Shimoda R, Takagi H, Yamada T,
patic reserve (< 19 MELD). However, portal emergency treatment and in the management Mori M. Emergency balloon-occluded retrograde
venous modulators besides TIPS have been of nongastric varices. transvenous obliteration for gastric varices. J
proposed. Chikamori and coworkers [62] found Gastroenterol 2005; 40:964–971
that concomitant splenic artery embolization References 16. Cho SK, Shin SW, Lee IH, et al. Balloon-occluded
offset the increasing portal pressures after 1. Al-Osaimi AM, Caldwell SH. Medical and endoscop- retrograde transvenous obliteration of gastric
transvenous variceal obliteration as evidenced ic management of gastric varices. Semin Intervent varices: outcomes and complications in 49 pa-
by the reduced development and bleeding rate Radiol 2011; 28:273–282 tients. AJR 2007; 189:1523; [web]W365–W372
of esophageal varices. 2. Saad WE, Al-Osaimi AM. Pre- and post-BRTO 17. Fukuda T, Hirota S, Sugimura K. Long-term re-
imaging and clinical evaluation: indications, sults of balloon-occluded retrograde transvenous
Future Directions management protocols and follow-up. Tech Vasc obliteration for the treatment of gastric varices
Combining balloon-occluded retrograde Interv Radiol 2012 (in press) and hepatic encephalopathy. J Vasc Interv Radiol
transvenous obliteration with portal vein modu- 3. Sarin SK, Lahoti D, Saxena SP, Murthy NS, 2001; 12:327–336
lator procedures (TIPS or splenic artery emboli- Makwana UK. Prevalence, classification and nat- 18. Hiraga N, Aikata H, Takaki S, et al. The long-term
zation) may be required in selected patients [29, ural history of gastric varices: a long-term follow- outcome of patients with bleeding gastric varices
62]. Further research is required to determine up study in 568 portal hypertension patients. after balloon-occluded retrograde transvenous
the ideal selection criteria for a TIPS or a splenic Hepatology 1992; 16:1343–1349 obliteration. J Gastroenterol 2007; 42:663–672
artery embolization. Expansion of the balloon- 4. Ryan BM, Stockbrugger RW, Ryan JM. A patho- 19. Hirota S, Matsumoto S, Tomita M, Sako M, Kono
occluded retrograde transvenous obliteration physiologic, gastroenterologic, and radiologic ap- M. Retrograde transvenous obliteration of gastric
concept to include management of other vari- proach to the management of gastric varices. varices. Radiology 1999; 211:349–356
ces is a new trend [63–68]. A few case reports Gastroenterology 2004; 126:1175–1189 20. Hirota S, Kobayashi K, Maeda H, Yamamoto S,
and small series reports show additional appli- 5. Sabri SS, Swee W, Turba UC, et al. Bleeding gastric Nakao N. Balloon-occluded retrograde transve-
cations of the technique, including treatment of varices obliteration with balloon-occluded retrograde nous obliteration for portal hypertension. Radiat
small-bowel varices [63–65], parastomal vari- transvenous obliteration using sodium tetradecyl sul- Med 2006; 24:315–320
ces [67], and spontaneous mesenteric portosys- fate foam. J Vasc Interv Radiol 2011; 22:309–316 21. Kitamoto M, Imamura M, Kamada K, et al.
temic shunts [66, 68]. Management of gastric 6. Henderson JM, Nagle A, Curtas S, Geisinger M, Balloon-occluded retrograde transvenous obliter-
varices with balloon-occluded retrograde trans- Barnes D. Surgical shunts and TIPS for variceal decom- ation of gastric fundal varices with hemorrhage.
venous obliteration via unconventional venous pression in the 1990s. Surgery 2000; 128:540–547 AJR 2002; 178:1167–1174
routes is being practiced with greater frequency 7. Eesa M, Clark T. Transjugular intrahepatic porto- 22. Kiyosue H, Mori H, Matsumoto S, Yamada Y,
[37, 39, 40]. There also has been a report of a systemic shunt: state of the art. Semin Roentgenol Hori Y, Okino Y. Transcatheter obliteration of
technique that entails both endoscopic and per- 2011; 46:125–132 gastric varices. Part 1. Anatomic classification.
cutaneous approaches, known as balloon-oc- 8. Rösch J, Hanafee WN, Snow H. Transjugular portal RadioGraphics 2003; 23:911–920
cluded endoscopic injection sclerotherapy [25]. venography and radiologic portacaval shunt: an ex- 23. Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori
Although this method can control gastric vari- perimental study. Radiology 1969; 92:1112–1114 Y, Okino Y. Transcatheter obliteration of gastric vari-
ces without the large draining veins needed for 9. Choi SY, Won JY, Kim KA, Lee do Y, Lee KH. ces: Part 2. Strategy and techniques based on hemo-
balloon-occluded retrograde transvenous oblit- Foam sclerotherapy using polidocanol for bal- dynamic features. RadioGraphics 2003; 23:921–937
eration, it requires percutaneous transhepatic loon-occluded retrograde transvenous oblitera- 24. Ninoi T, Nishida N, Kaminou T, et al. Balloon-
portography to gain access to the varices. tion (BRTO). Eur Radiol 2011; 21:122–129 occluded retrograde transvenous obliteration of
10. Tripathi D, Therapondos G, Jackson E, Redhead gastric varices with gastrorenal shunt: long-term
Conclusions DN, Hayes PC. The role of the transjugular intrahe- follow-up in 78 patients. AJR 2005; 184:1340–1346
Balloon-occluded retrograde transvenous patic portosystemic stent shunt (TIPSS) in the man- 25. Shiba M, Higuchi K, Nakamura K, et al. Efficacy
obliteration is a well-established, minimally agement of bleeding gastric varices: clinical and and safety of balloon-occluded endoscopic injec-
invasive technique popular in Asia for treating haemodynamic correlations. Gut 2002; 51:270–274 tion sclerotherapy as a prophylactic treatment for
gastric varices by an endovascular approach. 11. Watanabe K, Kimura K, Matsutani S, Ohto M, high-risk gastric fundal varices: a prospective, ran-
However, it is gaining popularity in the United Okuda K. Portal hemodynamics in patients with domized, comparative clinical trial. Gastrointest
States. Although the procedure can be per- gastric varices: a study in 230 patients with esoph- Endosc 2002; 56:522–528
formed when TIPS is contraindicated or when ageal and/or gastric varices using portal vein cathe- 26. Sonomura T, Sahara S, Ono W, et al. Usefulness of
endoscopic management fails, it is successful terization. Gastroenterology 1988; 95:434–440 microcatheters inserted overnight for additional
injection of sclerosant after initial balloon-occlud- obliteration (BRTO): technical results and out- 55. Arai H, Abe T, Takayama H, et al. Respiratory effects
ed retrograde transvenous obliteration of gastric comes. Semin Intervent Radiol 2011; 28:333–338 of balloon occluded retrograde transvenous oblitera-
varices. Case Rep Gastroenterol 2011; 5:534–539 42. Sonomura T, Sato M, Kishi K, et al. Balloon- tion of gastric varices: a prospective controlled study.
27. Sugimori K, Morimoto M, Shirato K, et al. Retrograde occluded retrograde transvenous obliteration for J Gastroenterol Hepatol 2011; 26:1389–1394
transvenous obliteration of gastric varices associated gastric varices: a feasibility study. Cardiovasc 56. Park SJ, Chung JW, Kim HC, Jae HJ, Park JH.
with large collateral veins or a large gastrorenal shunt. Intervent Radiol 1998; 21:27–30 The prevalence, risk factors, and clinical outcome
Downloaded from www.ajronline.org by 24.207.248.166 on 09/26/17 from IP address 24.207.248.166. Copyright ARRS. For personal use only; all rights reserved
J Vasc Interv Radiol 2005; 16:113–118 43. Akahoshi T, Hashizume M, Tomikawa M, et al. of balloon rupture in balloon-occluded retrograde
28. Olson E, Yune HY, Klatte EC. Transrenal-vein Long-term results of balloon-occluded retrograde transvenous obliteration of gastric varices. J Vasc
reflux ethanol sclerosis of gastroesophageal vari- transvenous obliteration for gastric variceal bleed- Interv Radiol 2010; 21:503–507
ces. AJR 1984; 143:627–628 ing and risky gastric varices: a 10-year experience. 57. Ceulen RP, Sommer A, Vernooy K. Microembolism
29. Saad WE. The history and evolution of balloon- J Gastroenterol Hepatol 2008; 23:1702–1709 during foam sclerotherapy of varicose veins. N
occluded retrograde transvenous obliteration 44. Duffy DM. Sclerosants: a comparative review. Engl J Med 2008; 358:1525–1526
(BRTO): from the United States to Japan and Dermatol Surg 2010; 36(suppl 2):1010–1025 58. Forlee MV, Grouden M, Moore DJ, Shanik G.
back. Semin Intervent Radiol 2011; 28:283–287 45. Akahoshi T, Tomikawa M, Kamori M, et al. Impact Stroke after varicose vein foam injection sclero-
30. Saad WE, Darcy MD. Transjugular intrahepatic of balloon-occluded retrograde transvenous oblit- therapy. J Vasc Surg 2006; 43:162–164
portosystemic shunt (TIPS) versus balloon-oc- eration on management of isolated fundal gastric 59. Morrison N, Neuhardt DL, Rogers CR, et al.
cluded retrograde transvenous obliteration variceal bleeding. Hepatol Res 2012; 42:385–393 Comparisons of side effects using air and carbon
(BRTO) for the management of gastric varices. 46. Takuma Y, Nouso K, Makino Y, Saito S, Shiratori dioxide foam for endovenous chemical ablation. J
Semin Intervent Radiol 2011; 28:339–349 Y. Prophylactic balloon-occluded retrograde trans- Vasc Surg 2008; 47:830–836
31. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. venous obliteration for gastric varices in compen- 60. Peterson JD, Goldman MP. An investigation into
Prevention and management of gastroesophageal sated cirrhosis. Clin Gastroenterol Hepatol 2005; the influence of various gases and concentrations
varices and variceal hemorrhage in cirrhosis. 3:1245–1252 of sclerosants on foam stability. Dermatol Surg
Hepatology 2007; 46:922–938 47. Hashizume M, Kitano S, Yamaga H, Sugimachi 2011; 37:12–17
32. Hong CH, Kim HJ, Park JH, et al. Treatment of K. Haptoglobin to protect against renal damage 61. Azoulay D, Castaing D, Majno P, et al. Salvage
patients with gastric variceal hemorrhage: endo- from ethanolamine oleate sclerosant. Lancet transjugular intrahepatic portosystemic shunt for un-
scopic N-butyl-2-cyanoacrylate injection versus 1988; 2:340–341 controlled variceal bleeding in patients with decom-
balloon-occluded retrograde transvenous obliter- 48. Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. pensated cirrhosis. J Hepatol 2001; 35:590–597
ation. J Gastroenterol Hepatol 2009; 24:372–378 Eight years of experience with transjugular retro- 62. Chikamori F, Kuniyoshi N, Kawashima T, Takase
33. Ferral H. Balloon-occluded retrograde transvenous grade obliteration for gastric varices with gastro- Y. Gastric varices with gastrorenal shunt: combined
occlusion. Tech Vasc Interv Radiol 2008; 11:225–229 renal shunts. Surgery 2001; 129:414–420 therapy using transjugular retrograde obliteration and
34. Khan S, Tudur Smith C, Williamson P, Sutton R. 49. Arai H, Abe T, Takagi H, Mori M. Efficacy of partial splenic embolization. AJR 2008; 191:555–559
Portosystemic shunts versus endoscopic therapy balloon-occluded retrograde transvenous obliter- 63. Tsurusaki M, Sugimoto K, Matsumoto S, et al.
for variceal rebleeding in patients with cirrhosis. ation, percutaneous transhepatic obliteration and Bleeding duodenal varices successfully treated with
Cochrane Database Syst Rev 2006; CD000553 combined techniques for the management of gas- balloon-occluded retrograde transvenous obliteration
35. Bosch J, Garcia-Pagan JC. Prevention of variceal tric fundal varices. World J Gastroenterol 2006; (B-RTO) assisted by CT during arterial portography.
rebleeding. Lancet 2003; 361:952–954 12:3866–3873 Cardiovasc Intervent Radiol 2006; 29:1148–1151
36. Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. 50. Choi YH, Yoon CJ, Park JH, Chung JW, Kwon JW, 64. Zamora CA, Sugimoto K, Tsurusaki M, et al.
Correlation between endoscopic and angiograph- Choi GM. Balloon-occluded retrograde transvenous Endovascular obliteration of bleeding duodenal
ic findings in patients with esophageal and isolat- obliteration for gastric variceal bleeding: its feasibil- varices in patients with liver cirrhosis. Eur Radiol
ed gastric varices. Dig Surg 2001; 18:176–181 ity compared with transjugular intrahepatic portosys- 2006; 16:73–79
37. Araki T, Hori M, Motosugi U, et al. Can balloon- temic shunt. Korean J Radiol 2003; 4:109–116 65. Hashimoto N, Akahoshi T, Yoshida D, et al. The
occluded retrograde transvenous obliteration be 51. Ouvry P, Allaert FA, Desnos P, Hamel-Desnos C. efficacy of balloon-occluded retrograde transve-
performed for gastric varices without gastrorenal Efficacy of polidocanol foam versus liquid in sclero- nous obliteration on small intestinal variceal
shunts? J Vasc Interv Radiol 2010; 21:663–670 therapy of the great saphenous vein: a multicentre bleeding. Surgery 2010; 148:145–150
38. Saad WE, Sze DH. Variations of balloon-occluded randomised controlled trial with a 2-year follow-up. 66. Hayashi S, Baba Y, Senokuchi T, Ueno K, Nakajo
transvenous obliteration (BRTO): balloon-occlud- Eur J Vasc Endovasc Surg 2008; 36:366–370 M. Successful portal-systemic shunt occlusion of a
ed antegrade transvenous obliteration (BATO) and 52. Fukuda T, Hirota S, Sugimoto K, Matsumoto S, direct shunt between the inferior mesenteric vein and
alternative/adjunctive routes for BRTO. Semin Zamora CA, Sugimura K. “Downgrading” of gas- inferior vena cava with balloon-occluded retrograde
Intervent Radiol 2011; 28:314–324 tric varices with multiple collateral veins in bal- transvenous obliteration following recanalization af-
39. Kageyama K, Nishida N, Matsui H, Yamamoto A, loon-occluded retrograde transvenous oblitera- ter placing a covered stent in the portal and superior
Nakamura K, Miki Y. Successful balloon-occluded tion. J Vasc Interv Radiol 2005; 16:1379–1383 mesenteric veins. Jpn J Radiol 2009; 27:180–184
retrograde transvenous obliteration for gastric varix 53. Tanoue S, Kiyosue H, Matsumoto S, et al. 67. Minami S, Okada K, Matsuo M, Kamohara Y,
mainly draining into the pericardiophrenic vein. Development of a new coaxial balloon catheter Sakamoto I, Kanematsu T. Treatment of bleeding
Cardiovasc Intervent Radiol 2012; 35:180–183 system for balloon-occluded retrograde transve- stomal varices by balloon-occluded retrograde trans-
40. Minamiguchi H, Kawai N, Sato M, et al. Balloon- nous obliteration (B-RTO). Cardiovasc Intervent venous obliteration. J Gastroenterol 2007; 42:91–95
occluded retrograde transvenous obliteration for Radiol 2006; 29:991–996 68. Minamiguchi H, Kawai N, Sato M, et al. Balloon
gastric varices via the intercostal vein. World J 54. Sabri SS, Turba UC, Saad WE, Park AW, Angle JF. occlusion retrograde transvenous obliteration for
Radiol 2012; 28:121–125 Balloon-occluded retrograde transvenous obliteration inferior mesenteric vein-systemic shunt. J Vasc
41. Saad WE, Sabri SS. Balloon-occluded transvenous of gastric varices. Endovasc Today 2010; April:1–5 Interv Radiol 2011; 22:1039–1044