Chapter 31: Clinical Outcomes of Balloon-Occluded Retrograde Transvenous Obliteration and Balloon-Occluded Antegrade Transvenous Obliteration

Gastric variceal bleeding is a major complication of portal hypertension (PHT). Although less common than bleeding associated with esophageal varices, gastric variceal bleeding is associated with a higher mortality rate1,2 and less effective endoscopic treatment options. Despite decades of varying endoscopic, percutaneous, and surgical treatment strategies, the literature is relatively less established, and treatment consequently is more empiric.³ From an interventional radiology perspective, transjugular intrahepatic portosystemic shunts (TIPS) to decompress the portal circulation and balloon-occluded retrograde transvenous obliteration (BRTO) are both used to address bleeding gastric varices.^4–6 The primary indications for BRTO are gastric variceal bleeding and hepatic encephalopathy refractory to medical management in the presence of gastrorenal shunt.^4,7–37 The bleeding control rate of gastric varices after BRTO is reported as high as 91% to 100%,^7,8 and gastric varices occluded by BRTO have recurrence rates of 0 to 10%.^38–44 Because BRTO diverts blood into the portal circulation and potentially into the liver, there is a favorable significant reduction in encephalopathy in most, if not all, patients treated with BRTO. Although transient and long-term preservation of hepatic function⁴⁵ can occur after BRTO, the obliteration of a low-pressure portal diversion pathway can lead to changes in portal hemodynamics that aggravate PHT and result in bleeding from esophageal varices. The 1-, 2-, and 3-year esophageal variceal bleeding rates after BRTO are 27% to 35%, 45% to 66%, and 45% to 91%, respectively.⁴⁵

The classic BRTO procedure is performed from a femoral or jugular venous access site with cannulation of the gastrorenal shunt through the left renal vein. Occlusion of the shunt using balloon-occlusion catheters is followed by placement of a coaxial microcatheter for retrograde injection of a sclerosing agent. The balloon is deflated and removed after confirmation of shunt thrombosis after a dwell period. A detailed description of the BRTO procedure is described in Chapter 29 of this book.

Candidates for the BRTO Procedure

Spontaneous gastrorenal shunts develop in up to 85% of patients with gastric varices.^4,46,47 These patients with shunts that can be occluded by available balloon occlusion catheters are candidates for the classic BRTO procedure.⁴⁸ Despite having treatable shunts, patients with a large (>5 cm) hepatocellular carcinoma (HCC) or large-volume intractable ascites are not candidates for BRTO.¹³ HCC itself significantly reduces survival in patients undergoing BRTO.

Technical Success

Using patient selection criteria discussed and when performed as described earlier, technical success for BRTO ranges from 79% to 100%.^{4,7,9–13,19–23,29,30,31,34,35,46,48} This success does not rely on additional adjunctive obliterative procedures such as balloon-occluded antegrade transvenous obliteration (BATO) and endoscopic sclerotherapy.

Technical success (defined as sclerosant completely filling the gastric varices and gastrorenal shunt) can also be achieved in patients with incomplete variceal obliteration using staged procedures with treatment goals completed over additional sessions. This alternate approach can be used to limit the volume of sclerosant per session. Dose-related hemolysis and hemoglobinuria-induced renal dysfunction can occur with ethanolamine oleate (EO) and sodium tetradecyl sulfate (STS) sclerosant agents.⁴⁹

Five centers studying 210 patients undergoing staged or sequential BRTO have reported progressive and complete obliteration of the gastric varices.^{5,13,31,33,48} Cumulatively, these studies show technical success in 71% after one treatment, 88% after the second, and 91% after three treatment sessions.

BATO as an adjunct or rescue technique along with the classic BRTO is a useful modification for control of gastric varices to increase technical success. BATO alone is successful in 44% to 100% of cases.^32,50 Approaching the varices from the portal venous side is most easily achieved through an existing TIPS. Transhepatic and transiliocolic routes are also used. BATO in conjunction with BRTO can reduce sclerosant overspill from the gastric varices into the portal vein (PV). Despite a relatively straightforward procedure, technical failure may occur for a variety of reasons. We have previously classified these technical factors into categories I to IV shown in Table 31.1.⁴⁵

The actual incidence of each of these type I to IV technical failures is difficult to determine from analyzing the existing literature as scant details of technical failures are reported in most of the large-scale reviews and studies.¹² Three studies evaluated 14 technical failures in 160 BRTO procedures. The studies reported type I failures in 2 of the 14; type II failures accounted for 5 of the 14 failures. Type III failures were to blame for 6 of the 14 technical failures. Type IV failure occurred in 1 of 14.^10,11,19 Type I and II technical failures are often related to operator inexperience and lack of appropriate catheters and occlusion balloons. A retrospective study on 41 BRTO procedures using a variety of occlusion balloon catheters available in the United States showed that a balloon occlusion catheter greater than 20 mm is rarely required. In that study, 75% of the gastrorenal shunts could be occluded using 13-mm balloons, but 30% could be occluded using 10-mm size balloons. Balloon catheters between 14 and 20 mm were necessary in 25%. In Asia, vascular sheaths, diagnostic catheters, and occlusion balloons are designed for BRTO. These specifically designed catheters can facilitate cannulation and occlusion of the shunts.^7,38,46

Type IV technical complications involve rupture of the balloon occlusion catheter early in the procedure. This early rupture requires instillation of added sclerosant through another occlusion balloon catheter. The reported incidence of type IV failure in the literature from Japan ranges from 2.8% to 8.7% of BRTO procedures.^30,51 BRTO in Japan uses EO as the sclerosant. EO is not available in the United States; therefore, 3% STS is used as the sclerosant. Typically, in the United States, a mixture of Lipiodol (Guerbet LLC, Bloomington, Indiana)–STS–air/CO₂ is used to created a fluoroscopically visible foam. A study by Saad et al⁵² specifically looked at the incidence of balloon rupture using STS as the sclerosing agent through balloon occlusion catheters available in the United States. In this retrospective study of 41 consecutive BRTO procedures on 40 patients, a balloon rupture rate of 15% was reported (double the 2.3%–8.7% incidence reported rates in the Japanese and Korean literature).⁵¹ The study concluded that dwell time (described as either greater than 6 hours or less than 6 hours) did not influence balloon rupture. Furthermore, the study revealed a trend for latex balloon occlusion catheters to be more prone to rupture during BRTO despite being inflated to industry specifications.

Table 31.1 Causes of Balloon-Occluded Retrograde Transvenous Obliteration Technical Failures

In the immediate post-BRTO period, transient fever, hematuria, and abdominal pain have been observed in a large percentage of patients.49 More serious procedure-related complications are rarely reported and include asymptomatic and symptomatic pulmonary embolus, anaphylactic reactions to EO, and pulmonary edema.

Portal vein thrombosis and renal vein thrombosis are also potential complications of BRTO. Interestingly, when postprocedural imaging (cone-beam computed tomography [CT] or fluoroscopy) demonstrates small overspill of sclerosant into the intrahepatic PVs this is usually without clinical consequence.¹² See Table 31.2 for procedure-related complications.

Follow-up endoscopic examinations reveal localized mucosal changes in the region of treated gastric varices in a majority of patients. A typical gastric ulceration pattern with or without associated bleeding has also been reported.³⁰ These endoscopically visible changes usually respond to short-term conservative therapy.

Postprocedure Imaging Evaluation

Imaging success is usually fluoroscopically apparent at the completion of the procedure; therefore, strict time frames for cross-sectional imaging or ultrasound follow-up are not strictly defined. Doppler ultrasonography can reliably evaluate PV and renal vein patency after the procedure.

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