Balloon occluded retrograde Transvenous obliteration for gastric varices (BRTO)

Balloon-occluded retrograde transvenous obliteration (BRTO) is a minimally invasive procedure used to treat gastric varices, particularly those at high risk of bleeding. 

Indications for BRTO

1. Gastric Varices: Patients with gastric varices, especially those with a history of variceal bleeding or at risk of bleeding.(Click here to read more on Gastric Variceal Bleeding)
2. Failed Medical Management: When conservative treatments (such as medication or endoscopic therapy) are ineffective or not suitable.
3. Unsuitable for Surgery: Patients who are not surgical candidates due to medical comorbidities or other factors.

Pre-procedure Preparation

1. Patient Assessment:
   • Comprehensive evaluation of the patient’s medical history, symptoms, severity of gastric varices, and coagulation status.
   • Imaging studies (such as CT angiography, MRI, or endoscopic ultrasound) to assess the anatomy, location, and extent of the varices.
2. Informed Consent:
   • Explanation of the BRTO procedure, its purpose, potential risks (such as bleeding, embolization-related complications, or catheter-related issues), benefits, and alternatives. Informed consent is obtained.

Procedure Steps

1. Access and Catheterization:
   • The procedure is typically performed under local anesthesia and conscious sedation.
   • A catheter is inserted into a vein in the groin area (femoral vein) and guided under fluoroscopic or ultrasound guidance to access the target veins supplying the gastric varices.
2. Venography and Balloon Occlusion:
   • Contrast dye is injected through the catheter to visualise the gastric varices and identify the feeding veins.
   • A balloon catheter is advanced through the catheter and positioned within the target vein, proximal to the varices, to occlude blood flow temporarily.
3. Ethanol Injection and Sclerotherapy:
   • A sclerosing agent, typically ethanol mixed with a contrast medium, is injected through the catheter into the varices while the balloon remains inflated.
   • The sclerosing agent induces thrombosis (clotting) within the varices, leading to their obliteration.
4. Post-procedure Embolization:
   • Additional embolic agents, such as coils or glue, may be deployed into the varices or feeding veins to enhance occlusion and prevent re-bleeding.
   • The catheter and balloon are then removed, and pressure is applied to the groin puncture site to achieve hemostasis.

Benefits of BRTO

• Effective Variceal Obliteration: Induces thrombosis and sclerosis of the varices, reducing the risk of bleeding and recurrent variceal haemorrhage.
• Minimally Invasive: Compared to surgical interventions, BRTO is minimally invasive, with lower risks, shorter recovery times, and fewer complications.
• Preservation of Portal Hemodynamics: Targets the varices while preserving portal venous flow and hepatic function.
• Suitable for High-Risk Patients: Provides a treatment option for patients who are not surgical candidates or have contraindications to other therapies.

Risks and Considerations

• Embolization-related Complications: Potential risks include embolization to unintended vessels, thrombosis in non-target areas, or migration of embolic agents.
• Bleeding: In rare cases, BRTO may result in bleeding complications requiring additional interventions or transfusions.
• Post-procedure Syndrome: Some patients may experience mild to moderate post-procedure symptoms such as fever, abdominal pain, or nausea, which typically resolve with conservative management.

Follow-up and Post-procedure Care

1. Monitoring:
   • Close monitoring of the patient’s vital signs, abdominal symptoms, and laboratory parameters (such as liver function tests, coagulation profile) post-procedure.
   • Observation for any signs of bleeding, infection, or embolization-related complications.
2. Nutritional Support:
   • Nutritional assessment and support, as needed, to optimise the patient’s nutritional status and liver function post-procedure.
3. Follow-up Imaging:
   • Follow-up imaging studies (such as CT or ultrasound) may be scheduled to assess the status of variceal obliteration and monitor for any recanalization or new varices.
4. Medication:
   • Patients may be prescribed medications (such as proton pump inhibitors or anticoagulants) based on their individual needs and risk factors.

BRTO is an effective and minimally invasive option for treating gastric varices and reducing the risk of variceal haemorrhage. Close collaboration between interventional radiologists, gastroenterologists, and hepatologists is essential for safe and successful BRTO procedures and post-procedure care.