Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Technical Results and Outcomes

Variceal bleeding is one of the major complications of portal hypertension. Gastric variceal (GV) bleeding is less common than esophageal variceal (EV) bleeding, however, is associated with a high morbidity and mortality. Balloon-occluded retrograde transvenous obliteration (BRTO) is an established procedure for the management of gastric varices in Japan and has shown promising results in the past decade. The technical success rate, intent-to-treat (including technically failed BRTO-procedures) obliteration rate, and the obliteration rate of gastric varices of technically successful BRTO procedures was 91% (79-100%), 86% (73-100%), and 94% (75-100), respectively. BRTO is successful in controlling active gastric variceal bleeding in 95% of cases (91-100%) and in significantly reducing or resolving encephalopathy in 100% of cases. However, BRTO diverts blood into the portal circulation and increases the portal hypertension, thus aggravating esophageal varices with their potential for bleeding. The 1-, 2-, and 3-year esophageal variceal aggravation rates are 27-35%, 45-66%, and 45-91%, respectively. The gastric variceal rebleed rate of successful BRTO procedures, the intent-to-treat gastric variceal rebleed rate, and the global (all types of varices) variceal rebleed rate are 3.2-8.7%, 10-20%, and 19-31%, respectively. However, the advantage of diverting blood into the portal circulation and potentially toward the liver is improved hepatic function and possible patient survival. Unfortunately, the improved hepatic function is transient (for 6-12 months); however, it is preserved in the long-term (1-3 years). Patient 1-, 2-, 3-, and 5-year survival rates are 83-98%, 76-79%, 66-85%, and 39-69%, respectively. Patient survival is determined by baseline hepatic reserve and the presence of hepatocellular carcinoma.