title: Pre- and post-balloon-occluded retrograde transvenous obliteration clinical evaluation, management, and imaging: indications, management protocols, and follow-up.
abstract: Patients with gastric variceal bleeding require a multidisciplinary team approach, which includes hepatologists, endoscopists, diagnostic radiologists, and interventional radiologists. Upper gastrointestinal endoscopy is the first-line diagnosis and management tool for bleeding gastric varices (GVs) as it is with all upper gastrointestinal bleeding scenarios. Traditionally, in the United States, when endoscopy fails to control gastric variceal bleeding, a transjugular intrahepatic portosystemic shunt (TIPS) is performed along the classic teachings of decompressing the portal circulation. However, TIPS has shown inconsistent effectiveness in controlling gastric variceal bleeding. Conversely, the balloon-occluded retrograde transvenous obliteration (BRTO) procedure has become common practice in Asia for the management of GVs. The BRTO procedure is gaining popularity in the United States. BRTO has shown to be effective in controlling gastric variceal bleeding with low gastric variceal rebleed rates. Regardless of the endovascular management (TIPS vs BRTO vs both), a multidisciplinary team with adequate preprocedural clinical assessment and management and endoscopic and imaging evaluation is required before and after the endovascular procedure. The article discusses the pre- and post-BRTO clinical evaluation and management, as well as endoscopic and imaging evaluation. Moreover, the article proposes indications, contraindications, and management protocols for the management of GVs.
authors.affiliation: Division of Vascular Interventional Radiology, Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA. wspikes@yahoo.com
authors.forename: Wael E A
authors.initials: WE
authors.lastname: Saad
authors.forename: Abdullah M S
authors.initials: AM
authors.lastname: Al-Osaimi
authors.forename: Stephen H
authors.initials: SH
authors.lastname: Caldwell
mesh_terms: D015901:Angiography, Digital Subtraction; D021721:Balloon Occlusion / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods; D003299:Cooperative Behavior; D019299:Decompression, Surgical / Q000379:methods; D003952:Diagnostic Imaging / Q000379:methods; D016099:Endoscopy, Gastrointestinal; D004932:Esophageal and Gastric Varices / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D016558:Hemostasis, Endoscopic; D006801:Humans; D006975:Hypertension, Portal / Q000150:complications*; D033183:Interdisciplinary Communication; D010348:Patient Care Team; D019168:Portasystemic Shunt, Transjugular Intrahepatic; D011237:Predictive Value of Tests; D015641:Radiography, Interventional; D012008:Recurrence; D016896:Treatment Outcome