plug assisted retrograde transvenous obliteration

RTOs are an endovascular alternative to TIPS for treatment of gastric varices. Retrograde transvenous obliteration (RTO) refers collectively to balloon-occluded retrograde transvenous obliteration (BRTO), plug-assisted retrograde transvenous obliteration (PARTO), and coil-assisted retrograde transvenous obliteration (CARTO). However, patients with severe hepatic dysfunction and high model for end-stage liver disease (MELD) scores may not tolerate TIPS, and risk worsening hepatic dysfunction and encephalopathy, as blood flow is diverted away from the liver.Īdditionally, gastric varices occur at lower portosystemic gradients than esophageal varices hence, further reduction of portal pressures may not result in resolution of hemorrhage. Typical endovascular treatment in the United States for variceal hemorrhage is transjugular intrahepatic portosystemic shunt (TIPS) creation with concomitant variceal embolization, which is 90% effective in controlling acute gastric variceal hemorrhage. Current practice guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) and the American Association for the Study of Liver Disease (AASLD) suggest initial endoscopic management, followed by endovascular treatment, for refractory cases. In the setting of gastric variceal hemorrhage, treatment considerations require a multidisciplinary approach, and include both endoscopic and endovascular therapies. When compared with bleeding from esophageal varices, gastric varices have a worse prognosis, with mortality rates as high as 45 to 55%, and are associated with more severe blood loss, along with higher rates of rebleeding. Gastric variceal bleeding is a major complication of portal hypertension, occurring in approximately 25% of patients with gastric varices a year.

Physicians should claim only the credit commensurate with the extent of their participation in the activity. Tufts University School of Medicine designates this journal-based CME activity for a maximum of TUSM is accredited by the ACCME to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Tufts University School of Medicine (TUSM) and Thieme Medical Publishers, New York. Upon completion of this article, the reader will be able to discuss the various techniques of retrograde transvenous obliteration for gastric varices and hepatic encephalopathy, their indications and limitations, choice of sclerosant, and current evidence supporting their use.

Plug assisted retrograde transvenous obliteration