P1008 - Accelerated Balloon-Retrograde Transvenous Obliteration (BRTO): An Effective Bow & Arrow in the Arsenal Against Isolated Gastric Varices (IGV)

Award: ACG Case Reports Journal Award
Award: Presidential Poster Award

Award: ACG Case Reports Journal Award

Award: Presidential Poster Award

Smit S. Deliwala, MD¹, Murtaza S. Hussain, MD¹, Anoosha Ponnapalli, MD¹, Samuel Igbinedion, MD², Mamoon Elbedawi, MD, FACG¹, Anish Bansal, MD³, Saurabh Chawla, MD, FACG^4
1Michigan State University at Hurley Medical Center, Flint, MI; ²LSU HSC Shreveport, Shreveport, LA; ³Hurley Medical Center, Flint, MI; ⁴Emory University School of Medicine, Atlanta, GA

Introduction: AASLD previously recommended TIPS as an effective first-line modality for acute isolated gastric varices (IGV). However, studies have suggested that the net benefit is seen in a subset of patients with small shunts or an IGV fed by gastric veins. A recent randomized trial and meta-analyses comparing BRTO to endoscopy and TIPS found effective and safer outcomes at 1-year - prevention, re-bleeding, and post-procedure hepatic encephalopathy, suggesting that BRTO should be considered the first-line treatment. BRTO does have its limitations that have hindered its scalabilities, such as equipment compatibility, prolonged length of stay, and balloon complications. We present a successfully treated IGV with a technical modification to the traditional procedure known as accelerated BRTO.

Case Description/Methods: A 59 yo female presented to our ED with hematemesis and melenic stools for 4 days with a history of cirrhosis from chronic hepatitis C, chronic thrombocytopenia, GERD, and hypertension on propranolol and ranitidine. Her MELD-Na score was 9 with a hemoglobin of 9.2 g/dL, platelets 65 k/uL, and renal failure. Intravenous hydration, esomeprazole, and octreotide infusions were initiated with ceftriaxone with blood transfusion. An EGD revealed two large gastric fundal varices[Figure 1 - Pane A]. A CT of the abdomen revealed cirrhosis and isolated gastric varices (IGV type 1) [Pane B]. BRTO was performed. She was discharged home. In 2 weeks, repeat EGD confirmed no blood or EV with shrinkage in the size of IGV[Pane C]. Repeat MELD-Na score was 7, and tissue examination was negative for H pylori. At her 4-month follow-up, she denied any bleeding episodes, and her CT angiography confirmed complete IGV obliteration [Pane D].

Discussion: BRTO achieves success in 75 to 100% of cases with a low re-bleeding rate and a superior 5-year survival. Band ligation is not recommended as failure to capture the affected segments can lead to blood loss. A significant limitation of the existing literature is small sample sizes, heterogeneity in baseline liver function, and selection biases. Accelerated BRTO demonstrated similar efficacy to traditional BRTO with reduced peri-procedural morbidity, streamlined logistics, and reduced time in the recovery area using coils[Table 1]. This technique can be performed in most community hospitals. Limitations include patients with large ascites or esophageal varices. Future studies are needed to explore the efficacy of accelerated BRTO against other IR or endoscopic interventions.


Figure: Figure 1: Pane A - Esophagogastroduodenoscopy (EGD) revealing gastric varices (GV). Pane B - Computed Tomography (CT) of the Abdomen demonstrating the prominent gastric varices (GV). Pane C - Follow-up Esophagogastroduodenoscopy (EGD) 2 weeks after BRTO demonstrating reduced gastric varices filled with sclerosant (arrowhead). Pane D - Follow-up Computed tomography (CT) of the Abdomen 4 months after BRO revealing complete obliteration of the gastric variceal complex (arrowhead).

Author	Country	Indication (Prophylaxis, acute management or rebleeding)	Substance used	Afferent	Efferent	Approach – Jugular (IJ), subclavian, saphenous or Femoral	Baseline MELD-Na/Child-Pugh-Hugh	Shunt	Outcomes (short term, long term and mortality)
Ibukuro 1999	Japan	Acute management	10% ethanolamine oleate and contrast	Left phrenic nerve	Left pericardiophrenic vein	Femoral	N/A	Left inferior phrenic vein joining left hepatic vein	Disappearance of varix at 2-month follow-up endoscopy
Matsumoto 2001	Japan	Acute management	Ethanolamine oleate and iopamidol	Short gastric vein	Posterior gastric veins	Right IJ	Pugh-Child class B	Gastrorenal	No varices on endoscopy 2 months, no recurrence or portal HTN 6 months
Nishida 2004	Japan	Prophylaxis	10% ethanolamine oleate and contrast (370 mg of iodine iopamidol)	Left adrenal vein/ Left Inferior Phrenic Vein	Pericardiophrenic Vein	Femoral	Pugh-Child class B	N/A	No varices on endoscopy 2 weeks, gastric varix reduction 2 months
Fukuda 2004 Pt 1	Japan	Rebleeding	5% ethanolamine oleate and iopamidol	Left adrenal vein	Left inferior phrenic vein	Femoral	Pugh-Child class C	Gastrorenal	No adverse effects in outpatient clinic 6 months
Fukuda 2004 Pt 2	Japan	Acute management	5% EOI	Left inferior phrenic vein	Pericardiophrenic and intercostal vein	Femoral	Pugh-Child class C		Complete thrombosis and decreased ascites 4 days after 2nd procedure
Izumiya 2004	Japan	Acute management	EOI	Short gastric vein	Gastrorenal shunt	Right IJ	N/A	Gastrorenal	No blood shown in varix 1 week, decrease size 1 month, no recurrence 1 year
Nishida 2006	Japan	Prophylaxis	10% EOI	Short gastric vein	Left gastric vein	Femoral	Pugh-Child class B	Gastrorenal	No blood flow in varix 1 week, reduction 3 moths
Nakai 2006	Japan	Acute management	5% EOI	Proper hepatic artery	Left inferior phrenic vein	Right IJ	N/A	Gastrorenal	BRTO remained 24 hrs, BP anemia and hepatic function stable
Matsumoto 2007	Japan	Prophylaxis	Mix of 5% EOI and 10% EOI	Left Inferior phrenic vein	Not clear, paraesophageal vein?	Right IJ	Pugh-Child class A	No gastrorenal shunt	Compete disappearance 1 week, reduction on scope 4 months, no bleeding 10 months
Takuma 2007	Japan	Prophylaxis	5% EOI	Gastrorenal?	Left Inferior Phrenic?	Femoral	N/A	Gastrorenal shunt	Deep gastric ulcer 7 days (healed with 1 week PPI)
Takao 2009	Japan	Prophylaxis	8 mL of 5% EOI	L gastric, posterior gastric and short gastric	Gastrorenal	Femoral	Pugh-Child class A	Gastrorenal	Disappearance 3 months
Tieu 2009	USA	Rebleeding	15 mL Absolute Ethanol	L Adrenal Vein	Not Clear Spenorenal?	Femoral	N/A	Splenorenal	No evidence of gastric or splenic collaterals 30 months
Liang 2009	Taiwan	Rebleeding	12 mL 3% NaCl + 2 mL absolute alcohol	Left Renal Vein	N/A	Femoral	Pugh-Child class B	Gastrorenal	Shrunk, no bleeds, no recurrence 1, 2, 4 months
Kikuchi 2010	Japan	Prophylaxis	5% EOI	N/A	N/A	Femoral	N/A	N/A	Varices shrank (no time period)
Sonomura 2011	Japan	Prophylaxis	5% EOI	Left Renal Vein	N/A	R IJ	Pugh-Child class B	Gastrorenal	Minor ascites, left pleural effusions and high fever, varices gone tho
Yoshimatsu 2011	Japan	Prophylaxis	5% EOI	Left pericardiophrenic	Azygous or Hemiazygous?	Left subclavian	Pugh-Child class A	No gastrorenal shunt	Disappearance 1 week, reduction on scope 3 weeks
JanneDOthee 2012	USA	Prophylaxis	Sodium tetradecyl sulfate 3% + contrast	Left inferior phrenic vein (IPV)	?	IJ	MELD 12	Gastrorenal	Focal RUQ pain 1 day, complete thrombosis of gastric varices 1 week, hematemsis from esophageal varices 2 months
Miura 2012 Pt 1	Japan	Prophylaxis	5% EOI, 10 mL 50% glucose, N-butyl-2-cyanoacrylate (NBCA) and lipiodol	Left IPV	Azygous	Femoral	N/A	N/A	Gastric varices occluded 1 week
Miura 2012 Pt 2	Japan	Prophylaxis	5% EOI	Left IPV	N/A	Femoral	N/A	No Gastrorenal	Gastric varices occluded 1 week
Yamagami 2014	Japan	Rebleeding	50% glucose + 5% EOI	Left pre-aortic renal vein	2 Branches of left IPV, left pericardiophrenic vein	Femoral	Pugh-Child class A	Gastrorenal	Complete disappearance 1 month
Basseri 2016	Canada	Rebleeding	3% sodium tetradecyl sulphate foam	IPV	Posterior gastric vein	Femoral	Pugh-Child class A	Gastrorenal	Uncomplicated recovery 4 days, obliteration 3 months, no GV but EV 10 months
Mine 2016	Japan	Prophylaxis	5% EOI + 33% mixture of NBCA (glue)	Left IPV	Anastomotic branches to azygous	Femoral	Pugh-Child class A	Gastrorenal	Reduction 2 months
Bundy 2018	USA	Acute management	1:1 Ethiodized oil + sodium tetradecyl sulfate	N/A	N/A	N/A	MELD-Na 30	Gastrorenal	Migrated plug into left pulm artery 2 months
Srinivasa 2018	USA	Rebleeding	3% sodium tetradecyl sulfate, ethiodized oil and air	Unclear	Unclear (created tract between IVC and SMV)	Right Saphenous vein	N/A	Splenorenal (created mesocaval shunt)	No bleeding or encephalopathy 1 month
Ravi 2019	USA	Acute management	N/A	Mid-splenic vein	N/A	N/A	Pugh-Child class A MELD-Na 10	Splenorenal shunt	Completely obliterated (no timeframe)

Table: Table 1 – Summary of isolated gastric varices (IGV) undergoing Balloon-Retrograde Transvenous Obliteration (BRTO)


Disclosures:
Smit Deliwala indicated no relevant financial relationships.
Murtaza Hussain indicated no relevant financial relationships.
Anoosha Ponnapalli indicated no relevant financial relationships.
Samuel Igbinedion indicated no relevant financial relationships.
Mamoon Elbedawi indicated no relevant financial relationships.
Anish Bansal indicated no relevant financial relationships.
Saurabh Chawla indicated no relevant financial relationships.


Smit S. Deliwala, MD¹, Murtaza S. Hussain, MD¹, Anoosha Ponnapalli, MD¹, Samuel Igbinedion, MD², Mamoon Elbedawi, MD, FACG¹, Anish Bansal, MD³, Saurabh Chawla, MD, FACG⁴. P1008 - Accelerated Balloon-Retrograde Transvenous Obliteration (BRTO): An Effective Bow & Arrow in the Arsenal Against Isolated Gastric Varices (IGV), ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.