Retrograde transvenous obliteration: lessons of a case series from a large academic center

Learning Objectives: (1) Provide an image-based review of select cases illustrating nuances in gastric variceal (GV) management. (2) Describe patient selection for variations of retrograde transvenous obliteration (RTO). (3) Provide a pictorial review of RTO variations.

Background: A known sequela of portal hypertension (PHTN), gastric varices (GV) often develop collaterals to relieve portal venous pressure, with subsequent draining via gastrorenal shunts into the left renal vein or less often via a gastrocaval shunt directly into the IVC {1}.  In RTO, the shunt is occluded so that retrograde delivery of sclerosing agent obliterates the GV, thereby preventing or treating bleeding. RTO variations including balloon-assisted retrograde transvenous obliteration (BRTO), coil-assisted retrograde transvenous obliteration (CARTO), and plug-assisted retrograde transvenous obliteration (PARTO) each bears its own technicalities, benefits, and potential complications {2}. Because RTO does not decompress portal venous pressure to control GV hemostasis as seen in transjugular intrahepatic portosystemic shunts (TIPS), success is contingent upon patient selection and technique selection {3}. Other factors include the patient’s history, portal venous anatomy, and clinician familiarity with RTO variations {4}. This exhibit will provide case-based lessons in matching the right patient with the right procedure to manage GVs.

Clinical Findings/Procedure Details: A series of cases will be used to illustrate clinician decision-making regarding proper patient selection and RTO technique. Technical considerations, challenges, and nuanced decision-making by the academic center’s clinicians will be highlighted. Visuals of the RTO variations including BRTO, CARTO, and PARTO will be provided either from case images or as original graphics. These visualizations will emphasize the procedural steps both common and unique to these variations. Procedural equipment utilized will be described as well.

Conclusion and/or Teaching Points: The clinician with a greater understanding of RTO variations can provide more efficacious management of GV.  A deeper understanding of possible anatomic variations, progression of abnormal physiology in PHTN and GV, as well as increased exposure to varying RTO techniques may benefit the clinician in the selection and effective management of a wider variety of patients presenting with PHTN and GV bleeding.