Home Procedures Balloon Retrograde Transluminal Occlusion (BRTO)

Balloon Retrograde Transluminal Occlusion (BRTO)

BRTO is a minimally invasive endovascular treatment for gastric varices and hepatic encephalopathy blocking the gastrorenal shunt to prevent life-threatening gastric variceal bleeding. Performed by Dr. Gurucharan S Shetty at Sparsh Hospitals Bangalore.

Hepatobiliary Interventional Radiology

What is Balloon Retrograde Transluminal Occlusion (BRTO)?

Balloon Retrograde Transluminal Occlusion (BRTO) is a minimally invasive endovascular procedure designed to treat gastric varices the large, dangerous abnormal veins in the stomach wall that develop as a complication of portal hypertension. Gastric varices carry a higher mortality when they bleed compared to oesophageal varices, and are less amenable to endoscopic treatment. BRTO accesses the gastrorenal shunt (the venous pathway draining gastric varices) via the femoral or jugular vein, inflates a balloon to occlude the shunt, and injects sclerosant to permanently close the variceal complex eliminating bleeding risk without open surgery.

Who is This Procedure For?

Balloon-occluded retrograde transvenous obliteration (BRTO) is indicated for patients with gastric varices due to portal hypertension, particularly when a gastrorenal shunt is identified on imaging. It is used in cases of acute gastric variceal bleeding as an emergency procedure when haemorrhage is not controlled by endoscopic cyanoacrylate glue injection. BRTO is also effective in preventing gastric variceal bleeding in high-risk varices such as GOV2 and IGV1, helping to eliminate the risk before a catastrophic bleed occurs. It plays an important role in preventing recurrent gastric variceal haemorrhage after an initial bleeding episode. Additionally, BRTO can be beneficial in patients with refractory hepatic encephalopathy by occluding large spontaneous gastrorenal shunts, thereby reducing portal blood bypass of the liver, improving ammonia clearance, and alleviating encephalopathy in carefully selected cases. It is also considered when gastric varices are not adequately controlled despite repeated endoscopic cyanoacrylate glue injections.

How is BRTO Performed?

  • Femoral Vein Access & Shunt Identification

    Femoral vein access. A catheter is guided into the left renal vein and then into the gastrorenal shunt draining the gastric varices. Venography maps the full variceal anatomy.

  • Balloon Occlusion of Gastrorenal Shunt

    An occlusion balloon is inflated within the gastrorenal shunt to prevent sclerosant agent from escaping into the systemic venous circulation during injection.

  • Sclerosant Injection

    Sclerosant agent (ethanolamine oleate with iopamidol, or sodium tetradecyl sulphate foam) is slowly injected to fill the entire variceal complex under fluoroscopic guidance.

  • Sclerosant Retention

    The balloon is maintained inflated for a defined retention period (modified BRTO: 2–4 hours; traditional: 4–12 hours) to allow complete sclerosis of the variceal complex.

  • Balloon Deflation & Follow-up

    Balloon is deflated and removed. CT angiography or Doppler ultrasound at 1 month confirms complete variceal thrombosis and absence of residual gastric varices.

Benefits of This Procedure

Eliminates Gastric Varices

BRTO achieves complete or near-complete obliteration of gastric varices in >90% of cases dramatically reducing the risk of catastrophic haemorrhage.

Improves Encephalopathy

By occluding large portosystemic shunts, BRTO redirects ammonia-rich portal blood through the liver improving hepatic encephalopathy in selected patients.

May Improve Liver Function

Unlike TIPSS, BRTO can increase portal blood flow to the liver potentially improving liver synthetic function and portal perfusion.

Avoids Open Surgery

Completely endovascular no abdominal incision, no general anaesthesia, significantly lower morbidity than surgical shunting procedures.

Frequently Asked Questions

Gastric varices are abnormal enlarged veins in the stomach wall analogous to oesophageal varices but generally larger and located in the fundus of the stomach. They develop because portal hypertension forces blood through alternative routes. When gastric varices bleed, the haemorrhage is typically more severe and harder to control endoscopically than oesophageal variceal bleeding, with mortality up to 30–45% per episode. Prevention is therefore critically important.
Both BRTO and TIPSS effectively treat gastric varices, but with important differences. TIPSS creates a shunt that decompresses the entire portal system and is preferred when refractory ascites is also present. BRTO specifically obliterates the gastric variceal complex via the gastrorenal shunt without creating a new portosystemic shunt. BRTO can actually improve portal perfusion of the liver (by redirecting flow), whereas TIPSS diverts portal flow away from the liver. BRTO is generally preferred in patients with minimal or no ascites, where encephalopathy risk needs to be minimised.
BRTO occludes the gastrorenal shunt that partially decompresses the portal circulation via the gastric variceal complex. After BRTO, this decompression is lost, which may cause portal pressure to rise slightly and oesophageal varices to worsen or appear in some patients. Upper endoscopy is recommended at 3–6 months post-BRTO to assess oesophageal varices and begin secondary prophylaxis with band ligation or non-selective beta-blockers if needed.
BRTO achieves durable obliteration of gastric varices in the majority of patients. Long-term follow-up studies show low rates of gastric variceal recurrence (approximately 10–15% at 3 years). However, portal hypertension persists in the underlying liver disease, and new varices or worsening oesophageal varices can develop. Regular endoscopic and imaging surveillance is therefore essential.
Most patients are hospitalised for 1–2 days for observation and management of post-procedure symptoms (mild abdominal discomfort, low-grade fever). Patients can return to light activities within 3–5 days and normal activity within 1–2 weeks. Follow-up CT or ultrasound at 1 month confirms variceal thrombosis.
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Concerned About Gastric Varices or Hepatic Encephalopathy?

Consult Dr. Gurucharan S Shetty at Sparsh Hospitals, Bengaluru for expert evaluation and minimally invasive treatment of gastric varices and portal hypertension complications.

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