Technically difficult (instability of guide wire in shunt and longer duration between access and shunt negotiation) shunt cannulations were thought to be due to an unfavorable angle between gastrorenal shunt and renal vein. Pre-procedural cross-sectional imaging helps to decide the approach, but it can be difficult to decide which route is most suitable for the BRTO procedure. Most operators use transfemoral approach and few use transjugular approach exclusively. Gastrocaval shunt and transdiaphragmatic veins provide venous outflow in the remaining 10% of patients with gastric varices. Gastrorenal shunt is the most common shunt blocked during a conventional BRTO procedure, and in 90% of patients with gastric varices, it provides venous outflow. Femoral and jugular routes are used, with the former being preferred.
In case of sclerosants, once the foam is injected, it causes endothelial damage and thrombosis of the shunt. Occlusion balloons are placed in the shunt either through a femoral or jugular vein access, through which these agents are deployed. These range from coils, plugs, sclerosants, and gelfoam. Various transcatheter agents have been described to treat these shunts. However, when the shunt is farther than 3.5 cm from the IVC, the jugular approach is suitable for a BRTO procedure.īalloon-occluded retrograde transvenous obliteration (BRTO) is performed to treat failed medical and endoscopic management of bleeding gastric varices and blocks shunts causing hepatic encephalopathy. The femoral approach is recommended for catheterization of the gastrorenal shunt for BRTO when the shunt joins the renal vein within 3.5 cm from the IVC. In each of the four failures, the alternative approach resulted in obtaining a successful BRTO. The ISD was >3.5 cm in two patients with failed initial femoral approach and < 3.5 cm in two other patients with failed initial jugular approach.
Two patients were having both proximal gastrorenal and distal splenorenal shunts. The IVC to shunt distance (ISD) was between 2.0 and 3.5 cm in 13 patients and >3.5 cm in five. In all patients, the inferior vena cava (IVC) to shunt distance (ISD) was measured on the reformatted coronal computed tomography image. There were four failed shunt catheterizations with the femoral or jugular approach two each. In two patients, both femoral and jugular approaches were used. Sixteen patients had undergone BRTO for variceal bleeding (11 cases) and encephalopathy (5 cases) with the femoral (13) and jugular approach (5).
#Plug assisted retrograde transvenous obliteration how to#
Why and how to decide whether femoral or jugular approach should be used for shunt catheterization for a successful balloon-occluded retrograde transvenous obliteration (BRTO) procedure.
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