What is the primary indication for Balloon-Occluded Retrograde Transvenous Obliteration (BRTO)?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: October 28, 2025 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Primary Indication for Balloon-Occluded Retrograde Transvenous Obliteration (BRTO)

The primary indication for BRTO is the management of bleeding from gastric varices, particularly cardiofundal gastric varices (GOV2 and IGV1) in the presence of a gastrorenal shunt. 1

Understanding Gastric Varices and BRTO

Gastric varices are classified based on their location:

  • Gastroesophageal varices (GOV): Connected to esophageal varices
    • GOV1: Extend along the lesser curvature (74% of cases) 1
    • GOV2: Extend to the gastric fundus 1
  • Isolated gastric varices (IGV)
    • IGV1: Located in the fundus 1
    • IGV2: Located in other regions of stomach or duodenum 1

Risk Factors for Gastric Variceal Bleeding

  • Location (IGV1 > GOV2 > GOV1) 1
  • Variceal size 1
  • Presence of red signs 1
  • Severe liver dysfunction 1

Specific Indications for BRTO

Primary Indications:

  • Treatment of bleeding from cardiofundal gastric varices (GOV2, IGV1) 1
  • Prevention of bleeding in high-risk gastric varices with a gastrorenal shunt 1, 2
  • Rescue therapy when endoscopic treatments fail 1

Secondary Indications:

  • Management of type B (portosystemic shunt-related) hepatic encephalopathy 1
  • Treatment of post-glue injection ulcer bleeding over gastric varices 3

Effectiveness of BRTO

  • Technical success rates range from 79% to 100% 1
  • Clinical success rate of 97.3% in preventing gastric variceal bleeding 1
  • Rebleeding rates consistently <5-7% at 1 year 1
  • Superior to observation in primary prophylaxis (7.3% vs 35.1% bleeding rate) 2
  • Better than endoscopic variceal obturation (EVO) in complete eradication of gastric varices (75.6% vs 45.8%) 2

Advantages of BRTO

  • Improves hepatic encephalopathy (0-5% incidence at 1 year post-procedure) 1
  • May improve liver synthetic function due to increased portal blood flow 1
  • Does not divert blood away from the liver (unlike TIPS) 1
  • Effective in patients who may not tolerate TIPS 4

Complications of BRTO

  • Aggravation of esophageal varices (27-35% at 1 year, 45-66% at 2 years) 1
  • Development or exacerbation of ascites (0-44%) or hepatic hydrothorax (0-8%) 1
  • Gross hematuria (15-100%) with potential hemoglobinuria-induced renal failure (up to 4.8%) 1
  • Pulmonary embolism (1.5-4.1%) 1
  • Fever, abdominal pain, and pleural effusion 5

Patient Selection for BRTO

BRTO is most appropriate for:

  • Patients with cardiofundal gastric varices (GOV2, IGV1) 1
  • Presence of a gastrorenal or gastrosplenorenal shunt 1
  • Patients with hepatic encephalopathy 1
  • Patients who may not tolerate TIPS 4

Follow-up After BRTO

  • EUS should be performed within 48 hours after BRTO to confirm obliteration 1
  • Repeat upper endoscopy within 2 weeks for high-risk esophageal varices 1
  • Contrast-enhanced CT or MRI at 4-6 weeks, then at 3 and 6 months 1
  • Monitor for development of esophageal varices, which may require prophylactic treatment 1

Clinical Pearl

When considering treatment options for gastric varices, the presence of a gastrorenal shunt is a key factor in determining whether BRTO is appropriate. In patients with cardiofundal gastric varices and a gastrorenal shunt, BRTO should be considered the treatment of choice when local expertise is available 1.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

4
Research

Management of gastric varices.

Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 2014

Related Questions

What is the initial management for a patient presenting with gastric varices?
What are the Kiyosue and Sarin classifications of gastric varices?
What is the recommended management approach for non-bleeding gastric varices?
What is the recommended surveillance interval for gastric varices in the United Kingdom (UK)?
What is the management of a hypertensive emergency?
What are examples of low-intensity exercises?
What is the recommended pediatric dose of Cefpodoxime (Cefpodoxime proxetil)?
What are the management guidelines for a 96-year-old female with unresolving pneumonia for 1 year, with computed tomography (CT) scan suggestive of fungal growth and chronic infection?
What is the most appropriate initial treatment for a child with right upper lobe pneumonia?
What is the use and dosage of Nintedanib (generic name) in treating idiopathic pulmonary fibrosis (IPF) and non-small cell lung cancer (NSCLC)?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question