Indications

• Uncontrolled bleeding from ruptured gastric varices (most common request in the acute setting is ongoing hemoptysis following failed endoscopy)

• Isolated gastric varices at high risk for rupture

• Treatment of hepatic encephalopathy refractory to medical mgmt

• Ectopic varices

Contraindications

• Relative:

  • • Portal vein occlusion (BRTO must often be paired with splenic artery embolization so that portal HTN is not made worse)

    • Refractory ascites (more blood shunted back to liver will worsen ascites)

    • High-risk esophageal varices (will worsen after BRTO)

Imaging Review

• CTA / MRA

  • • Anatomy of gastric varices and splenorenal (or ectopic) shunt

    • Plan approach to cannulate shunt from IJ or CF vein access.

    • Lack of adequate shunt for retrograde obliteration may necessitate antegrade access into gastric varices via transhepatic or transplenic routes (BATO)

Tips for Workup

• Anesthesia often necessary in the setting of hemoptysis and instability

• Consent: Worsening of ascites / esophageal varices, rupture of gastric varices or other hemorrhage, sclerosant migration causing PV or renal vein thrombosis or even PE, infection, contrast nephropathy, access site complications