Transcatheter obliteration of gastric varices - Part 2. Strategy and techniques based on hemodynamic features

Balloon-occluded retrograde transvenous obliteration (BRTO) has become the treatment of choice for gastric varices at many institutions in Japan. However, in some cases that involve complex types of afferent or draining veins, the use of standard BRTO for the treatment of gastric varices may be associated with several difficulties that can lead to unfavorable results. In such cases, additional techniques are required for successful treatment. These techniques include stepwise injection of the sclerosing agent, selective injection of the agent via a microcatheter, coil embolization of the afferent gastric veins, double-balloon catheterization, and BRTO performed with percutaneous transhepatic portal venous access or transileocolic venous access. The majority of gastric varices can be treated successfully with a combination of these techniques. However, accurate assessment of the variceal hemodynamic pattern is the most important factor in ensuring successful treatment.