Balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices using foam sclerosant and a reduced balloon inflation time: Feasibility and efficacy

Introduction: Balloon-occluded retrograde transvenous obliteration (BRTO) is recommended for secondary prevention of gastric variceal bleeding in the American Association for the Study of Liver Disease (AASLD) guidelines, as an alternative to Transjugular intrahepatic portosystemic shunt (TIPS). However, there is significant heterogeneity in how BRTO is performed, including how and how long to occlude the outflow venous shunt amongst other variables such as variceal size, flow rate, agent used, and preparation technique. We propose a method using foam sclerotherapy and reducing balloon occlusion to as little as 30 min, with assessment of the efficacy of this shorter balloon inflation time. Methods: Retrospective single-centre analysis of BRTO procedures between July 2015 and February 2019 for isolated gastric varices in a non-acute setting, where inflation time was 2 h or less. Results: Six patients underwent BRTO with a short inflation time, with a mean age of 66 years. The median balloon inflation and thus 3% athoxysclerol foam contact time was 30 min (range 30–60 min). Four of the 6 patients showed complete resolution of varices, while 2 of the 6 showed a partial response. Mean follow-up was 27 months. There were no patients who did not show a response to treatment and no episodes of clinically significant upper gastrointestinal bleeding. Conclusions: This technique using a shortened balloon occlusion time resulted in complete or partial clinical and technical success in all patients and suggests that the threshold for initiation of gastric variceal thrombosis may be below 30 min. This timepoint may provide a balance between adequate balloon inflation, angiography room efficiency and hospital resource allocation with resultant procedural cost implications.