Tips Vs Brto

TIPS Vs BRTO
Pratap Sagar Tiwari
1
Total slides : 52
Content
1 TIPS: Intro/ History/ Procedure
2 BRTO: Intro/ History/ Procedure
3 Role of TIPS & BRTO in VH
4 TIPS Vs BRTO
Algorithm for the MX of AVH in pts with LC
*Any of the following: varix spurting blood, varices with overlying clot or with white nipple sign, varices and no other lesion that would explain hemorrhage.
**A short-term course (10 days) of PPI may reduce the size of post-banding ulcers.
Zanetto A, et al. Management of acute variceal hemorrhage. F1000Research 2019, 8(F1000 Faculty Rev):966
3/56
Algorithm for the MX of AVH in pts with LC
***Excluding pts >75 years old or who have HCC outside Milan criteria, creat of at least 3 mg/dL, previous combination pharmacological plus endoscopic treatment to prevent re-
bleeding, bleeding from isolated gastric or ectopic varices, recurrent HE, pulmonary HTN, or heart failure or a combination of these.
†Patient should not be discharged on prophylactic antibiotic (consider discontinuing at same time as vasoactive drugs).
Zanetto A, et al. Management of acute variceal hemorrhage. F1000Research 2019, 8(F1000 Faculty Rev):966
4
Role of TIPS
Guidelines[1,2,3] recommend TIPS placement in the following pts at the time of acute
VH:
1. Rescue TIPS in pts with persistent bleeding or early re-bleeding despite treatment with
vasoconstrictors plus EVL.
2. Early (within 24 to 72 hours) pre-emptive TIPS can be considered in high-risk pts
(Child C with score < 14) without CI to TIPS.
High risk pt: HVPG≥ 20 mmHg or those with active bleeding at endoscopy.[5]
The feasibility of using MELD was evaluated in a retrospective cohort[4]. Among the 206 pts who received
early TIPS, those with MELD of at least 19 had a significant survival benefit.
1. de Franchis R, Baveno VI Faculty: Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;
63(3): 743–52.
2. European Association for the Study of the Liver: EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018; 69(2): 406–60.
3. Garcia-Tsao G, Abraldes JG, Berzigotti A, et al.: Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver
diseases. Hepatology. 2017; 65(1): 310–35.
4. Lv Y, Zuo L, Zhu X, et al.: Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: a multicentre observational study. Gut. 2019; 68(7): 1297–1310.
5. Monescillo A, Martínez-Lagares F, Ruiz-del-Arbol L, et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 2004; 40:793. 5
bTIPS Vs SX in RAVH (RCT)
Author Compa Numbe Child-pugh(%) Postoperative morbidity (%) Mortalit 1-year 2-year 5-year
rison r of y (%) survival survival survival
patient A B C VH SS HE (%) (%) (%)
s
Khaitiyar et TIPS Vs 35 Vs 34 Vs 66 Vs 0 26 Vs 69 Vs 43 Vs 6 Vs 83 Vs 80 Vs NA
al.1 DSRS 32 31 69 6 6 19 6 81 81
sPS
Henderson TIPS Vs 67 Vs 58 Vs 42 Vs 0 11 Vs 82 Vs 51 Vs 1 Vs 93 Vs 88 Vs 61 Vs
et al.2 DSRS 73 56 44 6 11 49 5 88 81 62
mPS
Rosemurgy TIPS Vs 66 Vs 18 Vs 38 Vs 44 Vs 30 Vs 48 Vs NA 15 Vs 64 Vs 53 Vs 31 Vs
et al.3 HGPCS 66 14 36 50 8 11 20 74 68 47
sPS
Orloff et TIPS Vs 78 Vs 21 Vs 50 Vs 29 Vs 41 Vs 0 84 Vs 61 Vs 22 Vs 55 Vs 49 Vs 20 Vs
al.4 PCS 76 20 49 32 3 21 23 75 68 61
sPS
1. Khaitiyar JS, Luthra SK, Prasad N, Ratnakar N, Daruwala DK. Transjugular intrahepatic portosystemic shunt versus distal splenorenal shunt – A comparative study. Hepatogastroenterology. 2000;47:492–7.
2. Henderson JM, Boyer TD, Kutner MH, Galloway JR, Rikkers LF, Jeffers LJ, et al. Distal splenorenal shunt versus transjugular intrahepatic portal systematic shunt for variceal bleeding: A randomized trial.
Gastroenterology. 2006;130:1643–51.
3. Rosemurgy AS, Frohman HA, Teta AF, Luberice K, Ross SB. Prosthetic H-graft portacaval shunts vs transjugular intrahepatic portasystemic stent shunts: 18-year follow-up of a randomized trial. J Am Coll Surg.
2012;214:445–53.
4. Orloff MJ, Vaida F, Haynes KS, Hye RJ, Isenberg JI, Jinich-Brook H. Randomized controlled trial of emergency transjugular intrahepatic portosystemic shunt versus emergency portacaval shunt treatment
6 of acute
bleeding esophageal varices in cirrhosis. J Gastrointest Surg. 2012;16:2094–111.
s
al.1 DSRS 32 31 69 6 6 19 6 81 81
sPS
et al.2 DSRS 73 56 44 6 11 49 5 88 81 62
mPS
et al.3 HGPCS 66 14 36 50 8 11 20 74 68 47
sPS
al.4 PCS 76 20 49 32 3 21 23 75 68 61
sPS
2012;214:445–53.
7 of acute
s
al.1 DSRS 32 31 69 6 6 19 6 81 81
sPS
et al.2 DSRS 73 56 44 6 11 49 5 88 81 62
mPS
et al.3 HGPCS 66 14 36 50 8 11 20 74 68 47
sPS
al.4 PCS 76 20 49 32 3 21 23 75 68 61
sPS
2012;214:445–53.
8 of acute
The outcomes of the meta-analysis[1] based on these 4 trials stated the superiority of
surgical shunting over TIPS.
The morbidity in VH was significantly higher in TIPS than in surgical shunts (OR = 7.45, 95% CI:3.93–14.15, P < 0.001),
the same outcomes were seen in shunt stenosis (OR = 20.01, 95% CI: 6.67–59.99, P < 0.001) and in HE (OR = 2.50,
95% CI:1.63–3.84, P < 0.0001). Significantly better 2-year survival (OR = 0.66; 95% CI: 0.44–0.98, P = 0.04) and 5-year
survival (OR = 0.44; 95% CI: 0.30–0.66, P < 0.00001) were seen in pts undergoing surgical shunting compared with TIPS.
1. Huang L, et al. Transjugular Intrahepatic Portosystemic Shunt Versus Surgical Shunting in the Management of Portal Hypertension. Chin Med J (Engl). 2015 Mar 20;
128(6): 826–834.
9
Why not shunt surgery ?
• Indeed, surgical shunts were considered before and were compared to TIPS as a
rescue therapy for variceal bleeding in RCTs [1,2].
Only bare stents were used in these studies, underestimating the benefits of TIPS
TIPS can technically be done in 90-100% of cases.
Surgical shuntsTIPS
is the first-class therapeutic for refractory variceal bleeding.
• needTIPS
• Covered to be is
performed by experienced
the treatment of choicesurgeons.
to prevent EV rebleeding
• may
• TIPS prevent considering
is effective a later LT[3]
in the prevention of bleeding recurrence from GV and should be
• a/with a higher mortality than TIPS [4,5]
considered in this setting. [Consensus conference on TIPS management;2017]
1. G. D'Amico and A. Luca, “TIPS is a cost effective alternative to surgical shunt as a rescue therapy for prevention of recurrent bleeding from EV,” Journal of Hepatology, vol. 48, no. 3, pp. 387–390, 2008.
2. M. J. Orloff, “Fifty-three years' experience with randomized clinical trials of emergency portacaval shunt for bleeding esophageal varices in cirrhosis 1958-2011,” JAMA Surgery, vol. 149, no. 2, pp. 155–169, 2014.
3. M. D'Amico, A. Berzigotti, and J. C. Garcia-Pagan, “Refractory acute variceal bleeding: what to do next?” Clinics in Liver Disease, vol. 14, no. 2, pp. 297–305, 2010.
4. S. Fagiuoli, R. Bruno, and V. W. Debernardi, “Consensus conference on TIPS management: Techniques, indications, contraindications,” Digestive and Liver Disease, vol. 49, no. 2, pp. 121–137, 2017.
5. J. M. Henderson, “Salvage therapies for refractory variceal hemorrhage,” Clinics in Liver Disease, vol. 5, no. 3, pp. 709–725, 2001. 10
HISTORY OF TIPS
Rosch [1] discussed the potential of a Richeter [3] creates the first
“radiologic portocaval shunt” human Palmaz stent TIPS
Early to mid-
1960s 1982 1990s
1969 1988
Inadvertent portal access during Colapinto [2] creates the first Widespread clinical use with self-
transjugular cholangiography human balloon dilated TIPS expanding bare stents
1. Rösch J, HanafeeWN, SnowH. Transjugular portal venography and radiologic portacaval shunt: an experimental study. Radiology 1969;92(5):1112–1114
2. Colapinto RF, Stronell RD, Gildiner M, et al. Formation of intrahepatic portosystemic shunts using a balloon dilatation catheter: preliminary clinical experience. AJR AmJ Roentgenol 1983;140(4): 709–714
11
3. Richter GM, Palmaz JC, Noldge G, et al. The transjugular intrahepatic portosystemic stent-shunt (TIPSS): a new nonoperative percutaneous procedure. Radiologie 1989;29:406–411
HISTORY OF TIPS
Procedure endpoint defined as a AASLD places practice guidelines on the

reduction in PSG to <12 mm Hg “role of TIPS in the MX of PHTN”
Mid- to late-
1990s Early 2000s 2009
2001 2005
Animal experimentation using AASLD adds BCS as an additional
• Early human e-PTFE covered stent-graft experience[4-7]
silicone and e-PTFE coated stents to indication & considers e-PTFE
• Defining TIPS candidacy by prognostic parameters (e.g.,
improve TIPS patency [1-3] covered stent grafts as standard of
MELD)
practice
References are at the end of the slides 12
Transjugular intrahepatic portosystemic shunt (TIPSS):
Introduction
• TIPS involve creation of a low-resistance channel between
the hepatic vein and the intrahepatic portion of the
portal vein (usually the right branch) using angiographic
techniques.
• The tract is kept patent by deployment of an expandable
metal stent across it, thereby allowing blood to return to the
systemic circulation.
• A TIPS is placed to reduce portal pressure in pts with
complications related to PHTN.[1,2]
1. Colombato L. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal
hypertension. J Clin Gastroenterol. 2007 Nov-Dec. 41 Suppl 3:S344-51.
2. Gaba RC, Omene BO, Podczerwinski ES, Knuttinen MG, Cotler SJ, Kallwitz ER, et al. TIPS for Treatment of Variceal
Hemorrhage: Clinical Outcomes in 128 Patients at a Single Institution over a 12-Year Period. J Vasc Interv Radiol. 2011
Dec 16. 13
Pic src: Sankar K, edt al. Transjugular Intrahepatic Portosystemic Shunts. JAMA. 2017;317(8):880.
Transjugular intrahepatic portosystemic shunt
• Creation of a vascular access by the puncture of the IJV, which
must be performed under US guidance.
• Catheterization of one of the HVs, which can be also punctured
percutaneously under real time US guidance when its ostium is not
easily accessible. When HVs are occluded (BCS), PV branches can
be reached by direct puncture from the IVC.
• Puncture through the liver parenchyma of one of the main
branches of PV with or without real time USG guidance .
• Measurement of the porto-systemic pressure gradient (PPG) by
a digital recording system properly set-up for venous pressure. IVC
and not RA BP should be subtracted to PV pressure to calculate the
gradient.
S. Fagiuoli, R. Bruno, and V. W. Debernardi, “Consensus conference on TIPS management: Techniques, indications, contraindications,”
Digestive and Liver Disease, vol. 49, no. 2, pp. 121–137, 2017. 14
©2018 UpToDate
Transjugular intrahepatic portosystemic shunt
• Balloon dilatation of the parenchymal tract between the hepatic (or
IVC) and PVs.
• Deployment of the stent within the parenchymal tract.
• Hemodynamic assessment of the resultant PPG reduction
followed by further balloon dilatation of the lumen to reach the
desired target of pressure gradient.
• Reduction of PPG to <12 mm Hg should be achieved when the
indication is bleeding from EV.
S. Fagiuoli, R. Bruno, and V. W. Debernardi, “Consensus conference on TIPS management: Techniques, indications, contraindications,”
©2018 UpToDate Digestive and Liver Disease, vol. 49, no. 2, pp. 121–137, 2017. 15
TIPS PROCEDURE
16
©2018 UpToDate
TIPS PROCEDURE
• Intravenous heparin is given for prevention of shunt thrombosis (bolus dose of
2500–5000 U followed by constant infusion for 1–2 weeks, targeted at an aPTT of 60–
80 seconds.
• A color Doppler USG is obtained 24 hours after the procedure to show shunt patency.
• It is usually repeated one week later if it is an uncovered stent or one month later if it
is covered. After that, if there are no complications, the USG is repeated 3 months later
and then every 6 months until the clinical outcome.
17/56
Are blood products routinely required during TIPS
placement?
• FFP, or pro-haemostatic agents are not required in cirrhotic pts
undergoing TIPS, irrespective of INR value (1,2).
• Although the threshold of platelet count needed to ensure normal primary
haemostasis in cirrhosis is not clearly defined, the 50X109/L cut-off can be
utilized for platelets infusion before TIPS (3).
1. Bosch J, Thabut D, Albillos A, Carbonell N, Spicak J, Massard J, et al. Recombinant factor VIIa for variceal bleeding in patients with advanced cirrhosis: A randomized, controlled trial. Hepatology. 2008
May;47(5):1604–14.
2. Segal JB, Dzik WH. Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based review. Transfusion. 2005 Sep;45(9):1413–25.
18
3. Tripodi A, Primignani M, Chantarangkul V, Lemma L, Jovani M, Rebulla P, et al. Global hemostasis tests in patients with cirrhosis before and after prophylactic platelet transfusion. Liver Int. 2013 Mar;33(3):362–7.
Post-TIPS assessment
Stent configuration / position
Flow direction in PV & branches Velocity in the shunt device

Direction of flow in PV: Hepatopetal >50 cm/s, ideally between 90 to 150 cm/s, but
Direction of main IHPV branches: retrograde/ stagnant. acceptable from 50 to 200~250 cm/s.
Evaluation of the collateral vessels

Reduction in the caliper of the collaterals;
(paraumbilical, left gastric, SRS).
LOREM Velocity of the mid PV
IPSUM >30 cm/s. Note that it should ↑ significantly
after TIPS (>50%).
Patency and flow direction in HVs

Flow direction in Splenic Vein (esp. the segment between the device and the IVC, of
If the flow in SV is hepatofugal before TIPS, should which we should determine the velocity)
be hepatopetal post-TIPS in a normal functionating
device.
19/56
EARLY EVENTS: Bacteriemia
• Bacteriemia after TIPS (defined by fever >38.5°C, or leucocytosis >15.000 / ul and
positive blood cultures) ranges between 2-25%(2-4,6) and in a prospective RCT was not
influenced by antibiotic prophylaxis (1)
• A longer duration of procedure, multiple stenting and the maintenance of a central
venous line are a/with a higher risk of infection after TIPS.
• In pts with uncomplicated procedure, the transjugular venous access should be removed
at the end of the intervention (1,5).
• A single dose of long acting cephalosporin ↓ the incidence of bacterial infection (20%
to 2.6%) justifying its use in anticipated complex procedures (2).
1. Deibert P, Schwarz S, Olschewski M, Siegerstetter V, Blum HE, Rössle M. Risk factors and prevention of early infection after implantation or revision of transjugular intrahepatic portosystemic shunts: results of a
randomized study. Dig Dis Sci. 1998 Aug;43(8):1708–13.
2. Gulberg V, Deibert P, Ochs A, Rossle M, Gerbes AL. Prevention of infectious complications after transjugular intrahepatic portosystemic shunt in cirrhotic patients with a single dose of
ceftriaxone.Hepatogastroenterology. Jan;46(26):1126–30.
3. Ghinolfi D, De Simone P, Catalano G, Petruccelli S, Coletti L, Carrai P, et al. Transjugular intrahepatic portosystemic shunt for hepatitis C virus-related portal hypertension after liver transplantation. Clin Transplant.
Jan;26(5):699–705.
4. Moon E, Tam MDBS, Kikano RN, Karuppasamy K. Prophylactic antibiotic guidelines in modern interventional radiology practice. Semin Intervent Radiol. 2010 Dec;27(4):327–37.
5. Mizrahi M, Roemi L, Shouval D, Adar T, Korem M, Moses A, et al. Bacteremia and “Endotipsitis” following transjugular intrahepatic portosystemic shunting. World J Hepatol. 2011 May 27;3(5):130–6. 20
6. Navaratnam AM, Grant M, Banach DB. Endotipsitis: A case report with a literature review on an emerging prosthetic related infection. World J Hepatol. 2015 Apr 8;7(4):710–6.
LATE EVENTS: Endotipsitis
• Defined by the presence of sustained bacteriemia a/with the evidence of thrombus or
vegetations inside the TIPS. This clinical condition is rare (1%).
• Early endotipsitis (< 120 days of the procedure) is usually related to Gram-positive
organisms and the antibiotic therapy must be long-lasting (at least 3 months) to avoid
recurrence (1).
• In pts with uncontrolled or recurrent infection LT should be considered(2).
• There is no evidence for adopting long-term prophylaxis for the prevention of endotipsitis.
The term “endotipsitis” was proposed by Sanyal and Reddy[3], who defined it as: (1) the presence of continuous
bacteremia indicating an infectious focus in continuity with the venous circulation and (2) failure to find an alternate
source of infection despite an extensive search.
1. Navaratnam AM, Grant M, Banach DB. Endotipsitis: A case report with a literature review on an emerging prosthetic related infection. World J Hepatol. 2015 Apr 8;7(4):710–6.
2. Kochar N, Tripathi D, Arestis NJ, Ireland H, Redhead DN, Hayes PC. Tipsitis: incidence and outcome-a single centre experience. Eur J Gastroenterol Hepatol. 2010 Jun;22(6):729–35. 21
3. Sanyal AJ, Reddy KR. Vegetative infection of transjugular intrahepatic portosystemic shunts. Gastroenterology. 1998;115:110-115.
Hepatic encephalopathy
• HE is one of the major complications of TIPS. The incidence of overt episodic or
recurrent HE post-TIPS varies between 15 and 67% in a 2-year follow-up. The
incidence of persistent overt HE is around 8% (1) and that of covert HE around
35% (2-9,12,13).
• Prophylaxis of post-TIPS HE with either lactulose or rifaximin is not routinely
recommended (9).
• Stent lumen reduction or occlusion is effective in case of persistent overt post-TIPS
HE (10,11).
References are present at the end of the slides. 22

Contraindications to TIPS positioning
S. Fagiuoli, “Consensus conference on TIPS management" 2017
• The absence of vascular accesses represents the only technical CI to TIPS (1).
• The presence of PVT resulting in a portal cavernoma is not an absolute CI in presence of
a “portal” landing zone with adequate flow and calibre to receive the device (2,3)
Clinical contraindications to TIPS placement are:
• Advanced liver disease (CP > 11, serum bilirubin > 5 mg/dl, MELD >18) (4).
• Severe organic renal failure (serum creat > 3 mg/dl)
• Heart failure
• Severe porto-pulmonary HTN (mPAP>45mmHg)
• Recurrent or persistent overt HE grade > 2 (WH scale) despite adequate RX
• Uncontrolled sepsis
1. Gazzera C, Fonio P, Gallesio C, Camerano F, Doriguzzi Breatta A, Righi D, et al. Ultrasound-guided transhepatic puncture of the hepatic veins for TIPS placement. Radiol Med. 2013 Apr;118(3):379–85.
2. Senzolo M, Tibbals J, Cholongitas E, Triantos CK, Burroughs AK, Patch D. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation. Aliment Pharmacol
Ther. 2006 Mar 15;23(6):767–75.
3. Van Ha TG, Hodge J, Funaki B, Lorenz J, Rosenblum J, Straus C, et al. Transjugular intrahepatic portosystemic shunt placement in patients with cirrhosis and concomitant portal vein thrombosis. Cardiovasc
Intervent Radiol. Jan;29(5):785–90.
4. Chiva T, Ripoll C, Sarnago F, Rincón D, Gómez-Camarero J, Galindo E, et al. Characteristic haemodynamic changes of cirrhosis may influence the diagnosis of portopulmonary hypertension. Liver Int. 2015
Feb;35(2):353–61.
23
• Relative technical CIs are anatomical conditions a/with a reduction in
technical success rate or with an ↑ risk of complications, such as liver
tumours, the presence of multiple hepatic cysts.
The clinical appropriateness of TIPS positioning should be evaluated on a
case-by-case basis according with the relevance of the indication and the
presence of general CIs. Indeed, in the context of a life-threatening condition
such as AVH, a broader range can be adopted (CP C score < 14).
24
TIPS: Bare stent Vs PTFE-covered stent
• A major complication after TIPS insertion using bare stent grafts is the development
of HE, which can occur in up to 50% of pts.[1,2]
• The incidence of this complication can be significantly reduced to about 18% with the
use of PTFE-covered stent grafts of 8 mm,[3] a result confirmed by a recent RCT
comparing 8 mm and 10mm stent grafts.[4]
• Dysfunction of TIPS with bare stent grafts because of stent thrombosis and stenosis
can develop in up to 80% of cases.[1] This complication has been significantly reduced
with the use of PTFE-covered stents.[5]
Note: Use of polytetrafluoroethylene coated stents was first reported in 1995 [6]

TIPS: Covered Vs Bare
In the recent meta-analysis by Qi et al[1], covered stents not only significantly
improved the shunt patency, but also significantly ↓the risk of death. Additionally, the
risk of HE was not ↑ by the use of covered stents.
Bureau et al. 2015[2] Perarnau et al. 2015[3]

Multi center single blind RCT Multi center single blind RCT
CS: 10.5 ± 0.9 versus BS: 11.7 ± 0.8 mm Stent diameter data: NA
After median follow-up of 300 days; Median follow-up :23.6 and 21.8 months, respectively.
Shunt dysfunction: 13% Vs 44%,P < 0.001. Shunt dysfunction :RR= 0.60; 95% CI:0.38-0.96, p=0.032.
HE @1 yr: 21% Vs 41% (NS). The 2-year rate of shunt dysfunction: 44.0% vs. 63.6% .
The 1-year and 2-year survival rates: 70.9 % and 64.5 % Risk of HE: 0.89; 95% CI: 0.53-1.49,NS
Vs 59.5 % and 40.5 % (NS) 2-year survival: 70% vs. 67.5%, NS
CS provided a significant 40% reduction in dysfunction
The use of CS improves shunt patency without increasing
compared to BS. No significant difference with regard to
the risk of HE.
HE or death.
39 Vs 41 66 Vs 71
Prevention of recurrent variceal bleeding:
bTIPS Vs Medical therapy + EVL
• Most indications for TIPS were established in the era Zheng et al. 2015
of bare stents.
• Decreased incidence of RVH;
• For example, a meta-analysis(12 HQ RCT;883 pts) OR=0.32, 95% CI:0.24-0.43,
by Zheng et al[1] suggested that TIPS with bare P<0.00001
stents should be superior to endoscopic and • Deaths due to rebleeding;
OR=0.35, 95% CI:0.18-0.67,
pharmacological treatment for decreasing the risk P=0.002
of variceal rebleeding, but inferior in relation to • Increased rate of HE; OR=2.21,
HE . 95% CI:1.61-3.03, P<0.00001
TIPS is currently the first choice to
prevent rebleeding except that TIPS is
worse than endoscopic therapy for HE.
12 RCT; 883 pts
1. Zheng M., Chen Y., Bai J., Zeng Q., You J., Jin R., et al. (2008) Transjugular intrahepatic portosystemic shunt versus endoscopic therapy
in the secondary prophylaxis of variceal rebleeding in cirrhotic patients: meta-analysis update. J Clin Gastroenterol 2009; 42: 507–16. 27
cTIPS Vs Medical therapy + EVL
Sauerbruch et al. 2015 Luo et al. 2015 Holster et al. 2016

Multicenter prospective RCT Single center prospective RCT Multicenter prospective RCT
Germany China Netherlands
RVH within 2 yrs: 7% Vs 26%; p = The 2-year probability of remaining free Median follow‐up of 23 months,
0.002 of RVH: 77.8% Vs 42.9%; p = 0.002 RVH: 0% vs 29 %; p = 0.001
HE: 18% vs 8%; p = 0.05. HE; no sig differences; p = 0.53. Mortality: 32% vs. 26%; p = 0.418
No difference in survival curve. The 2-year survival: 72.9% Vs 57.2% ;p Early HE: 35% vs. 14%; p = 0.035
= 0.23
TIPS was more straightforward and TIPS had a significantly lower risk of TIPS had a significantly lower risk
prevented RVH more effectively, but RVH, but a similar risk of HE and of RVH, but the risk of HE and
did not improve the survival. death. death was not sig different.
92 Vs 95 37 Vs 36 37 Vs 35

Balloon-occluded retrograde transvenous
obliteration
29
Picture credit:Shou-Dong Lee, Cheng Hsin General Hospital
Transvenous obliteration
• Transvenous obliteration is an old idea that was practiced in the 1970s in
the pre TIPS era as an procedure for the MX of bleeding EV and GOV from
a percutaneous transhepatic approach.[1-5]
• These percutaneous transhepatic obliteration were mostly performed
utilizing coils, Gelfoam, and/or sclerosants (such as absolute alcohol and
30–50% glucose solution) without utilizing occlusive balloons to
modulate blood flow.[1-5]
• These procedures, utilizing current terminology, are now referred to as
PTO[6,7], which is a type of balloon-occluded antegrade transvenous
obliteration (BATO).
1. Choi YH, Yoon CJ, Park JH, Chung JW, Kwon JW, Choi GM. Balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding: its feasibility compared with transjugular intrahepatic portosystemic shunt. Korean J Radiol 2003;4(2):109–116
2. Funaro AH, Ring EJ, Freiman DB, Oleaga JA, Gordon RL. Transhepatic obliteration of esophageal varices using the stainless steel coil. AJR Am J Roentgenol 1979;133(6):1123–1125
3. Scott J, Dick R, Long RG, Sherlock S. Percutaneous transhepatic obliteration of gastro-oesophageal varices. Lancet 1976;2(7976):53–55
4. Lunderquist A, Simert G, Tyle´n U, Vang J. Follow-up of patients with portal hypertension and esophageal varices treated with percutaneous obliteration of gastric coronary vein. Radiology 1977;122(1):59–63
5. Lunderquist A, Vang J. Transhepatic catheterization and obliteration of the coronary vein in patients with portal hypertension and esophageal varices. N Engl J Med 1974; 291(13):646–649
6. Lunderquist A, Vang J. Sclerosing injection of esophageal varices through transhepatic selective catheterization of the gastric coronary vein. A preliminary report. Acta Radiol Diagn (Stockh) 1974;15(5):546–550 30
7. Tajiri T, Onda M, Yamashita K, et al. Interventional radiology for portal hypertension. PTO.TIO. Nippon Geka Gakkai Zasshi 1996;97(1):70–77
PERCUTANEOUS TRANSHEPATIC OBLITERATION
OF G-E VARICES
• The PV was localised in both anteroposterior and lateral planes
by venography, or grey-scale ultrasound.
• Under local anaesthesia the liver is punctured during apnea
in the mid-axillary line below the costophrenic reflection by
means of a cholangiography needle with a radio-opaque
catheter.
• The needle is advanced under image guidance in the direction
of the PV.
• The needle is removed and the radio-opaque catheter gradually drawn with suction applied until blood is
freely aspirated. A test injection of contrast medium is made to confirm the position of the catheter in
the PV or one of its branches. The catheter is advanced over a guide wire as far as possible along the SV.
The portal pressure is measured and a portal venogram obtained.
Scott J, Dick R, Long RG, Sherlock S. Percutaneous transhepatic obliteration of gastro-oesophageal varices. Lancet 1976;2(7976):53–55 31/56
PERCUTANEOUS TRANSHEPATIC OBLITERATION
OF G-E VARICES
• The major variceal supply veins (LGV and short gastric)
are selectively catheterised and thrombosed. 30 ml of 50
% dextrose is injected to traumatise the intima of the
veins, increasing quantities of human thrombin (500-
3000 units) is injected to induce complete thrombosis,
and small pieces of gelatin foam are injected to stabilise
the thrombus.
• Contrast medium is then injected to confirm successful
obliteration, and if this had been achieved the catheter is
carefully withdrawn.
• A portal venogram is obtained to ensure complete obliteration of all variceal supply veins and PV
patency. Finally, before complete withdrawal of the catheter from the liver, the hepatic puncture wound is
plugged by an injection of gelatin foam into the subcapsular parenchyma.
Scott J, Dick R, Long RG, Sherlock S. Percutaneous transhepatic obliteration of gastro-oesophageal varices. Lancet 1976;2(7976):53–55 32
First published document of
an attempt at balloon-
occluded sclerotherapy
BRTO
(absolute alcohol) of the
GRS for the MX of GVs.[2]
Term used for the procedure
was ‘‘transrenal-vein reflux
1970 ethanol sclerosis’’.
Transvenous obliteration Practiced and published
is an old idea that was BRTO procedure, coining the
practiced in the 1970s in term ‘‘balloon-occluded
the pre-TIPS era as an retrograde transvenous
1984 obliteration’’ (B-RTO).[3]
procedure for the MX of
bleeding varices from a Olson et al Ethanolamine-oleate
percutaneous transhepatic
approach.[1]
1991-1993
First BRTO in US, with 3%
Kanagawa et al Sotradecol [4]
1. Scott J, Dick R, Long RG, Sherlock S. Percutaneous transhepatic obliteration of gastro-oesophageal varices. Lancet 1976;2(7976):53–55
2. Fukatsu H, Kawamoto H, Harada R, et al. Gastric fundal varices with an exposed microcoil after the combined BRTO and PTO therapy. Endoscopy 2007;39(Suppl
1):E247–E248
3. Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by balloonoccluded retrograde transvenous obliteration. J 2006
Gastroenterol Hepatol 1996;11(1):51–58
4. Saad, W. E. A. (2011). The History and Evolution of Balloon-occluded Retrograde Transvenous Obliteration (BRTO): From the United States to Japan and Back. John Kaufman 33
Seminars in Interventional Radiology, 28(03), 283–287. doi:10.1055/s-0031-1284454
Gastric Varices
• The Sarin classification is most commonly used for
risk stratification and MX of GV. [1] GV are present
in about 20% of pts with LC.
• GOV 1 are commonly managed following guidelines
for EV.[2]
• Cardiofundal varices (GOV2 & IGV1) bleed less
frequently. However, is often more severe, more
difficult to control and shows a ↑ risk of rec bleeding
and mortality (up to 45%) compared to EV.[1]
• In CFV, the 5-year cumulative incidence of bleeding
is 44% in the natural course, and the 1-year survival
rate is 48% in case of bleeding. [3]
1. Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term followup study in 568 portal hypertension patients. Hepatology 1992;16:1343–1349. (also for table shown)
2. De Franchis RBaveno VI faculty. Expanding consensus in portal hypertension: report of the BAVENO VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015;63:743–752.
3. T. Kim, H. Shijo, H. Kokawa et al., “Risk factors for hemorrhage from gastric fundal varices,” Hepatology, vol. 25, no. 2, pp. 307–312, 1997. 34
Pic src: Mehta, G., Abraldes, J. G., & Bosch, J. (2010). Developments and controversies in the management of oesophageal and gastric varices. Gut, 59(6), 701–705.
Anatomy of gastric varices
The afferent channel for gastric varix is mostly from LGV or
posterior gastric veins.[1-3] The efferent channel for most
GVs (80–85%) is the GRS, which opens into the LRV.[2,4]
B
A. Gonzalez JM, et al. Management of fundic varices. Endoscopic aspects. Rev esp enfeRm Dig 2015. 107;8, pp. 501-508
B. Kim M, Lee K-Y. Understanding the pathophysiology of portosystemic shunt by simulation using an electric circuit. Biomed Res Int. 2016;2016(81):ID 2097363.7
1. Watanabe K, Kimura K, Matsutani S, Ohto M, Okuda K. Portal hemodynamics in patients with gastric varices: A study in 230 patients with esophageal and/or gastric varices using portal vein catheterization.
2. Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Correlation between endoscopic and angiographic findings in patients with esophageal and isolated gastric varices. Dig Surg. 2001;18:176–81.
3. Kimura K, Ohto M, Matsutani S, Furuse J, Hoshino K, Okuda K. Relative frequencies of portosystemic pathways and renal shunt formation through the “posterior” gastric vein: Portographic study in 460 patients.
Hepatology. 1990;12:725–8.
4. Koito K, Namieno T, Nagakawa T, Morita K. Balloon-occluded retrograde transvenous obliteration for gastric varices with gastrorenal or gastrocaval collaterals. AJR Am J Roentgenol. 1996;167:1317–20.
35
• The two main infra-diaphragmatic portosystemic shunts:
the gastrocaval and gastrorenal shunts.
• The common afferent (portovenous feeders) to the GV
are LGV (also known as the coronary vein), the PGV, and
the SGV.
• The SGV and PGV arise from the SV, and the LGV arises
from the confluence of the SV and the mesenteric vein(s)
(SMV). The LGV may also arise from the proximal main
PV.
• The efferent limbs of the GV, which drain the GV into the
systemic circulation, either drain directly into the IVC (the
GCS) or into the LRV (GRS).
• The asterisk denotes a direct communication between the
SV and the shunt/left renal vein, demonstrating a SRS.
36
Al-Osaimi AMS, Caldwell SH. Medical and endoscopic management of gastric varices. Semin Interv Radiol 2011 ;28:273–282.
• Basic anatomy of a GV, with the portal circulation shaded
dark gray and the systemic circulation shaded light gray.
• The figure demonstrates the para- and supradiaphragmatic
portosystemic venous circulation, representing alternative
access routes to the BRTO procedure.
• The GRS in this drawing is rudimentary.
Rt BCV,right brachiocephalic vein; Lt BCV, left

brachiocephalic vein;
Lt SV, left subclavian vein; Peric V, Pericardiol or pericardio-
phrenic vein; AzA, azygous arch; AV, azygous venous system
or azygo-paraesophageal venous system; IPV, inferior
phrenic vein: descending portion (DpIPV) and transverse
portion (TpIPV);
37
Saad WEA, Sze DY. Variations of balloonoccluded antegrade transvenous obliteration (BATO) and alternative/ adjunctive routes for BRTO. Semin Interv Radiol 2011;28:314–324
(A) The balloon-occlusion catheter being advanced from a
transfemoral approach and positioned and inflated in the
transverse portion of the inferior phrenic vein and filling of
the GV with contrast (black).
(B) The balloon-occlusion catheter being advanced from a transfemoral

approach and positioned and inflated in the transverse portion of the inferior
phrenic vein via the left brachiocephalic and pericardial veins ,with
ultimate filling of the GV with contrast (black).
(C) Balloon-occlusion catheter being advanced from a transfemoral approach
and positioned and inflated in the descending portion of the inferior phrenic
vein via the azygous arch and azygous-paraesophageal venous system,
ultimately filling the GV with contrast (black).
38
• The basic and surgical anatomy of a gastric
varix, with the portal circulation shaded gray
and the systemic circulation shaded black.
• A combined balloon-occluded antegrade
transvenous obliteration (BATO) and BRTO
access is illustrated.
• The BATO access is via a TIPS.
• The BRTO access is via the traditional
transfemororenal access.
39
The Kiyosue classification of GV
(a) Classification based on drainage pathway
• Type A consists of a
portosystemic shunt as the only
drainage
• Type B: PSS along with
additional small portosystemic
collaterals
• Type C: there is presence of
• multiple large PSS
Type D consists of multiple small portosystemic collaterals as the drainage pathways
without proper shunt formation.
A.Arora, S.Rajesh, Y. S.Meenakshi, B. Sureka,K.Bansal, and S. K. Sarin, “Spectrumof hepatofugal collateral pathways in portal hypertension: an illustrated radiological review,” Insights into Imaging, vol. 6, no.
405, pp.
559–572, 2015.
The Kiyosue classification of GV
(b) Classification based on the inflow pathway
• Type 1 consists of single
afferent vein for the varices
• Type 2 has multiple afferent
vessels contributing to the
variceal formation
• Type 3 is similar to Type 2 but with additional small collateral/shunts directly

communicating with outflow tract.
A.Arora, S.Rajesh, Y. S.Meenakshi, B. Sureka,K.Bansal, and S. K. Sarin, “Spectrumof hepatofugal collateral pathways in portal hypertension: an illustrated radiological review,” Insights into Imaging, vol. 6, no. 5, pp.
559–572, 2015. 41
Coil-assisted retrograde transvenous obliteration
42/56
The concept of BRTO
• The concept of BRTO involves accessing the GRS via the
LRV through the femoral or jugular route and injecting a
sclerosant agent such as ethanolamine oleate, absolute
alcohol, gelfoam, or sodium tetradecyl sulphate into the
varices after inflating a balloon in the GRS to obstruct the
shunt outflow, thereby obliterating the varices[1-4] Taken from: https://articl.net/resource/balloon-occluded-retrograde-
transvenous-obliteration-brto
• In the presence of a completely thrombosed main PV, GRS act as the primary outflow of the splenic and mesenteric
veins. So, occlusion of the GRS, which is a by-product of the BRTO procedure, would potentially cause mesenteric
venous hypertension, mesenteric ischemia, and possibly thrombosis of the entire splanchnic portal venous
circulation.
• Although PVT is not an absolute CI to BRTO, it is a hemodynamic dilemma that has not been investigated fully. Chronic
occlusion of the main PV with cavernous transformation may provide sufficient outflow for the portal venous system
after occluding the portosystemic shunts, and therefore it may be acceptable to proceed with the BRTO procedure with
the risks and benefits of the procedure taken into consideration.[5]
43
References are at the end of the slides
Clinical Outcomes of BRTO Procedure for the
management of Gastric Varices
In most studies, GV rebleeding rates of pts who had undergone a successful BRTO range from zero-12%
after a median follow-up of 33 to 75 wks, and rates for complete obliteration of GV range from 86-
100%.
44
Clinical Outcomes of BRTO Procedures for GV
Procedural complications: • The 30-day mortality rates range from zero

• Gross hematuria with AKI(up to 4.8%)
to 4.1%, and the most common cause of death
• Pulmonary embolism (1.5%–4.1%)
• Anaphylaxis to ethanolamine oleate (up to
is progressive liver failure.[1-9]
5%) • Most of these complication were related with
• Cardiac arrhythmias (up to 1.5%) use of ethanolamine oleate. Sodium
• Rapidly declining hepatic function (5%– tetradecyl sulfate (STS) foam is also widely
7%) used for BTRO procedure,[2,3] and
complication of BRTO has also changed. For
example, STS foam does not lead to AKI.
But it could make air embolism.
References are at the end of the slides 45

PHTN complications related to BRTO
Other complications from increased PHTN after BRTO
• Development of PHG (5%–13%)
• Ascites (0%–44%)
• Hydrothorax (0%–8%).[1-9]
Another most important complications a/with BRTO is the aggravation of EV. Reported rates of
worsening EV vary up to 63%, with 11% to 24% subsequent variceal bleeding rate.[1-9]
1. Fukuda T, Hirota S, Sugimura K. Long-term results of balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy. J Vasc Interv Radiol. 2001; 12:327–36.
2. Ninoi T, Nishida N, Kaminou T, Sakai Y, Kitayama T, Hamuro M, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices with gastrorenal shunt: long-term follow-up in 78 patients. AJR Am J Roentgenol. 2005; 184:1340–6.
3. Ninoi T, Nakamura K, Kaminou T, Nishida N, Sakai Y, Kitayama T, et al. TIPS versus transcatheter sclerotherapy for gastric varices. AJR Am J Roentgenol. 2004; 183:369–76.
4. Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 1996; 11:51–8.
5. Sonomura T, Sato M, Kishi K, Terada M, Shioyama Y, Kimura M, et al. Balloon-occluded retrograde transvenous obliteration for gastric varices: a feasibility study. Cardiovasc Intervent Radiol. 1998; 21:27–30.
6. Kitamoto M, Imamura M, Kamada K, Aikata H, Kawakami Y, Matsumoto A, et al. Balloon-occluded retrograde transvenous obliteration of gastric fundal varices with hemorrhage. AJR Am J Roentgenol. 2002; 178:1167–74.
7. Arai H, Abe T, Shimoda R, Takagi H, Yamada T, Mori M. Emergency balloon-occluded retrograde transvenous obliteration for gastric varices. J Gastroenterol. 2005; 40:964–71.
8.
9.
Cho SK, Shin SW, Lee IH, Do YS, Choo SW, Park KB, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices: outcomes and complications in 49 patients. AJR Am J Roentgenol. 2007; 189:W365–72.
Hiraga N, Aikata H, Takaki S, Kodama H, Shirakawa H, Imamura M, et al. The long-term outcome of patients with bleeding gastric varices after balloon-occluded retrograde transvenous obliteration. J Gastroenterol. 2007; 42:663–72.
46
HCC after BRTO
• Yooyama et al investigated the incidence of HCC after BRTO in pts with
chronic viral hepatatits related CLD (HCV:66, HBV:5) .
• Group A, pts without H/O HCC before BRTO (n=40) and group B, pts
with H/O RX for HCC and DX with no HCC appearance when BRTO
was performed (n=31).
• Non-BRTO group: 51 pts with chronic viral hepatatits related and
without H/O HCC
Group A Group B Non BRTO

% % %
1 YR 20.9 35.8 6.3
3 YR 41.1 80.0 19.2
5 YR 60.7 0 42.5
The study demonstrated a high incidence of HCC after BRTO in
LC pts with viral hepatitis infection. This suggested the potential
for BRTO to accelerate hepatocarcinogenesis.
47
Yokohama et al. The Incidence of Hepatocellular Carcinoma after Balloon-Occluded Retrograde Transvenous Obliteration. Volume 2015, Article ID 605292, 7 pages
Clinical Outcomes of the TIPS procedure for GV
• There are limited data addressing TIPS for the treatment of GV, as most TIPS studies
have included all EV with or without GV. There are 8 studies evaluating the placement
of a TIPS for bleeding GV.[1-8]

48/56
cTIPS Vs BRTO : in treatment of pt bleeding from gastric varices
Bare stents were used in earlier studies, which, are known to have lower patency when compared to covered
stents, and likely account for the higher rebleeding rates. More recently, Sabri et al[1] and Sauk et al [2] did
a retrospective study to compare cTIPS with BRTO for MX of pts bleeding from GV.
Sabri et al. 2014[1] Sauk et al. 2014[2]

Single center retrospective Single center retrospective
cTIPS versus BRTO (foam sclerosant) cTIPS versus BRTO (EO or Sotradecol foam)
Procedural complications: 7% Vs 12%, p = 0.463
Technical success rate: 100% Vs 91%, p = 0.21 Resolution of GV on follow-up: 60% Vs 87%, p= 0.079
Major complications: 4% Vs 9%, p = 0 .344 Rebleeding rates: 7% Vs 12%, p = 0.463
HE: 15% Vs 0%, p = 0.12 HE: 22% Vs 0%,p = 0.012
At 12 mnths, incidence of rebleeding: 11% Vs 0%, p = 0.25 Development of new ascites: 4% Vs 4%, p = 0.937
BRTO is an effective method in the RX of GV with
BRTO appears to be equivalent to TIPS in the short-term for
similar outcomes and complication rates as TIPS, but
management of bleeding GV
with a lower rate of HE.
27 Vs 23 27 Vs 25
49
TIPS or BRTO ?
• In Summary, reviewing the literature suggest that both TIPS and BRTO can effectively
treat GV with low rebleeding rates, however careful pt selection is required to best
treat the pt’s individual clinical situation.
For pts with GV and severe HE or If a pt’s MELD score is

high
If there is recurrent gastric variceal bleeding even after TIPS

revision
In pts in whom a TIPS placement is technically difficult

For eg: In pts with cavernous transformation of a chronically thrombosed
main PV, a TIPS procedure could be technically difficult.
If there is a centrally located tumor and no window for the

TIPS stent to land without violating the tumor 50
TIPS or BRTO ?
• As discussed from the review of the literature, both TIPS and BRTO can effectively
treat GV with low rebleeding rates, however careful pt selection is required to best
treat the pt’s individual clinical situation.
If the BRTO procedure is complicated by vein rupture or

balloon rupture with subsequent clinical failure, TIPS could be
placed .
For pts with GV and intractable ascites or hydrothorax, TIPS
is a better option.
If there is EV in addition to GV, a TIPS procedure or BRTO

after endoscopic ligation of the EV can be performed.
51
Role of adjunct therapy ?
• BRTO and TIPS are two procedures that are considered for the RX of bleeding GV.
[1,2,3]
TIPS creates a portosystemic TIPS BRTO BRTO involves occlusion of a commonly

shunt and thus decompresses the associated spontaneous portosystemic
portal circulation shunt that usually causes increased PP
The effectiveness of adjunctive variceal embolization after decompressing the portal circulation with a TIPS
is a matter of debate.
Adjunctive embolization is performed after TIPS if the varices are still visualized during the post-TIPS
portal venogram,[4,5] Variceal embolization likely helps reduce the risk of bleeding in the setting of
subsequent TIPS dysfunction as well.[6]
1. Saad W EA Al-Osaimi A M Caldwell S et al.For the Expert Panel on Interventional Radiology for the American College of Radiology ACR Appropriateness Criteria(r): Radiologic Management of Gastric Varices. Available at:
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Interventional/RadiologicManagementGastricVarices.pdf.
2. Saad W E, Darcy M D. Transjugular intrahepatic portosystemic shunt (TIPS) versus balloon-occluded retrograde transvenous obliteration (BRTO) for the management of gastric varices. Semin Intervent Radiol. 2011;28(3):339–349.
3. Saad W E, Wagner C C, Lippert A. et al.Protective value of TIPS against the development of hydrothorax/ascites and upper gastrointestinal bleeding after balloon-occluded retrograde transvenous obliteration (BRTO) Am J Gastroenterol. 2013;108(10):1612–1619.
4. Kessler J, Trerotola S O. Use of the Amplatzer Vascular Plug for embolization of a large retroperitoneal shunt during transjugular intrahepatic portosystemic shunt creation for gastric variceal bleeding. J Vasc Interv Radiol. 2006;17(1):135–140.
5. Gaba R C, Bui J T, Cotler S J. et al.Rebleeding rates following TIPS for variceal hemorrhage in the Viatorr era: TIPS alone versus TIPS with variceal embolization. Hepatol Int. 2010;4(4):749–756.
6. Lunderquist A, Vang J. Transhepatic catheterization and obliteration of the coronary vein in patients with portal hypertension and esophageal varices. N Engl J Med. 1974;291(13):646–649. 52
TIPS + Emb Vs TIPS alone
Tesdal et al. 2005[1] Chen et al. 2013[2] Qi et al. 2013[3]

bTIPS and variceal embolization Vs cTIPS and variceal embolization Vs mTIPS and variceal embolization Vs
bTIPS alone (RS) cTIPS alone (PS) mTIPS alone (MA)
lower incidence of RVH: OR 2.02, 95% CI
1.29-3.17, p = 0.002
The 2-year and 4-year rebleeding rates 16 6-month rebleeding rate: 6 vs. 20%; p = Shunt dysfunction: OR 1.26, 95% CI 0.76-
and 19%, Vs 39 and 47%; p = 0.02 0.02 2.08, p = 0.38
HE: OR 0.81, 95% CI 0.46-1.43, p = 0.4
Death: OR 0.90, 95% CI 0.55-1.47, p=
0.68
TIPS and adjunctive embolotherapy of The TIPS+E regimen may reduce the risk Adjunctive variceal embolization during
gastroesophageal collateral vessels of RVH during the first 6 months by TIPS procedures might be beneficial in the
significantly lower the rebleeding rate in preventing shunt dysfunction, which may prevention of RVH.
comparison to TIPS alone. improve liver function.
53 Vs 42 54 Vs 52 6 studies

53
BRTO Vs BRTO + TIPS
• One study directly compared the outcomes of BRTO only
Saad et al. 2013[1] versus the outcomes of combining BRTO and TIPS; this
study demonstrated the superior outcomes of combining
TIPS with BRTO instead of BRTO alone.[1]
BRTO Vs BRTO + TIPS; (RS) • Moreover, when comparing the available literature, the
combined TIPS–BRTO procedure has demonstrated superior
• Pre-BRTO ascites / HH resolved in7 % Vs 56 results to TIPS alone in the MX of GV.[2-6]
% ;p = 0.006
• The ascites / HH free rate at 6, 12, and 24 months
58 % , 43 % ,29 % , and 100 % , 100 % , 100 %;
p= 0.01
• RVH at 6, 12, and 24 months was 9 % , 9 % , 21 1. Saad W E, Wagner C C, Lippert A. et al.Protective value of TIPS against the development of hydrothorax/ascites and upper gastrointestinal
bleeding after balloon-occluded retrograde transvenous obliteration (BRTO) Am J Gastroenterol. 2013;108(10):1612–1619.
% vs. 0 % , 0 % , 0 %; p= 0.03 2. Sabri S S, Abi-Jaoudeh N, Swee W. et al.Short-term rebleeding rates for isolated gastric varices managed by transjugular intrahepatic
portosystemic shunt versus balloon-occluded retrograde transvenous obliteration. J Vasc Interv Radiol. 2014;25(3):355–361.
• The 1-year survival of both groups (80 – 88 % ) 3. Mahadeva S, Bellamy M C, Kessel D, Davies M H, Millson C E. Cost-effectiveness of N-butyl-2-cyanoacrylate (histoacryl) glue injections versus
transjugular intrahepatic portosystemic shunt in the management of acute gastric variceal bleeding. Am J Gastroenterol. 2003;98(12):2688–
was similar; p> 0.05 4.

2693.
Ninoi T, Nakamura K, Kaminou T. et al.TIPS versus transcatheter sclerotherapy for gastric varices. AJR Am J Roentgenol. 2004;183(2):369–376.
5. Choi Y H, Yoon C J, Park J H, Chung J W, Kwon J W, Choi G M. Balloon-occluded retrograde transvenous obliteration for gastric variceal
bleeding: its feasibility compared with transjugular intrahepatic portosystemic shunt. Korean J Radiol. 2003;4(2):109–116.
6. Lo G H, Liang H L, Chen W C. et al.A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus
27 Vs 9 cyanoacrylate injection in the prevention of gastric variceal rebleeding. Endoscopy. 2007;39(8):679–685.
54
• In conclusion, there is growing evidence that embolizing or obliterating varices
arising from the portal system leads to reduced rebleed rates.
• Moreover, combining TIPS and BRTO is more effective than either procedure alone
when managing gastric varices.
55
56
References: History
1. Saxon RR, Mendel-Hartvig J, Corless CL, et al. Bile duct injury as a major cause of stenosis and occlusion in transjugular intrahepatic
portosystemic shunts: comparative histopathologic analysis in humans and swine. J Vasc Interv Radiol 1996;7(4):487–497
2. Nishimine K, Saxon RR, Kichikawa K, et al. Improved transjugular intrahepatic portosystemic shunt patency with PTFE-covered stent-grafts:
experimental results in swine. Radiology 1995; 196(2):341–347
3. Haskal ZJ, Davis A, McAllister A, Furth EE. PTFE-encapsulated endovascular stent-graft for transjugular intrahepatic portosystemic shunts:
experimental evaluation. Radiology 1997;205(3): 682–688
4. Barrio J, Ripoll C, Bañares R, et al. Comparison of transjugular intrahepatic portosystemic shunt dysfunction in PTFE-covered stent-grafts
versus bare stents. Eur J Radiol 2005;55(1):120–124
5. Charon JP, Alaeddin FH, Pimpalwar SA, et al. Results of a retrospective multicenter trial of the Viatorr expanded polytetrafluoroethylene-
covered stent-graft for transjugular intrahepatic portosystemic shunt creation. J Vasc Interv Radiol 2004;15(11):1219–1230
6. Maleux G, Nevens F, Wilmer A, et al. Early and long-term clinical and radiological follow-up results of expanded-polytetrafluoroethylene-
covered stent-grafts for transjugular intrahepatic portosystemic shunt procedures. Eur Radiol 2004;14(10):1842–1850
7. Hausegger KA, Karnel F, Georgieva B, et al. Transjugular intrahepatic portosystemic shunt creation with the Viatorr expanded
polytetrafluoroethylene-covered stent-graft. J Vasc Interv Radiol 2004;15(3):239–248
8. Angeloni S, Merli M, Salvatori FM, et al. Polytetrafluoroethylenecovered stent grafts for TIPS procedure: 1-year patency and clinical results.
Am J Gastroenterol 2004;99(2):280–285
57
References: Hepatic encephalopathy
1. Riggio O, Angeloni S, Salvatori FM, De Santis A, Cerini F, Farcomeni A, et al. Incidence, natural history, and risk factors of hepatic encephalopathy after transjugular intrahepatic
portosystemic shunt with polytetrafluoroethylene-covered stent grafts. Am J Gastroenterol. 2008 Nov;103(11):2738–46.
2. Nolte W, Wiltfang J, Schindler C, Münke H, Unterberg K, Zumhasch U, et al. Portosystemic hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients
with cirrhosis: clinical, laboratory, psychometric, and electroencephalographic investigations. Hepatology. 1998 Nov;28(5):1215–25.
3. Berlioux P, Robic MA, Poirson H, Métivier S, Otal P, Barret C, et al. Pre-transjugular intrahepatic portosystemic shunts (TIPS) prediction of post-TIPS overt hepatic encephalopathy:
the critical flicker frequency is more accurate than psychometric tests. Hepatology. 2014 Feb;59(2):622–9.
4. Salerno F, Cammà C, Enea M, Rössle M, Wong F. Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data. Gastroenterology .
2007 Sep;133(3):825–34.
5. Chalasani N, Clark WS, Martin LG, Kamean J, Khan MA, Patel NH, et al. Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic
shunting. Gastroenterology. 2000 Jan;118(1):138–44.
6. Kim HK, Kim YJ, Chung WJ, Kim SS, Shim JJ, Choi MS, et al. Clinical outcomes of transjugular intrahepatic portosystemic shunt for portal hypertension: Korean multicenter real-
practice data. Clin Mol Hepatol. 2014 Mar;20(1):18–27.
7. Bai M, Qi X-S, Yang Z-P, Yang M, Fan D-M, Han G-H. TIPS improves liver transplantation-free survival in cirrhotic patients with refractory ascites: an updated meta-analysis. World J
Gastroenterol. 2014 Mar 14;20(10):2704–14.
8. D’Amico G, Luca A, Morabito A, Miraglia R, D’Amico M. Uncovered transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis. Gastroenterology. 2005
Oct;129(4):1282–93.
9. Riggio O, Masini A, Efrati C, Nicolao F, Angeloni S, Salvatori FM, et al. Pharmacological prophylaxis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt:
a randomized controlled study. J Hepatol. 2005 May;42(5):674–9.
10. Fanelli F, Salvatori FM, Rabuffi P, Boatta E, Riggio O, Lucatelli P, et al. Management of refractory hepatic encephalopathy after insertion of TIPS: long-term results of shunt
reduction with hourglass-shaped balloon-expandable stent-graft. AJR Am J Roentgenol. 2009 Dec;193(6):1696–702.
11. Vilstrup H, Amodio P, Bajaj J, Cordoba J, Ferenci P, Mullen KD, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the
Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014 Aug;60(2):715–35.
12. Casado M, Bosch J, García-Pagán JC, Bru C, Bañares R, Bandi JC, et al. Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings.
Gastroenterology. 1998 Jun;114(6):1296–303.
13. Rössle M, Gerbes AL. TIPS for the treatment of refractory ascites, hepatorenal syndrome and hepatic hydrothorax: a critical update. Gut. 2010 Jul;59(7):988–1000.
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References: TIPS: Bare stent Vs PTFE-covered stent
1. Casado M, Bosch J, Garcia-Pagan JC, Bru C, Banares R, Bandi JC, et al. Clinical events after transjugular intrahepatic portosystemic
shunt: correlation with hemodynamic findings. Gastroenterology 1998;114:1296–1303.
2. Riggio O, Angeloni S, Salvatori FM, De Santis A, Cerini F, Farcomeni A, et al. Incidence, natural history, and risk factors of hepatic
encephalopathy after transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stent grafts. Am J
Gastroenterol 2008;103:2738–2746.
3. Sauerbruch T, Mengel M, Dollinger M, Zipprich A, Rossle M, Panther E, et al. Prevention of rebleeding from esophageal varices in
patients with cirrhosis receiving small-diameter stents vs. hemodynamically controlled medical therapy. Gastroenterology
2015;149:660–668.
4. Wang Q, Lv Y, Bai M, Wang Z, Liu H, He C, et al. Eight millimetre covered TIPS does not compromise shunt function but reduces
hepatic encephalopathy in preventing variceal rebleeding. J Hepatol 2017;67: 508–516.
5. Bureau C, Garcia-Pagan JC, Otal P, Pomier-Layrargues G, Chabbert V, Cortez C, et al. Improved clinical outcome using
polytetrafluoroethylene-coated stents for TIPS: results of a randomized study. Gastroenterology 2004;126:469–475.
6. Nishimine K, Saxon RR, Kichikawa K, Mendel-Hartvig J, Timmermans HA, Shim HJ, Uchida BT, Barton RE, Keller FS, Rösch J. Improved
transjugular intrahepatic portosystemic shunt patency with PTFE-covered stent-grafts: experimental results in swine. Radiology.
1995;196:341-347.
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References: TIPS: Covered Vs Bare
1. Qi X, et al. Covered versus bare stents for transjugular intrahepatic portosystemic shunt: an updated meta-analysis of randomized
controlled trials. Therap Adv Gastroenterol. 2017 Jan; 10(1): 32–41.
2. Bureau C., Garcia-Pagan J., Otal P., Pomier-Layrargues G., Chabbert V., Cortez C., et al. (2004) Improved clinical outcome using
polytetrafluoroethylene-coated stents for TIPS: results of a randomized study. Gastroenterology 126: 469–475.
3. Perarnau J., Le Gouge A., Nicolas C., D’Alteroche L., Borentain P., Saliba F., et al. (2014) Covered vs. uncovered stents for
transjugular intrahepatic portosystemic shunt: a randomized controlled trial. J Hepatol 60: 962–968
60
References: Prevention of recurrent variceal bleeding:
cTIPS Vs Medical therapy + EVL
1. Sauerbruch T., Mengel M., Dollinger M., Zipprich A., Rossle M., Panther E., et al. (2015) Prevention of rebleeding from esophageal
varices in patients with cirrhosis receiving small-diameter stents versus hemodynamically controlled medical therapy.
Gastroenterology 149: 660.e1–668.e1.
2. Luo X., Wang Z., Tsauo J., Zhou B., Zhang H., Li X. (2015) Advanced cirrhosis combined with portal vein thrombosis: a randomized
trial of tips versus endoscopic band ligation plus propranolol for the prevention of recurrent esophageal variceal bleeding. Radiology
276: 286–293.
3. Holster I., Tjwa E., Moelker A., Wils A., Hansen B., Vermeijden J., et al. (2016) Covered transjugular intrahepatic portosystemic shunt
versus endoscopic therapy + β-blocker for prevention of variceal rebleeding. Hepatology 63: 581–589.
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References: The concept of BRTO
1. Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by
balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 1996;11:51–8.
2. Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori Y, Okino Y. Transcatheter obliteration of gastric varices:
Part-1: Anatomic classification. Radiographics. 2003;23:911–20.
3. Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori Y, Okino Y. Transcatheter obliteration of gastric varices:
Part-2: Strategy and techniques based on hemodynamic features. Radiographics. 2003;23:921–37.
4. Olson E, Yune HY, Klatte EC. Transrenal-vein reflux ethanol sclerosis of gastroesophageal varices. Am J Taken from: https://articl.net/resource/balloon-occluded-retrograde-
Roentgenol. 1984;143:627–8. transvenous-obliteration-brto
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preprocedural evaluation and imaging. Semin Intervent Radiol 2011;28:288–295
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References: Clinical Outcomes of BRTO Procedures for GV
1. Ninoi T, Nakamura K, Kaminou T, Nishida N, Sakai Y, Kitayama T, et al. TIPS versus transcatheter sclerotherapy for gastric varices. AJR
Am J Roentgenol. 2004; 183:369–76. DOI: 10.2214/ajr.183.2.1830369. PMID: 15269027.
2. Sabri SS, Abi-Jaoudeh N, Swee W, Saad WE, Turba UC, Caldwell SH, et al. Short-term rebleeding rates for isolated gastric varices
managed by transjugular intrahepatic portosystemic shunt versus balloon-occluded retrograde transvenous obliteration. J Vasc
Interv Radiol. 2014; 25:355–61.
3. Sauk S, Niemeyer M, Kim SK, Korenblat K. Outcomes from balloon-occluded retrograde transvenous obliteration (BRTO) versus
transjugular intrahepatic portosystemic shunt (TIPS) in the management of isolated gastric varices: a retrospective study in single US
medical center. J Vasc Interv Radiol. 2014; 25(Suppl 3):S80.
4. Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by balloon-occluded retrograde
transvenous obliteration. J Gastroenterol Hepatol. 1996; 11:51–8.
5. Sonomura T, Sato M, Kishi K, Terada M, Shioyama Y, Kimura M, et al. Balloon-occluded retrograde transvenous obliteration for
gastric varices: a feasibility study. Cardiovasc Intervent Radiol. 1998; 21:27–30.
6. Kitamoto M, Imamura M, Kamada K, Aikata H, Kawakami Y, Matsumoto A, et al. Balloon-occluded retrograde transvenous
obliteration of gastric fundal varices with hemorrhage. AJR Am J Roentgenol. 2002; 178:1167–74.
7. Arai H, Abe T, Shimoda R, Takagi H, Yamada T, Mori M. Emergency balloon-occluded retrograde transvenous obliteration for gastric
varices. J Gastroenterol. 2005; 40:964–71.
8. Cho SK, Shin SW, Lee IH, Do YS, Choo SW, Park KB, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices:
outcomes and complications in 49 patients. AJR Am J Roentgenol. 2007; 189:W365–72.
9. Hiraga N, Aikata H, Takaki S, Kodama H, Shirakawa H, Imamura M, et al. The long-term outcome of patients with bleeding gastric
varices after balloon-occluded retrograde transvenous obliteration. J Gastroenterol. 2007; 42:663–72.
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References: Clinical Outcomes of BRTO Procedure for the
management of Gastric Varices
1. Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by balloon-occluded retrograde
transvenous obliteration. J Gastroenterol Hepatol. 1996; 11:51–8.
2. Sonomura T, Sato M, Kishi K, Terada M, Shioyama Y, Kimura M, et al. Balloon-occluded retrograde transvenous obliteration for
gastric varices: a feasibility study. Cardiovasc Intervent Radiol. 1998; 21:27–30.
3. Kitamoto M, et al. Balloon-occluded retrograde transvenous obliteration of gastric fundal varices with hemorrhage. AJR Am J
Roentgenol. 2002; 178:1167–74.
4. Ninoi T, et al. TIPS versus transcatheter sclerotherapy for gastric varices. AJR Am J Roentgenol. 2004; 183:369–76.
5. Arai H, Abe T, Shimoda R, Takagi H, Yamada T, Mori M. Emergency balloon-occluded retrograde transvenous obliteration for gastric
varices. J Gastroenterol. 2005; 40:964–71.
6. Cho SK, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices: outcomes and complications in 49 patients.
AJR Am J Roentgenol. 2007; 189:W365–72.
7. Hiraga N, Aikata H, Takaki S, Kodama H, Shirakawa H, Imamura M, et al. The long-term outcome of patients with bleeding gastric
varices after balloon-occluded retrograde transvenous obliteration. J Gastroenterol. 2007; 42:663–72.
8. Sabri SS, et al. Short-term rebleeding rates for isolated gastric varices managed by transjugular intrahepatic portosystemic shunt
versus balloon-occluded retrograde transvenous obliteration. J Vasc Interv Radiol. 2014; 25:355–61.
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References to: Clinical Outcomes of the TIPS Procedure for GV
1. Chau TN, Patch D, Chan YW, Nagral A, Dick R, Burroughs AK. “Salvage” transjugular intrahepatic portosystemic shunts: gastric fundal
compared with esophageal variceal bleeding. Gastroenterology. 1998; 114:981–7.
2. Barange K, Péron JM, Imani K, Otal P, Payen JL, Rousseau H, et al. Transjugular intrahepatic portosystemic shunt in the treatment of
refractory bleeding from ruptured gastric varices. Hepatology. 1999; 30:1139–43.
3. Rees CJ, Nylander DL, Thompson NP, Rose JD, Record CO, Hudson M. Do gastric and oesophageal varices bleed at different portal
pressures and is TIPS an effective treatment? Liver. 2000; 20:253–6.
4. Choi YH, Yoon CJ, Park JH, Chung JW, Kwon JW, Choi GM. Balloon-occluded retrograde transvenous obliteration for gastric variceal
bleeding: its feasibility compared with transjugular intrahepatic portosystemic shunt. Korean J Radiol. 2003; 4:109–16.
5. Ninoi T, Nakamura K, Kaminou T, Nishida N, Sakai Y, Kitayama T, et al. TIPS versus transcatheter sclerotherapy for gastric varices. AJR
Am J Roentgenol. 2004; 183:369–76.
6. Lo GH, Liang HL, Chen WC, Chen MH, Lai KH, Hsu PI, et al. A prospective, randomized controlled trial of transjugular intrahepatic
portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding. Endoscopy. 2007; 39:679–85.
7. Sabri SS, Abi-Jaoudeh N, Swee W, Saad WE, Turba UC, Caldwell SH, et al. Short-term rebleeding rates for isolated gastric varices
managed by transjugular intrahepatic portosystemic shunt versus balloon-occluded retrograde transvenous obliteration. J Vasc
Interv Radiol. 2014; 25:355–61.
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References to cTIPS Vs BRTO : in treatment of pt bleeding from gastric varices
1.Sabri SS, Abi-Jaoudeh N, Swee W, Saad WE, Turba UC, Caldwell SH, et al. Short-term
rebleeding rates for isolated gastric varices managed by transjugular intrahepatic
portosystemic shunt versus balloon-occluded retrograde transvenous obliteration. J Vasc
Interv Radiol. 2014; 25:355–61.
2.Sauk S, Niemeyer M, Kim SK, Korenblat K. Outcomes from balloon-occluded retrograde
transvenous obliteration (BRTO) versus transjugular intrahepatic portosystemic shunt
(TIPS) in the management of isolated gastric varices: a retrospective study in single US
66
References: Prevention of recurrent variceal bleeding: TIPS + Emb Vs TIPS alone
1. Tesdal IK, Filser T, Weiss C, Holm E, Dueber C, Jaschke W. Transjugular intrahepatic portosystemic shunts: adjunctive
embolotherapy of gastroesophageal collateral vessels in the prevention of variceal rebleeding. Radiology 2005; 236:
360–7.
2. Chen S, Li X, Wei B et al. Recurrent variceal bleeding and shunt patency: prospective randomized controlled trial of
transjugular intrahepatic portosystemic shunt alone or combined with coronary vein embolization. Radiology 2013; 268:
900–6.
3. Qi, X., Liu, L., Bai, M., Chen, H., Wang, J., Yang, Z., Fan, D. (2014). Transjugular intrahepatic portosystemic shunt in
combination with or without variceal embolization for the prevention of variceal rebleeding: A meta-analysis. Journal of
Gastroenterology and Hepatology, 29(4), 688–696.
ETC
Kim k,et al. Transjugular intrahepatic portosystemic shunts versus balloon-occluded retrograde transvenous obliteration for the management of gastric varices: Treatment algorithm according to clinical manifestations.
68
Gastrointestinal Intervention 2016; 5(3): 170-176.

Tips Vs Brto

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Tips Vs Brto

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TIPS Vs BRTO

Pratap Sagar Tiwari

1 TIPS: Intro/ History/ Procedure

2 BRTO: Intro/ History/ Procedure

3 Role of TIPS & BRTO in VH

Procedure endpoint defined as a AASLD places practice guidelines on the

Flow direction in PV & branches Velocity in the shunt device

Evaluation of the collateral vessels

Patency and flow direction in HVs

References are present at the end of the slides. 22

References are present at the end of the slides. 25

Bureau et al. 2015[2] Perarnau et al. 2015[3]

12 RCT; 883 pts

Sauerbruch et al. 2015 Luo et al. 2015 Holster et al. 2016

References are present at the end of the slides. 28

Rt BCV,right brachiocephalic vein; Lt BCV, left

(B) The balloon-occlusion catheter being advanced from a transfemoral

• Type 3 is similar to Type 2 but with additional small collateral/shunts directly

Procedural complications: • The 30-day mortality rates range from zero

References are at the end of the slides 45

Group A Group B Non BRTO

References are at the end of the slides

Sabri et al. 2014[1] Sauk et al. 2014[2]

For pts with GV and severe HE or If a pt’s MELD score is

If there is recurrent gastric variceal bleeding even after TIPS

In pts in whom a TIPS placement is technically difficult

If there is a centrally located tumor and no window for the

If the BRTO procedure is complicated by vein rupture or

If there is EV in addition to GV, a TIPS procedure or BRTO

TIPS creates a portosystemic TIPS BRTO BRTO involves occlusion of a commonly

Tesdal et al. 2005[1] Chen et al. 2013[2] Qi et al. 2013[3]

References are at the end of the slides

was similar; p> 0.05 4.

27 Vs 9 cyanoacrylate injection in the prevention of gastric variceal rebleeding. Endoscopy. 2007;39(8):679–685.

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