Va s c u l a r a n d I n t e r ve n t i o n a l R a d i o l o g y • R ev i ew

Patel et al.
Transvenous Obliteration of Gastric Varices

Vascular and Interventional Radiology

Review
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Balloon-Occluded Retrograde
FOCUS ON:

Transvenous Obliteration of
Gastric Varices
Amish Patel1 OBJECTIVE. The purpose of this review is to describe the clinical factors related to
Aaron M. Fischman1 balloon-occluded retrograde transvenous obliteration, including the preparation needed, the
Wael E. Saad2 technique and challenges, and the outcomes.
CONCLUSION. Although the procedure can be performed when transjugular intrahe-
Patel A, Fischman AM, Saad WE patic portosystemic shunt is contraindicated or when endoscopic management fails, balloon-
occluded retrograde transvenous obliteration is successful as a first-line or second-line thera-
py. Gastric variceal rebleeding rates are low and serious complications are rare. Randomized
controlled trials are required to evaluate the superiority of this procedure over other methods
of treating gastric varices and to determine which sclerosant should be used. In the near fu-
ture, this procedure may play a larger role in emergency care and in the management of non-
gastric varices.

Background and History is recommended for the treatment of bleeding

Keywords: balloon-occluded retrograde transvenous
obliteration, gastric varices, TIPS, variceal bleeding
DOI:10.2214/AJR.12.9052
Received April 8, 2012; accepted without revision
April 23, 2012.
1
Department of Radiology, Division of Interventional
Radiology, Mount Sinai School of Medicine, One Gustave
L. Levy Pl, New York, NY 10029. Address correspondence
to A. M. Fischman (aaron.fischman@mountsinai.org).
2
Department of Radiology, Division of Vascular
Interventional Radiology, University of Virginia Health
System, Charlottesville, VA.
AJR 2012; 199:721–729
0361–803X/12/1994–721
© American Roentgen Ray Society
Gastric varices are notorious for being dif-
ficult to manage and often require a multi-
disciplinary approach [1, 2]. Although less
prevalent and less likely to bleed than esoph-
ageal varices [1, 3], gastric varices tend to
require more blood transfusions and have
higher mortality when bleeding occurs [3–5].
Treatment options for bleeding gastric vari-
ces are varied and include medical, surgical,
endoscopic, and endovascular approaches
[1]. Two general procedural approaches ex-
ist: indirectly decrease the pressure in the var-
ices by decompressing the portal system or
directly exclude (sclerose) the varices from
the portosystemic system. An indirect ap-
proach can be performed either surgically or
percutaneously by establishing a transjugular
intrahepatic portosystemic shunt (TIPS) [6–
8]. However, portosystemic shunts such as a
TIPS are typically used as second-line acute
therapy (second to endoscopic management)
or to prevent rebleeding [4, 9]. Although de-
creasing portal pressure is considered effec-
tive in reducing the bleeding rate of esopha-
geal varices, it is inconsistently effective for
gastric varices, which tend to occur and bleed
at lower portal pressures [10, 11].
The first-line approach is typically en-
doscopic with injection of adhesive or scle-
rosant directly into the gastric varices [4, 12].
Although endoscopic variceal sclerotherapy
esophageal varices, its long-term success is
limited for isolated gastric varices [13]. This
difference is attributed to the relatively large
size and high flow of gastric varices, which
require large volumes of sclerosant that are
susceptible to being washed away, potentially
leading to systemic (pulmonary) embolization
[4, 14]. Allowing modulation of flow within
the varices, a new endovascular approach is
widely used in Japan, where it has been exten-
sively studied and accepted as the treatment
of choice of gastric varices [9, 14–27]. This
endovascular approach is currently referred to
as balloon-occluded retrograde transvenous
obliteration. In 1984 Olsen and coworkers
[28], in their case report on transrenal vein re-
flux ethanol sclerosis, first described this pro-
cedure as we now know it [29].
In 1996, Kanagawa and colleagues [14]
revived the procedure using ethanolamine
oleate and coined the term balloon-occluded
retrograde transvenous obliteration. The con-
cept is to optimize the action of the sclerosing
agent by inducing stagnation in the gastric
varices, thereby allowing maximal sclerosant
dwell time to cause endothelial sclerosis and
vascular thrombosis [14]. It is approached
with a technique similar to that for high-flow
vascular malformation [29, 30].
In this review, we describe the pathophys-
iology of portal hypertension, indications for

AJR:199, October 2012 721


the procedure, key features in patient eval-
uation, the importance of preprocedure im-
aging, and the relevant anatomy of gastric
varices. We also describe the technical fea-
tures of the procedure, including equipment,
choice of embolic agent, and technical chal-
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lenges and considerations. Finally, we review
the literature on outcomes and comparison
with other therapies and propose future di-
rections for the procedure.
Pathophysiology of Portal
Hypertension
Venous blood draining from the stomach,
pancreas, spleen, and intestines enters the
liver via the portal vein, which is formed by
the confluence of the splenic and mesenteric
veins. Intrahepatically, blood passes through
the hepatic sinusoids and into the hepat-
ic veins and subsequently the inferior vena
cava. In liver disease such as cirrhosis, blood
flow through the hepatic sinusoids is limited,
and portal pressure increases. This increased
portal pressure, normally 2–5 mm Hg, de-
fines portal hypertension, the complications
of which typically develop at greater than
12 mm Hg [7, 13]. In addition to gastric and
esophageal varices, the stigmata of portal
hypertension include transudative complica-
tions (ascites and hepatic hydrothorax) and
splenomegaly that can result in sequestration
and pancytopenia. Little is known about why
gastric varices occur in some patients and
esophageal varices in others [4]. The vari-
ous causes of portal hypertension are classi-
fied by location, as follows [7]: extrahepatic
postsinusoidal (Budd–Chiari syndrome), in-
trahepatic postsinusoidal (hepatic venooc-
clusive disease), sinusoidal (cirrhosis, cystic
liver disease, partial nodular transformation
of the liver, metastatic malignant disease),
intrahepatic presinusoidal (schistosomiasis,
sarcoidosis, congenital hepatic fibrosis, vi-
nyl chloride, drugs), and extrahepatic presi-
nusoidal (portal vein thrombosis, malignant
disease of pancreas, pancreatitis, congenital
extrahepatic portal vein occlusion). In a mi-
nority of cases in the United States (< 10%),
gastric varices occur with sentinel portal hy-
pertension (splenic vein thrombosis) and not
global portal hypertension [1, 2].
Indications
Despite being widely used in Asia, balloon-
occluded retrograde transvenous obliteration
is uncommon in the United States and is not
mentioned in the American Association for
the Study of Liver Diseases practice guide-
722 AJR:199, October 2012
Patel et al.
lines [31]. For this reason, indications to treat
gastric varices with this technique are not well
established in the United States. Although it
has been described for the management of ac-
tively bleeding gastric varices [32] and for he-
patic encephalopathy [17, 19], the procedure
appears most useful for preventing gastric
variceal rebleeding after endoscopic ther-
apy or when management with endoscopy
fails [15, 21, 24, 33]. This is particularly true
when patients are not good candidates for
TIPS (see later) [2]. Reasons for utilizing bal-
loon-occluded retrograde transvenous oblit-
eration over TIPS include coagulopathy, high
Model for End-stage Liver Disease (MELD)
score, and hepatic encephalopathy [5, 7, 17–
19, 24, 33]. Several reports from Asia have
described the use of the technique for both
emergency treatment and as prophylaxis of
bleeding from high-risk gastric varices [14,
17–19, 21, 24, 25], yet medical and endoscop-
ic therapies predominate in the United States,
where reports of endovascular obliteration are
few [13]. Although endoscopic therapy has re-
sulted in good initial hemostasis, reported re-
bleeding rates are high, ranging from 34% to
53% [10, 13, 34, 35]. Furthermore, mortality
from each episode of rebleeding is also high,
approximately 20% [35].
Patient Evaluation and
Preprocedure Imaging
Patients with cirrhosis and upper gastro-
intestinal bleeding should be in stable condi-
tion and undergo upper endoscopy for first-
line diagnostic and therapeutic purposes [1].
Aggressive volume resuscitation should be
avoided because variceal bleeding is pressure
driven, and overzealous fluid resuscitation can
increase bleeding [1]. With the indications for
balloon-occluded transvenous obliteration be-
ing poorly defined in the absence of random-
Fig. 1—47-year-old man
with portal hypertension
and recent gastric
bleeding. Contrast-
enhanced CT venogram
shows prominent gastric
varices (arrow) protruding
into gastric lumen.
ized controlled trials comparing its efficacy
with that of other therapies, patients should be
carefully evaluated to determine which ther-
apy is best in the clinical situation. Although
exact protocols differ between institutions,
evaluation should include preprocedure lab-
oratory studies (serum electrolytes, complete
blood cell count, coagulation panel, and liver
and kidney function tests) and cross-sectional
imaging (CT or MRI with coronal reformation
and acquisition) [1, 2]. Cross-sectional imag-
ing is required to determine the candidacy of
the patient for the procedure and the patency of
the splenic and portal veins [1, 2] (Fig. 1). The
traditional balloon-occluded retrograde trans-
venous obliteration procedure requires a por-
tosystemic shunt, usually a gastrorenal shunt
(Fig. 2). Preprocedure imaging should be ob-
tained immediately before balloon-occluded
transvenous obliteration so that the anatomy
of the shunt can be delineated and an approach
formulated. Any clinically significant coagu-
lation laboratory abnormality should be cor-
rected before the procedure. In addition, the
MELD score should be calculated for each pa-
tient to identify patients whose liver-related
mortality after TIPS would be high, perhaps
making balloon-occluded transvenous obliter-
ation more suitable [2, 30].
Anatomy of Gastric Varices
Eighty-five percent of gastric varices have
gastrorenal shunts, 10% have gastrocaval shunts,
and 5% have gastrocardiophrenic shunts [36].
A minority of patients with gastric varices have
a portosystemic communication along the
left gastric azygohemiazygous axis [37, 38].
Although balloon-occluded retrograde trans-
venous obliteration of gastropericardiophrenic
shunts and gastroazygous shunts is more chal-
lenging than that of gastrorenal and gastroca-
val shunts, success has been achieved, albeit in
 Transvenous Obliteration of Gastric Varices
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small case series and case reports [39, 40].
From the limited data available, the technical
success rate of conventional balloon-occluded
retrograde transvenous obliteration via a gas-
trorenal shunt compared with via unconven-
tional portosystemic venous routes is 92% ver-
sus 67% [37, 38, 41]. Nevertheless, difficult
variceal anatomy can make some patients in-
eligible for transcatheter obliteration, particu-
larly if draining veins are too large to be oc-
cluded by the balloon [19].
The technical difficulty of balloon-occluded
retrograde transvenous obliteration relies on
the anatomy of the afferent and draining veins
of the varices. This anatomy and how it alters
the approach have been thoroughly reviewed
by Kiyosue et al. [22, 23] and are briefly sum-
marized in this review. Other techniques, such
as coil embolization of collateral vessels and
use of multiple balloons, may be needed de-
pending on the variceal anatomy [23].
Gastric varices are most often supplied by
the left gastric, posterior gastric, or short gas-
tric veins or a combination of these vessels.
The pattern of this afferent supply is divided
into three types, each associated with an in-
creasing degree of technical difficulty. Gastric
varices supplied by a single afferent vein are
classified as type 1, those supplied by multiple
afferent veins as type 2, and those with contig-
uous gastric or portal branch veins that do not
contribute to the shunt as type 3 [22, 23]. With
type 3 afferent veins, balloon occlusion of the
draining vein can lead to a hemodynamic shift
within the varices and result in shunting of the
sclerosant away from the varices through the
contiguous gastric veins [22, 23].
The pattern of the draining systemic veins
(the shunts) is divided into four types, each
also posing an increasing degree of technical
difficulty. Gastric varices with a single drain-
ing vein are classified as type A, those with
AJR:199, October 2012 723
Fig. 2—55-year-old
woman with gastric
varices. CT venogram
shows gastrorenal
shunt leading to variceal
complex (arrow).
a single draining vein with collaterals as type
B, those with veins draining into both the
gastrorenal and gastrocaval systems as type
C, and those that do not drain into the renal or
caval systems as type D. Type B gastric var-
ices are further divided into three subtypes
depending on the degree of flow through
the collateral veins. Because type D gastric
varices drain through small tributaries that
cannot be catheterized, they are usually not
amenable to conventional balloon-occluded
retrograde transvenous obliteration [22, 23].
Technique
The balloon-occluded retrograde transve-
nous obliteration procedure is typically per-
formed with nursing-monitored moderate se-
dation [5], but it can be performed with local
anesthesia alone [9]. Access to the caval venous
system is achieved by right femoral or internal
jugular access through a 6- to 12-French vascu-
A B
Fig. 3—52-year-old man (A) and 42-year-old man (B) with gastric varices.
A and B, Fluoroscopic images show right femoral vein access (A) and right internal jugular vein access (B).
Arrows indicate catheters in gastrorenal shunts.
lar sheath (Fig. 3). Preoperative imaging may
reveal details about draining vein anatomy (fea-
tures of the gastrorenal shunt) that may make
one approach more favorable than the other
(Fig. 4). A compliant balloon catheter is po-
sitioned in the gastrorenal shunt. The compli-
ant balloon is inflated, the draining vein (gas-
trorenal shunt) is occluded, and the balloon is
sized appropriately. A retrograde venogram is
obtained manually through the balloon occlu-
sion catheter to better define the anatomy of the
varices and identify collateral vessels (Fig. 5).
If the collateral vessels shunt blood into or
contrast medium away from the varices, di-
lution of the sclerosant or nontarget emboli-
zation can occur. For this reason, the collat-
eral vessels are occluded before delivery of
the sclerosant (see later). A microcatheter is
placed through the occlusion balloon cathe-
ter, and the sclerosant is slowly injected into
the varices and left to sclerose and coagulate
(Fig. 6). Such dwelling times vary greatly be-
tween institutions, from 30 minutes [14, 42]
to 24 hours [43]. Several studies with dwell-
ing times less than 3 hours showed low initial
technical success rates, and repeat balloon-
occluded retrograde transvenous obliteration
was necessary, sometimes with longer dwell-
ing times, to achieve technical success rates
close to 100% [14, 17, 19, 42].
Excess sclerosant is aspirated, the balloon
is deflated (usually under real-time fluorosco-
py), and the catheters are removed. If repeat
venography shows insufficient clot formation
in the varices, balloon-occluded retrograde
transvenous obliteration can be reattempted
with additional sclerosant.

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Fig. 4—47-year-old man with gastric varices. Coronal
reformatted image from CT venogram reveals
angulation of left renal vein (arrow) in relation to
gastrorenal shunt. Acute angle suggests jugular
access is more appropriate for balloon-occluded
retrograde transvenous obliteration procedure.
Choice of Sclerosant
Sclerosants are harsh chemical agents that
act by denaturing biologic tissue. When in-
jected into a vein, they incite complete en-
dothelial destruction and fibrosis [44]. The
balance is delicate between chemical toxic-
ity and clinical efficacy. Agents such as etha-
nolamine oleate (Ethamolin, QOL Medical)
have been cited as being too prone to com-
plication and are rarely used in the United
States [44]. Detergent sclerosants have saf-
er profiles. Most sclerosants (including eth-
anolamine oleate and detergent sclerosants)
can be made into foam or froth by agitating
them with gas (carbon dioxide or air). This
process increases the volume-to-sclerosant
ratio, markedly increasing potency and safe-
ty [9, 44]. Because balloon-occluded retro-
grade transvenous obliteration is becoming
more popular outside Asia, use of detergent
sclerosants is being studied and has had good
preliminary results [5, 9].
Ethanolamine Oleate
Ethanolamine oleate is the predominant and
traditional sclerosant agent used in the balloon-
occluded retrograde transvenous obliteration
procedure, particularly in Asia [14–17, 19–21,
24, 32, 42, 43, 45, 46]. Ten percent ethanol-
amine oleate is typically mixed with an equal
volume of contrast medium, typically iopami-
dol, resulting in a 5% ethanolamine oleate–
iopamidol mixture. However, ethanolamine
724 AJR:199, October 2012
Patel et al.
Fig. 5—51-year-old man
with gastric varices.
Retrograde venogram
shows occlusion balloon
and multiple collateral
vessels in gastric variceal
complex. Metallic
coils are from previous
embolization procedure.
oleate is hemolytic, and the resultant free hemo-
globin can cause renal failure [47]. Therefore,
patients are typically pretreated with 4000
units of haptoglobin [19, 47]. In addition to the
lack of ready availability of haptoglobin in the
United States, lack of experience with ethanol-
amine oleate has made its use infrequent in the
United States [5]. Some authors [17, 48–50]
attempt to minimize the renal risk by using a
reserved approach and injecting less ethanol-
amine oleate but accepting the probable need
for additional obliteration sessions.
Sodium Tetradecyl Sulfate
Sodium tetradecyl sulfate (STS) is the pre-
dominant sclerosant agent used in the bal-
loon-occluded retrograde transvenous oblit-
eration procedure in the United States (Saad
WE, unpublished data). Unlike ethanolamine
Fig. 6—51-year-old man with gastric varices.
Fluoroscopic image shows sclerosant mixture inside
gastric varices.
oleate, STS (STS 1% and 3% Sotradecol,
AngioDynamics) is a detergent, and U.S. op-
erators are experienced with its use throughout
the body [5]. Sabri et al. [5] found that com-
pared with obliteration with ethanolamine ole-
ate, performing the procedure with STS re-
quired a smaller volume of sclerosant. They
suggested that the smaller volume of sclerosant
can yield fewer systemic effects, and its prepa-
ration as a foam can make it a more effective
sclerosant [5, 29]. STS foam is typically pre-
pared with the use of a three-way stopcock to
combine a 3:2:1 ratio of gas (air or carbon di-
oxide) to 3% STS to lipiodol (Ethiodol, Savage
Laboratories). Other proportions of gas to STS
to lipiodol (less gas and more STS, producing a
froth and not a foam) have been used success-
fully in the United States [29].
Polidocanol (Hydroxy Polyethoxydodecane)
Also a detergent and used in foam form
for varicose vein sclerotherapy [51], poli-
docanol (0.5% polidocanol; 1% Asclera,
Merz Aesthetics) is widely used in the United
States [44] and has been studied as a sclerosant
for balloon-occluded retrograde transvenous
obliter­ation [9]. Choi et al. found that relative-
ly small volumes of polidocanol were required
for this procedure, decreasing the risk of com-
plication and avoiding the use of haptoglobin
to protect against renal failure. This complica-
tion was not observed in any of the 16 patients
in the study. The technical success, oblitera-
tion, and rebleeding rates with polidocanol
were similar to those with other sclerosants.
Polidocanol is relatively new to the U.S. mar-
ket and is not available in the United States in
the high concentrations it is elsewhere.
Foam Versus Liquid Sclerosant
The use of sclerosant in a foam or froth start-
ed in 2005–2006 in both Japan (polidocanol)
 Transvenous Obliteration of Gastric Varices
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Fig. 7—45-year-old woman with gastric varices. Venogram (left) shows collateral flow through inferior phrenic
vein (thick arrow) and pericardiophrenic vein (thin arrow). Fluoroscopic image (right) shows microcatheter
delivering coil.
and the United States (3% STS) [9, 29]. Even
ethanolamine oleate has been used as a foam
sclerosant [29]. The advantage of foam is that it
reduces the sclerosant-to-volume ratio, requir-
ing less sclerosant per procedure [29]. In addi-
tion, the foam sclerosant is thought to percolate
better into the numerous varices and convolu-
tions of the gastric variceal system (gastric vari-
ces and gastrorenal shunt) [29].
Technical Challenges and
Considerations
One potential technical challenge is the
presence of collateral vessels that might di-
lute the sclerosant or expose it to the system-
ic circulation [22, 23]. The reported use of
adjunctive techniques to prevent this prob-
lem ranges from 0% to 70%. Such adjunc-
tive techniques entail the use of coils [5, 9,
18, 19, 21, 46], gelatin sponge [5, 9, 16, 46],
50% glucose [18, 21, 43], or absolute ethanol
[17–19, 21] to occlude collateral vessels (Fig.
7). Although most gastric varices have a sin-
gle gastrorenal shunt, several include multi-
ple shunts [16, 21], which can be embolized
before injection of the sclerosant or occluded
with a second balloon [16, 18, 21].
Much of the literature on balloon-occluded
retrograde transvenous obliteration originates
from Japan, where 85% of people have meta-
bolic sensitivity to ethanol. Hirota et al. [19]
have suggested the use of an ethanol and eth-
anolamine oleate–iopamidol mixture for the
embolization of collateral vessels. Although
this problem is encountered less frequently in
AJR:199, October 2012 725
the United States, it should be considered in
the care of patients of Asian descent. Citing
the additional cost, time, and risk of coil mi-
gration and alcohol toxicity, Fukuda et al. [52]
described a method of decreasing the grade of
gastric varices to make them more amenable
to treatment. In that technique, the occlusion
balloon is positioned in the draining vein clos-
er to the varices, proximal to collateral vessels
that would have otherwise required emboliza-
tion. More proximal treatment is also achieved
by the use of a coaxial balloon catheter system
in which a 5-French balloon catheter is insert-
ed through a 9-French balloon catheter [53].
Fig. 8—51-year-old man with gastric varices. Preoperative CT image (left) shows large complex of gastric
varices. CT image 1 month after balloon-occluded retrograde transvenous obliteration (right) shows no residual
enhancement of varices. Residual lipiodol and interval increase in perisplenic ascites are evident.
However, several types of catheters, including
other types of microballoon catheters avail-
able in Asia and described in the literature, are
not readily available in the United States [54].
Although published technical failure rates
are low, the most often cited cause of techni-
cal failure is inability to cannulate or com-
pletely occlude the draining vein, which is
either too tortuous or too large [5, 16, 18, 21,
32, 43]. Other less common causes are mas-
sive variceal rupture and bleeding [14, 32],
the presence of complex collaterals decom-
pressing the varices [16, 21, 43], and use of
an insufficient amount of sclerosant [16].
In addition to these anatomic challenges,
physiologic challenges exist. Akahoshi et al.
[43] found that higher portal venous pressure
before the procedure resulted in significantly
longer procedure times. These patients also
needed more adjunctive therapies for collat-
eral vessels.
Complications
The complications described most often
are typically transient and self-limited. One
prospective trial [32] showed a similar inci-
dence of complications of balloon-occluded
retrograde transvenous obliteration and en-
doscopic n-butyl cyanoacrylate glue injec-
tion. Epigastric and back pain, fever, and he-
maturia were most common, often found in a
large percentage of patients [15–18, 21, 42,
46]. Other symptoms, such as nausea, elevat-
ed blood pressure, and changes in laboratory
values (liver and renal) were also found, but
in fewer patients [15, 42]. Bacterial peritonitis
was found in 8% of patients in one study, but

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Fig. 9—56-year-old woman with recent gastric hemorrhage. Preoperative CT image (left) shows varices
(arrow) protruding into lumen of stomach. Intraprocedural CT image (right) shows immediate technical success
and complete opacification of variceal complex (arrow) with sclerosant mixture.
these patients recovered after only conserva-
tive therapy [16], and this complication is oth-
erwise rarely mentioned in the literature.
The reported rates of new or worse ascites
and hydrothorax vary. One study [16] showed
worse ascites in 44% and hydrothorax in 72%
of patients [16] (Fig. 8). These patients’ con-
ditions returned to baseline a few months af-
ter the procedure. Portal vein and renal vein
thrombosis is found in a small number of pa-
tients and is typically clinically silent [5, 16].
Pulmonary embolism has been reported and
can be symptomatic, but the embolus is not
described as having high-density material in
it to suggest it has an origin from the treat-
ed gastric varices [5, 16, 43]. Even more rare
but potentially life-threatening ventricular fi-
brillation [43], pulmonary edema [5, 16], and
anaphylaxis to ethanolamine oleate [19] have
also been reported. Changes in pulmonary
function parameters can occur after balloon-
occluded retrograde transvenous oblitera-
tion even if clinical symptoms are not pres-
ent; thus careful respiratory monitoring is
recommended [55]. Although balloon rup-
ture has not been reported as a complication
in most series, in one series [56] it occurred
in 9% of patients. Although not yet reported
with transcatheter variceal obliteration but
seen with use of foam sclerosant elsewhere
in the body, air in the foam can embolize to
the lungs or to the systemic arterial circula-
tion through a patent foramen ovale [57, 58].
For lower extremity varicose vein sclerother-
apy, side effects are markedly decreased with
the use of carbon dioxide, a more physiologic
gas, instead of air in the foam [59, 60].
Outcomes
The details and outcomes of the reviewed
studies are shown in Table 1 [5, 9, 14–19,
21, 24, 32, 42, 43, 45, 46]. Technical suc-
726 AJR:199, October 2012
Patel et al.
cess, defined by successful filling of gastric
varices with sclerosant, is reported to occur
in 77–100% of patients (Fig. 9). Complete
obliteration of the gastric varices is reported
in 82–100% of patients. In some studies [14,
17, 19, 24], repeat balloon-occluded retro-
grade transvenous obliteration was necessary
to achieve such high percentages, but repeat
procedures often required large volumes of
sclerosants (greater than 30–40 cm3). Follow-
up periods are typically short-term and mid-
term, the longest mean follow-up period being
66 months [45]. Rebleeding rates are report-
ed to be as high as 15% [32] but are typically
much lower, most studies showing rebleeding
rates lower than 5%. Hong et al. [32] prospec-
tively compared balloon-occluded retrograde
transvenous obliteration with endoscopic n-
butyl cyanoacrylate injection and found the
latter to have a significantly decreased prob-
ability of rebleeding-free survival. That study
also showed significantly higher probabil-
ity of survival among patients treated with
transcatheter therapy and rescue transcath-
eter therapy after failed endoscopic therapy
than among patients treated with endosco-
py alone in the acute phase. In a recent ret-
rospective study comparing balloon-occluded
retrograde transvenous obliteration with en-
doscopic sclerotherapy, Akahoshi et al. [45]
found that transcatheter obliteration required
significantly fewer treatment sessions, had a
significantly higher eradication rate, and re-
quired a significantly shorter hospital stay.
Worsening esophageal varices occurs in
10–68% of patients and has been found to be
significantly more likely to occur when those
varices are already present [24, 43]. These var-
ices are most often successfully treated endo-
scopically, but a single patient death has been
reported [16]. Overall survival rates are re-
ported to be as low as 65% [46], but this same
study also showed that the cumulative survival
rate after balloon-occluded retrograde transve-
nous obliteration was significantly higher than
for patients not treated.
Just as occlusion of gastric varices can
cause redirection of portal blood to esoph-
ageal varices, portal blood can be redirect-
ed toward the liver, resulting in clinical im-
provement in the patient’s condition. Cho et
al. [16] described two patients in whom ex-
isting main portal vein bland thrombus re-
solved after balloon-occluded retrograde
transvenous obliteration but recurred later.
Marked improvement or resolution of hepat-
ic encephalopathy has been reported [17, 19],
as has a significant decrease in serum am-
monia concentration [19, 46], improvement
in serum albumin concentration [18, 20], res-
olution of ascites [17], and improvement of
Child-Pugh class [17, 46].
Balloon-Occluded Retrograde
Transvenous Obliteration Versus
TIPS and in Addition to Portal
Venous Modulator Procedures
TIPS has been previously reported as effec-
tive in the treatment of bleeding gastric vari-
ces [10, 61]. However, unlike balloon-occlud-
ed retrograde transvenous obliteration, TIPS
achieves the effect at the cost of a higher inci-
dence of encephalopathy compared with en-
doscopic therapy [34]. In addition, large gas-
tric varices not only tend to exist at lower portal
pressures because of their decompressive effect
Fig. 10—43-year-old man with cirrhosis and chronic
bleeding gastric varices. Venogram shows balloon-
occluded retrograde transvenous obliteration after
continued bleeding after placement of transjugular
intrahepatic portosystemic shunt (TIPS) 9 months
earlier. TIPS was confirmed to be widely patent on
previous studies.
 Downloaded from www.ajronline.org by 24.207.248.166 on 09/26/17 from IP address 24.207.248.166. Copyright ARRS. For personal use only; all rights reserved

TABLE 1: Summary of Published Reports of Balloon-Occluded Retrograde Transvenous Obliteration

Child-Pugh
Class Nature of Procedure (no.)
Technical Esophageal Adjunct
No. of Active, Elective, Success Obliteration Follow-Up Rebleed Varices Technique Survival
Reference Year Sclerosant Patients A B C Emergency Urgent Prophylactic Rate (%) Dwell Time (%) Period Rate (%) Worse (%) (%) Rate (%)
Akahoshi et al. [43] 2008 Ethanolamine 68 27 28 13 20 48 92 24 h 97 Mean 3 22 41 78.1
oleate–iopamidol 62 mo
Akahoshi et al. [45] 2012 Ethanolamine 42 8 20 14 42 100 24 h 95 Mean 5 26 100
oleate–iopamidol 66.2 mo
Arai et al. [15] 2005 Ethanolamine 11 5 4 1 11 91 1h 100 Mean 0 55 18 64
oleate–iopamidol 1136 d
Cho et al. [16] 2007 Ethanolamine 49 17 23 9 4 45 84 Mean 12.8 h 95 Mean 0 68 83
oleate–iopamidol 637 d
Fukuda et al. [17] 2001 Ethanolamine 43 6 29 8 43 100a ≥1 h 100a Mean 0 10 98
oleate–iopamidol 30 mo
Hiraga et al. [18] 2007 Ethanolamine 34 12 18 3 12 22 93 20 h 91 Median 0 29 71
oleate–iopamidol 33 mo
Hirota et al. [19] 1999 Ethanolamine 20 4 11 5 20 100a 1–3 h 100 Mean 0 16 70 95
oleate–iopamidol 16.6 mo
Hong et al. [32] 2009 Ethanolamine 13 5 6 2 13 77 4h 100 Median 15 31 77
oleate–iopamidol 14 mo
Kanagawa et al. [14] 1996 Ethanolamine 32 16 13 3 32 97a 30 min 97 Mean 0 19
oleate–iopamidol 14 mo
Kitamoto et al. [21] 2002 Ethanolamine 24 8 13 3 11 13 88 ≈20 h 100 Mean 0 35 33 96
oleate–iopamidol 21.2 mo
Ninoi et al. [24] 2005 Ethanolamine 78 52 24 2 11 67 87 Overnight 95 Mean 1 37 76
oleate–iopamidol 837 d
Sonomura et al. [42] 1998 Ethanolamine 14 1 6 7 1 13 100a 30 min 86 Mean 0 14
oleate–iopamidol 24 mo
Takuma et al. [46] 2005 Ethanolamine 17 7 10 0 17 100 Overnight 82 Mean 6 50 65
Transvenous Obliteration of Gastric Varices

oleate–iopamidol 35.5 mo
Choi et al. [9] 2011 Polidocanol 16 7 8 1 14 2 94 1h 91 Median 7 50
273 d
Sabri et al. [5] 2011 Sodium tetradecyl 22 22 91 4h 89a Mean 0 41
sulfate 130 d
aProcedure repeated multiple times.

AJR:199, October 2012 727


on the portal system [5] but also tend to bleed
at lower pressures compared with esophageal
varices [10, 11]. In the series reported by Sabri
et al. [5], two patients underwent balloon-oc-
cluded retrograde transvenous obliteration for
bleeding gastric varices despite having a func-
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tioning TIPS (Fig. 10). Saad and Darcy [30]
speculated on combining balloon-occluded
retrograde transvenous obliteration and TIPS
for patients with baseline substantial ascites
or hydrothorax or uncontrolled concomitant
esophageal varices who have reasonable he-
patic reserve (< 19 MELD). However, portal
venous modulators besides TIPS have been
proposed. Chikamori and coworkers [62] found
that concomitant splenic artery embolization
offset the increasing portal pressures after
transvenous variceal obliteration as evidenced
by the reduced development and bleeding rate
of esophageal varices.
Future Directions
Combining balloon-occluded retrograde
trans­venous obliteration with portal vein modu-
lator procedures (TIPS or splenic artery emboli-
zation) may be required in selected patients [29,
62]. Further research is required to determine
the ideal selection criteria for a TIPS or a splenic
artery embolization. Expansion of the balloon-
occluded retrograde transvenous obliteration
concept to include management of other vari-
ces is a new trend [63–68]. A few case reports
and small series reports show additional appli-
cations of the technique, including treatment of
small-bowel varices [63–65], parastomal vari-
ces [67], and spontaneous mesenteric portosys-
temic shunts [66, 68]. Management of gastric
varices with balloon-occluded retrograde trans-
venous obliteration via unconventional venous
routes is being practiced with greater frequency
[37, 39, 40]. There also has been a report of a
technique that entails both endoscopic and per-
cutaneous approaches, known as balloon-oc-
cluded endoscopic injection sclerotherapy [25].
Although this method can control gastric vari-
ces without the large draining veins needed for
balloon-occluded retrograde transvenous oblit-
eration, it requires percutaneous transhepatic
portography to gain access to the varices.
Conclusions
Balloon-occluded retrograde transvenous
obliteration is a well-established, minimally
invasive technique popular in Asia for treating
gastric varices by an endovascular approach.
However, it is gaining popularity in the United
States. Although the procedure can be per-
formed when TIPS is contraindicated or when
endoscopic management fails, it is successful
728 AJR:199, October 2012
Patel et al.
as a first- or second-line therapy. Gastric vari-
ceal rebleeding rates are low, and serious com-
plications are rare. Aggravation of esophageal
varices and transudative complications may be
an issue, but their exact clinical importance is
unknown. Randomized controlled trials are re-
quired to determine the superiority of balloon-
occluded retrograde transvenous obliteration
over other methods of treating gastric varices
and to better define the role of the technique in
managing gastric varices. In the near future,
this procedure may play an even larger role in
emergency treatment and in the management
of nongastric varices.
References
1. Al-Osaimi AM, Caldwell SH. Medical and endoscop-
ic management of gastric varices. Semin Intervent
Radiol 2011; 28:273–282
2. Saad WE, Al-Osaimi AM. Pre- and post-BRTO
imaging and clinical evaluation: indications,
management protocols and follow-up. Tech Vasc
Interv Radiol 2012 (in press)
3. Sarin SK, Lahoti D, Saxena SP, Murthy NS,
Makwana UK. Prevalence, classification and nat-
ural history of gastric varices: a long-term follow-
up study in 568 portal hypertension patients.
Hepatology 1992; 16:1343–1349
4. Ryan BM, Stockbrugger RW, Ryan JM. A patho-
physiologic, gastroenterologic, and radiologic ap-
proach to the management of gastric varices.
Gastroenterology 2004; 126:1175–1189
5. Sabri SS, Swee W, Turba UC, et al. Bleeding gastric
varices obliteration with balloon-occluded retrograde
transvenous obliteration using sodium tetradecyl sul-
fate foam. J Vasc Interv Radiol 2011; 22:309–316
6. Henderson JM, Nagle A, Curtas S, Geisinger M,
Barnes D. Surgical shunts and TIPS for variceal decom-
pression in the 1990s. Surgery 2000; 128:540–547
7. Eesa M, Clark T. Transjugular intrahepatic porto-
systemic shunt: state of the art. Semin Roentgenol
2011; 46:125–132
8. Rösch J, Hanafee WN, Snow H. Transjugular portal
venography and radiologic portacaval shunt: an ex-
perimental study. Radiology 1969; 92:1112–1114
9. Choi SY, Won JY, Kim KA, Lee do Y, Lee KH.
Foam sclerotherapy using polidocanol for bal-
loon-occluded retrograde transvenous oblitera-
tion (BRTO). Eur Radiol 2011; 21:122–129
10. Tripathi D, Therapondos G, Jackson E, Redhead
DN, Hayes PC. The role of the transjugular intrahe-
patic portosystemic stent shunt (TIPSS) in the man-
agement of bleeding gastric varices: clinical and
haemodynamic correlations. Gut 2002; 51:270–274
11. Watanabe K, Kimura K, Matsutani S, Ohto M,
Okuda K. Portal hemodynamics in patients with
gastric varices: a study in 230 patients with esoph-
ageal and/or gastric varices using portal vein cathe-
terization. Gastroenterology 1988; 95:434–440
12. Trudeau W, Prindiville T. Endoscopic injection
sclerosis in bleeding gastric varices. Gastrointest
Endosc 1986; 32:264–268
13. Jalan R, Hayes PC. UK guidelines on the manage-
ment of variceal haemorrhage in cirrhotic pa-
tients. British Society of Gastroenterology. Gut
2000; 46(suppl 3-4):III1–III15
14. 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; 11:51–58
15. Arai H, Abe T, Shimoda R, Takagi H, Yamada T,
Mori M. Emergency balloon-occluded retrograde
transvenous obliteration for gastric varices. J
Gastroenterol 2005; 40:964–971
16. Cho SK, Shin SW, Lee IH, et al. Balloon-occluded
retrograde transvenous obliteration of gastric
varices: outcomes and complications in 49 pa-
tients. AJR 2007; 189:1523; [web]W365–W372
17. Fukuda T, Hirota S, Sugimura K. Long-term re-
sults of balloon-occluded retrograde transvenous
obliteration for the treatment of gastric varices
and hepatic encephalopathy. J Vasc Interv Radiol
2001; 12:327–336
18. Hiraga N, Aikata H, Takaki S, et al. The long-term
outcome of patients with bleeding gastric varices
after balloon-occluded retrograde transvenous
obliteration. J Gastroenterol 2007; 42:663–672
19. Hirota S, Matsumoto S, Tomita M, Sako M, Kono
M. Retrograde transvenous obliteration of gastric
varices. Radiology 1999; 211:349–356
20. Hirota S, Kobayashi K, Maeda H, Yamamoto S,
Nakao N. Balloon-occluded retrograde transve-
nous obliteration for portal hypertension. Radiat
Med 2006; 24:315–320
21. Kitamoto M, Imamura M, Kamada K, et al.
Balloon-occluded retrograde transvenous obliter-
ation of gastric fundal varices with hemorrhage.
AJR 2002; 178:1167–1174
22. Kiyosue H, Mori H, Matsumoto S, Yamada Y,
Hori Y, Okino Y. Transcatheter obliteration of
gastric varices. Part 1. Anatomic classification.
RadioGraphics 2003; 23:911–920
23. Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori
Y, Okino Y. Transcatheter obliteration of gastric vari-
ces: Part 2. Strategy and techniques based on hemo-
dynamic features. RadioGraphics 2003; 23:921–937
24. Ninoi T, Nishida N, Kaminou T, et al. Balloon-
occluded retrograde transvenous obliteration of
gastric varices with gastrorenal shunt: long-term
follow-up in 78 patients. AJR 2005; 184:1340–1346
25. Shiba M, Higuchi K, Nakamura K, et al. Efficacy
and safety of balloon-occluded endoscopic injec-
tion sclerotherapy as a prophylactic treatment for
high-risk gastric fundal varices: a prospective, ran-
domized, comparative clinical trial. Gastrointest
Endosc 2002; 56:522–528
26. Sonomura T, Sahara S, Ono W, et al. Usefulness of
microcatheters inserted overnight for additional
 Transvenous Obliteration of Gastric Varices
injection of sclerosant after initial balloon-occlud-
ed retrograde transvenous obliteration of gastric
varices. Case Rep Gastroenterol 2011; 5:534–539
27. Sugimori K, Morimoto M, Shirato K, et al. Retrograde
transvenous obliteration of gastric varices associated
with large collateral veins or a large gastrorenal shunt.
Downloaded from www.ajronline.org by 24.207.248.166 on 09/26/17 from IP address 24.207.248.166. Copyright ARRS. For personal use only; all rights reserved
J Vasc Interv Radiol 2005; 16:113–118
28. Olson E, Yune HY, Klatte EC. Transrenal-vein
reflux ethanol sclerosis of gastroesophageal vari-
ces. AJR 1984; 143:627–628
29. Saad WE. The history and evolution of balloon-
occluded retrograde transvenous obliteration
(BRTO): from the United States to Japan and
back. Semin Intervent Radiol 2011; 28:283–287
30. Saad WE, Darcy MD. Transjugular intrahepatic
portosystemic shunt (TIPS) versus balloon-oc-
cluded retrograde transvenous obliteration
(BRTO) for the management of gastric varices.
Semin Intervent Radiol 2011; 28:339–349
31. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W.
Prevention and management of gastroesophageal
varices and variceal hemorrhage in cirrhosis.
Hepatology 2007; 46:922–938
32. Hong CH, Kim HJ, Park JH, et al. Treatment of
patients with gastric variceal hemorrhage: endo-
scopic N-butyl-2-cyanoacrylate injection versus
balloon-occluded retrograde transvenous obliter-
ation. J Gastroenterol Hepatol 2009; 24:372–378
33. Ferral H. Balloon-occluded retrograde transvenous
occlusion. Tech Vasc Interv Radiol 2008; 11:225–229
34. Khan S, Tudur Smith C, Williamson P, Sutton R.
Portosystemic shunts versus endoscopic therapy
for variceal rebleeding in patients with cirrhosis.
Cochrane Database Syst Rev 2006; CD000553
35. Bosch J, Garcia-Pagan JC. Prevention of variceal
rebleeding. Lancet 2003; 361:952–954
36. Chikamori F, Kuniyoshi N, Shibuya S, Takase Y.
Correlation between endoscopic and angiograph-
ic findings in patients with esophageal and isolat-
ed gastric varices. Dig Surg 2001; 18:176–181
37. Araki T, Hori M, Motosugi U, et al. Can balloon-
occluded retrograde transvenous obliteration be
performed for gastric varices without gastrorenal
shunts? J Vasc Interv Radiol 2010; 21:663–670
38. Saad WE, Sze DH. Variations of balloon-occluded
transvenous obliteration (BRTO): balloon-occlud-
ed antegrade transvenous obliteration (BATO) and
alternative/adjunctive routes for BRTO. Semin
Intervent Radiol 2011; 28:314–324
39. Kageyama K, Nishida N, Matsui H, Yamamoto A,
Nakamura K, Miki Y. Successful balloon-occluded
retrograde transvenous obliteration for gastric varix
mainly draining into the pericardiophrenic vein.
Cardiovasc Intervent Radiol 2012; 35:180–183
40. Minamiguchi H, Kawai N, Sato M, et al. Balloon-
occluded retrograde transvenous obliteration for
gastric varices via the intercostal vein. World J
Radiol 2012; 28:121–125
41. Saad WE, Sabri SS. Balloon-occluded transvenous
AJR:199, October 2012 729
obliteration (BRTO): technical results and out-
comes. Semin Intervent Radiol 2011; 28:333–338
42. Sonomura T, Sato M, Kishi K, et al. Balloon-
occluded retrograde transvenous obliteration for
gastric varices: a feasibility study. Cardiovasc
Intervent Radiol 1998; 21:27–30
43. Akahoshi T, Hashizume M, Tomikawa M, et al.
Long-term results of balloon-occluded retrograde
transvenous obliteration for gastric variceal bleed-
ing and risky gastric varices: a 10-year experience.
J Gastroenterol Hepatol 2008; 23:1702–1709
44. Duffy DM. Sclerosants: a comparative review.
Dermatol Surg 2010; 36(suppl 2):1010–1025
45. Akahoshi T, Tomikawa M, Kamori M, et al. Impact
of balloon-occluded retrograde transvenous oblit-
eration on management of isolated fundal gastric
variceal bleeding. Hepatol Res 2012; 42:385–393
46. Takuma Y, Nouso K, Makino Y, Saito S, Shiratori
Y. Prophylactic balloon-occluded retrograde trans-
venous obliteration for gastric varices in compen-
sated cirrhosis. Clin Gastroenterol Hepatol 2005;
3:1245–1252
47. Hashizume M, Kitano S, Yamaga H, Sugimachi
K. Haptoglobin to protect against renal damage
from ethanolamine oleate sclerosant. Lancet
1988; 2:340–341
48. Chikamori F, Kuniyoshi N, Shibuya S, Takase Y.
Eight years of experience with transjugular retro-
grade obliteration for gastric varices with gastro-
renal shunts. Surgery 2001; 129:414–420
49. Arai H, Abe T, Takagi H, Mori M. Efficacy of
balloon-occluded retrograde transvenous obliter-
ation, percutaneous transhepatic obliteration and
combined techniques for the management of gas-
tric fundal varices. World J Gastroenterol 2006;
12:3866–3873
50. Choi YH, Yoon CJ, Park JH, Chung JW, Kwon JW,
Choi GM. Balloon-occluded retrograde transvenous
obliteration for gastric variceal bleeding: its feasibil-
ity compared with transjugular intrahepatic portosys-
temic shunt. Korean J Radiol 2003; 4:109–116
51. Ouvry P, Allaert FA, Desnos P, Hamel-Desnos C.
Efficacy of polidocanol foam versus liquid in sclero-
therapy of the great saphenous vein: a multicentre
randomised controlled trial with a 2-year follow-up.
Eur J Vasc Endovasc Surg 2008; 36:366–370
52. Fukuda T, Hirota S, Sugimoto K, Matsumoto S,
Zamora CA, Sugimura K. “Downgrading” of gas-
tric varices with multiple collateral veins in bal-
loon-occluded retrograde transvenous oblitera-
tion. J Vasc Interv Radiol 2005; 16:1379–1383
53. Tanoue S, Kiyosue H, Matsumoto S, et al.
Development of a new coaxial balloon catheter
system for balloon-occluded retrograde transve-
nous obliteration (B-RTO). Cardiovasc Intervent
Radiol 2006; 29:991–996
54. Sabri SS, Turba UC, Saad WE, Park AW, Angle JF.
Balloon-occluded retrograde transvenous obliteration
of gastric varices. Endovasc Today 2010; April:1–5
55. Arai H, Abe T, Takayama H, et al. Respiratory effects
of balloon occluded retrograde transvenous oblitera-
tion of gastric varices: a prospective controlled study.
J Gastroenterol Hepatol 2011; 26:1389–1394
56. Park SJ, Chung JW, Kim HC, Jae HJ, Park JH.
The prevalence, risk factors, and clinical outcome
of balloon rupture in balloon-occluded retrograde
transvenous obliteration of gastric varices. J Vasc
Interv Radiol 2010; 21:503–507
57. Ceulen RP, Sommer A, Vernooy K. Microembolism
during foam sclerotherapy of varicose veins. N
Engl J Med 2008; 358:1525–1526
58. Forlee MV, Grouden M, Moore DJ, Shanik G.
Stroke after varicose vein foam injection sclero-
therapy. J Vasc Surg 2006; 43:162–164
59. Morrison N, Neuhardt DL, Rogers CR, et al.
Comparisons of side effects using air and carbon
dioxide foam for endovenous chemical ablation. J
Vasc Surg 2008; 47:830–836
60. Peterson JD, Goldman MP. An investigation into
the influence of various gases and concentrations
of sclerosants on foam stability. Dermatol Surg
2011; 37:12–17
61. Azoulay D, Castaing D, Majno P, et al. Salvage
transjugular intrahepatic portosystemic shunt for un-
controlled variceal bleeding in patients with decom-
pensated cirrhosis. J Hepatol 2001; 35:590–597
62. Chikamori F, Kuniyoshi N, Kawashima T, Takase
Y. Gastric varices with gastrorenal shunt: combined
therapy using transjugular retrograde obliteration and
partial splenic embolization. AJR 2008; 191:555–559
63. Tsurusaki M, Sugimoto K, Matsumoto S, et al.
Bleeding duodenal varices successfully treated with
balloon-occluded retrograde transvenous obliteration
(B-RTO) assisted by CT during arterial portography.
Cardiovasc Intervent Radiol 2006; 29:1148–1151
64. Zamora CA, Sugimoto K, Tsurusaki M, et al.
Endovascular obliteration of bleeding duodenal
varices in patients with liver cirrhosis. Eur Radiol
2006; 16:73–79
65. Hashimoto N, Akahoshi T, Yoshida D, et al. The
efficacy of balloon-occluded retrograde transve-
nous obliteration on small intestinal variceal
bleeding. Surgery 2010; 148:145–150
66. Hayashi S, Baba Y, Senokuchi T, Ueno K, Nakajo
M. Successful portal-systemic shunt occlusion of a
direct shunt between the inferior mesenteric vein and
inferior vena cava with balloon-occluded retrograde
transvenous obliteration following recanalization af-
ter placing a covered stent in the portal and superior
mesenteric veins. Jpn J Radiol 2009; 27:180–184
67. Minami S, Okada K, Matsuo M, Kamohara Y,
Sakamoto I, Kanematsu T. Treatment of bleeding
stomal varices by balloon-occluded retrograde trans-
venous obliteration. J Gastroenterol 2007; 42:91–95
68. Minamiguchi H, Kawai N, Sato M, et al. Balloon
occlusion retrograde transvenous obliteration for
inferior mesenteric vein-systemic shunt. J Vasc
Interv Radiol 2011; 22:1039–1044