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      Optimizing logistics for balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices by doing away with the indwelling balloon: concept and techniques.

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          Abstract

          Since the conception of balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices 25 years ago, the placement of an indwelling balloon for hours has been central to the BRTO procedure. Numerous variables and variations of the BRTO procedure have been described, including methods to reduce sclerosant, combining percutaneous transhepatic obliteration, varying sclerosant, and using multiple sclerosants within the same procedure. However, the consistent feature of BRTO has always remained the indwelling balloon. Placing an indwelling balloon over hours for the BRTO procedure is a logistical burden that taxes the interventional radiology team and hospital resources. Substituting the balloon with hardware (coils or Amplatzer vascular plugs [AVPs] or both) is technically feasible and its risks most likely correlate with gastrorenal shunt (GRS) size. The current authors use packed 0.018- or 0.035-in coils or both for small gastric variceal systems (GRS size A and B) and AVPs for GRS sizes up to size E (from size A-E). The current authors recommend an indwelling balloon (no hardware substitute) for very large gastric variceal system (GRS size F). Substituting the indwelling balloon for hardware in size F and potentially size E GRS can also be risky. The current article describes the techniques of placing up to 16-mm AVPs through balloon occlusion guide catheters and then deflating the balloon once it has been substituted with the AVPs. In addition, 22-mm AVPs can be placed through sheaths once the balloon occlusion catheters are removed to further augment the 16-mm Amplatzer occlusion. To date, there are no studies describing, let alone evaluating, the clinical feasibility of performing BRTO without indwelling balloons. The described techniques have been successfully performed by the current authors. However, the long-term safety and effectiveness of these techniques is yet to be determined.

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          Author and article information

          Journal
          Tech Vasc Interv Radiol
          Techniques in vascular and interventional radiology
          Elsevier BV
          1557-9808
          1557-9808
          Jun 2013
          : 16
          : 2
          Affiliations
          [1 ] Division of Vascular and Interventional Radiology, Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA. wspikes@yahoo.com
          Article
          S1089-2516(13)00027-9
          10.1053/j.tvir.2013.02.006
          23830672
          3167d04b-563f-4345-8a86-67cf3bdc0aaf
          History

          obliteration,no balloon,ectopic varices,coils,balloon occlusion,BRTO,Amplatzers,transvenous obliteration,sclerosant

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