Say Goodbye to CARTO; Introducing Web- Straddled Plug- Assisted Retrograde Transvenous Obliteration of Gastric Varices (WS-PARTO).

Learning Objectives:

• To review the anatomy of the gastrorenal shunt pertinent to plug deployment.


• To introduce a refined technique for performing plug-assisted retrograde transvenous obliteration of gastric varices in patients with portal hypertension and large gastrorenal shunts.


• To present a case series in which this refined technique was used, along with a review of outcomes and safety.

Background: Gastric varices (GV) are a known complication of portal hypertension. Bleeding from GV can be fatal, as it can lead to catastrophic blood loss. Additionally, bleeding from GV is more difficult to control endoscopically. Plug-assisted transvenous obliteration (PARTO) of gastric varices is an established treatment option. Plugs should be oversized by at least 25-30%. However, the largest available Amplatzer II plugs are 22 mm in size, which allows for embolization of gastrorenal shunts up to 16-17 mm. Although coil-assisted retrograde transvenous obliteration can be used for larger gastrorenal shunts, this refinement of the standard PARTO technique can replace CARTO, with high clinical and technical success rates while decreasing procedural times for shunts larger than 16-18 mm in diameter.

Clinical Findings/Procedure Details: GV with large gastrorenal shunts may require the use of CARTO to effectively embolize the shunt. Performing PARTO on these patients can be limited by the available plug sizes and the traditional deployment techniques described in the literature. A modified technique, where the plug is straddled by the venous web at the junction of the distal gastrorenal shunt with the left adrenal vein, allows for secure and safe deployment of the plug even in larger gastrorenal shunts where oversizing is not possible (Shunts greater than 16 mm). We present a case series in which this refined technique was used, demonstrating an excellent technical and clinical outcomes and safety profile.

Conclusion and/or Teaching Points: Web-straddled PARTO is a newer, refined version of the standard PARTO technique that can replace CARTO and enable safe and effective embolization of significantly larger gastrorenal shunts.