786 - A Comprehensive Review of Interventional Methods for Gastric Variceal Management: BRTO, CARTO, PARTO and TIPS Techniques

Learning Objectives: To classify gastric varices using Sarin classification, compare balloon-occluded (BRTO), coil-assisted (CARTO), plug-assisted (PARTO) retrograde transvenous obliteration, and trans jugular intrahepatic portosystemic shunt (TIPS) techniques, analyze success rates and complications, and apply evidence-based treatment selection criteria.

Background: Gastric variceal bleeding is life-threatening with 30% mortality and 44% rebleeding rates within five years. Unlike esophageal varices, gastric varices bleed at lower portal pressures with more severe hemorrhage. Sarin classification categorizes them as GOV1, GOV2, IGV1, IGV2, with IGV1 having highest bleeding risk. Traditional endoscopic cyanoacrylate injection achieves 91-99% hemostasis but risks systemic embolization. Interventional radiology offers highly effective alternatives.

Clinical Findings/Procedure Details: TIPS achieves 95-100% technical success for bleeding control but shows reduced efficacy with gastro-renal shunts, often requiring adjunctive embolization. Combined TIPS with variceal embolization demonstrates 3-18% rebleeding rates at 12-18 months. BRTO represents the gold standard with 84-100% technical success and 75-100% obliteration rates, achieving 95% bleeding control and resolving hepatic encephalopathy in 100% of patients. However, BRTO increases portal pressure, causing esophageal variceal development in 27-91% over 1-3 years. Modified techniques CARTO and PARTO achieve 100% and 92-100% technical success respectively, with excellent efficacy profiles and reduced complications. Optimal technique selection depends on shunt anatomy, with large spontaneous shunts favoring BRTO-based approaches, while patients with refractory ascites or hepatic encephalopathy benefit more from portal decompressive TIPS procedures. Procedure-related mortality rates remain low across all techniques, with overall 30-day mortality primarily correlating with underlying hepatic reserve rather than procedural technique.

Conclusion and/or Teaching Points: Interventional radiology provides superior outcomes for gastric varices compared to endoscopic therapy alone. TIPS remains first-line for portal decompression but may require adjunctive embolization. BRTO and modified techniques offer excellent gastric variceal obliteration with minimal morbidity but increase portal pressure. Patient selection should consider hepatic reserve, portal hemodynamics, and variceal anatomy. Long-term surveillance for esophageal varices is essential post-procedure.