P2505 - BRTO as a Definitive Treatment for Gastric Varices with Concurrent Splenorenal Shunt

Luis Rodriguez, DO, Scott Diamond, DO, Brian Carlson, MD
Valley Hospital Medical Center, Las Vegas, NV

Introduction: Transjugular intrahepatic portosystemic shunt (TIPS) is the preferred intervention for decompressing elevated portal pressures, especially with life-threatening esophageal and gastric variceal bleeds. Balloon retrograde transvenous obliteration (BRTO) is lesser-used and performed when TIPS is contraindicated; MELD score >18-20, right-sided heart failure, hepatic encephalopathy (HE), low hepatic venous portal pressure, or presence of spontaneous portosystemic shunt (SPSS).

Case Description/Methods: A 53-year-old male with decompensated cirrhosis from MASH, hypertension, diabetes mellitus type 2, and peptic ulcer disease was admitted for melena and coffee ground emesis. EGD done six months prior showed two small esophageal varices, two gastric varices, and a 3mm Forrest class III duodenal ulcer for which daily PPI was prescribed. Vital signs were stable. Hemoglobin was 4.5g/dL and MELD score was 12. He was resuscitated with fluids and blood products and started on IV pantoprazole, ceftriaxone, and octreotide drip.

CT abdomen and pelvis with and without IV contrast showed cirrhotic liver, gastric varices, splenomegaly, and duodenal wall thickening. EGD was performed showing two esophageal varices, one with red wale sign, one gastric varix (GOV2), and severe portal hypertensive gastropathy. No bleeding was seen.

Interventional Radiology was consulted for presumed bleeding GOV2. Angiography showed altered anatomy with overlapping portal and right hepatic vein, free and hepatic wedge gradient of 3-4mmHg, and a splenorenal shunt. Since there was a low portosystemic gradient, the decision was made to proceed with BRTO with coil embolization of gastric varices and splenorenal shunt.

Discussion: BRTO is an effective and lesser-used alternative when TIPS is contraindicated in the setting of a recurrent gastric variceal bleed with SPSS. TIPS is preferred in patients with a MELD< 20 with large esophageal varices, significant ascites, portal vein thrombosis, and absence of HE. BRTO is warranted in HE, MELD >20, or Freiburg Index of Post TIPS Survival >0.927.

In the presence of SPSS, BRTO has demonstrated higher rates of variceal obliteration, lower rates of bleeding recurrence, and fewer complications than TIPS. It does lead to elevated portal pressures which can aggravate known esophageal varices warranting close surveillance. BRTO is a safe and effective alternative to TIPS and understanding its restrictions and indications can lead to better patient outcomes for the management of portal hypertension.


Disclosures:


Luis Rodriguez, DO, Scott Diamond, DO, Brian Carlson, MD. P2505 - BRTO as a Definitive Treatment for Gastric Varices with Concurrent Splenorenal Shunt, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.