When might BRTO rather than TIPS be indicated to treat gastric varices

When might BRTO rather than TIPS be indicated to treat gastric varices? 

  • BRTO is indicated in patients with a large gastrorenal or gastrocaval shunt who have hepatic encephalopathy, poor hepatic reserve, or a low portal pressure.
  • With TIPS, portal flow is diverted away from the liver and through the shunt; thus there is a risk of hepatic encephalopathy and deterioration of hepatic function.
  • With BRTO, the portal flow is often diverted toward the liver, which can potentially reduce hepatic encephalopathy and improve hepatic function.
  • In patients with a decompressive gastrorenal or splenorenal shunt, the portal pressure might already be lower than the traditional hemodynamic endpoint of the TIPS procedure (< 12 mm Hg) and there is little gain to further lower the gradient by creating a TIPS.
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