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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