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Balloon-occluded antegrade transvenous obliteration (BATO). Subtype: trans-transjugular intrahepatic portosystemic shunt (TIPS) BATO: BATO involves embolization of the varices from the portal venous side. The graphic shows a subclassification of the BATO procedure known as trans-TIPS obliteration, in which the portal vein, and subsequently the portal venous side of varices, is accessed via indwelling TIPS.
Source publication
Bleeding gastric varices (GVs) is a life-threatening complication of portal hypertension, with higher morbidity and mortality rates compared with bleeding esophageal varices (EVs). The endovascular techniques for the management of GVs are mainly transjugular intrahepatic portosystemic shunt (TIPS) and transvenous obliteration of the GVs. Transvenou...
Context in source publication
Context 1
... procedure can be used as an adjunct to RTO procedures or as an alternative procedure in treating GVs without a GRS. 35 The two most common subtypes of the ATO procedure are PTO and trans-TIPS obliteration (Figures 6, 7), with the former involving accessing the portal vein using a micropuncture technique under real-time ultrasound guidance. Once access is achieved, the needle is exchanged for a sheath of adequate size (5-7 Fr) to accommodate most occlusion balloons, coils, or plugs. ...
Similar publications
Patients with both achalasia and decompensated cirrhosis can often present a therapeutic challenge because portal hypertension has generally been considered a contraindication to definitive therapies for achalasia. This case report depicts a patient who presented with progressive dysphagia, weight loss, and large-volume ascites; was diagnosed with...
Citations
... Accurate size estimation of esophageal varices (EVs) is essential for determining the exact diagnostic category, appropriate therapy, and observational intervals for patients with liver cirrhosis [1][2][3]. Visual estimation is currently the most commonly used method, but the estimation of EV size during endoscopy is highly inconsistent among different endoscopists [4][5][6], with only fair to moderate interobserver agreements reflected by kappa values of 0.38-0.59. In clinical practice, a cut-off diameter of 5 mm is used to classify varices as large or small. ...
... Upper gastrointestinal bleeding due to EVs in patients with portal hypertension is associated with high morbidity and mortality rates [1]. As the risk of variceal bleeding is assessed by variceal size [1], accurate measurement of EV size is important. ...
... Upper gastrointestinal bleeding due to EVs in patients with portal hypertension is associated with high morbidity and mortality rates [1]. As the risk of variceal bleeding is assessed by variceal size [1], accurate measurement of EV size is important. We therefore aimed to improve the accuracy of endoscopists to estimate EV size. ...
BACKGROUND
To avoid acute variceal bleeding in cirrhosis, current guidelines recommend screening for high-risk esophageal varices (EVs) by determining variceal size and identifying red wale markings. However, visual measurements of EV during routine endoscopy are often inaccurate.
AIM
To determine whether biopsy forceps (BF) could be used as a reference to improve the accuracy of binary classification of variceal size.
METHODS
An in vitro self-made EV model with sizes ranging from 2 to 12 mm in diameter was constructed. An online image-based survey comprising 11 endoscopic images of simulated EV without BF and 11 endoscopic images of EV with BF was assembled and sent to 84 endoscopists. The endoscopists were blinded to the actual EV size and evaluated the 22 images in random order.
RESULTS
The respondents included 48 academic and four private endoscopists. The accuracy of EV size estimation was low in both the visual (13.81%) and BF-based (20.28%) groups. The use of open forceps improved the ability of the endoscopists to correctly classify the varices by size (small ≤ 5 mm, large > 5 mm) from 71.85% to 82.17% (P < 0.001).
CONCLUSION
BF may improve the accuracy of EV size assessment, and its use in clinical practice should be investigated.
This editorial describes the milestones to optimize of transjugular intrahepatic portosystemic shunt (TIPS) technique, which have made it one of the main methods for the treatment of portal hypertension complications worldwide. Innovative ideas, subsequent experimental studies and preliminary experience of use in cirrhotic patients contributed to the introduction of TIPS into clinical practice. At the moment, the main achievement in optimize of TIPS technique is progress in the qualitative characteristics of stents. The transition from bare metal stents to extended polytetrafluoroethylene-covered stent grafts made it possible to significantly prevent shunt dysfunction. However, the question of its preferred diameter, which contributes to an optimal reduction of portal pressure without the risk of developing post-TIPS hepatic encephalopathy, remains relevant. Currently, hepatic encephalopathy is one of the most common complications of TIPS, significantly affecting its effectiveness and prognosis. Careful selection of patients based on cognitive indicators, nutritional status, assessment of liver function, etc., will reduce the incidence of post-TIPS hepatic encephalopathy and improve treatment results. Optimize of TIPS technique has significantly expanded the indications for its use and made it one of the main methods for the treatment of portal hypertension complications. At the same time, there are a number of limitations and unresolved issues that require further randomized controlled trials involving a large cohort of patients.
Vascular plug-assisted retrograde transvenous obliteration (PARTO) obliterates the gastric varices and portosystemic shunt, thus resulting in a lower rebleeding rate than endoscopic glue/sclerotherapy.
To evaluate the safety and efficacy of PARTO as salvage therapy in liver cirrhosis with gastric variceal bleed (GVB) after failed endotherapy. We assessed the clinical success rate and changes in liver function at 6- months.
Patients who underwent salvage PARTO after failed endotherapy for GVB (between December 2021 and November 2022) were searched and analyzed from the hospital database. Clinical success rate and rebleed rate were obtained at six months. Child–Pugh score (CTP) and Model for end-stage liver disease (MELD) score were calculated and compared between baseline and 6-month follow-up.
Fourteen patients (n = 14, Child–Pugh class A/B) underwent salvage PARTO. Nine had GOV-2, and five had IGV-1 varices. The mean shunt diameter was 11.6 ± 1.6 mm. The clinical success rate of PARTO was 100% (no recurrent gastric variceal hemorrhage within six months). No significant deterioration in CTP (6.79 ± 0.98 vs. 6.21 ± 1.52; p = 0.12) and MELD scores (11.5 ± 4.05 vs. 10.21 ± 3.19; p = 0.36) was noted at 6 months. All patients were alive at 6 months. One patient (n = 1, 7.1%) bled from esophageal varices after three days of PARTO and was managed with variceal banding. 21.4% (3/14) patients had progression of esophageal varices at 6 months requiring prophylactic band ligation. Three patients (21.4%) had new onset or worsening ascites and responded to low-dose diuretics therapy.
PARTO is a safe and effective procedure for bleeding gastric varices without any deterioration in liver function even after six months. Patient selection is critical to prevent complications. Further prospective studies with larger sample size are required to validate our findings.
