BRTO /PARTO

Indications and outcomes

Saher Sabri, MD

Associate Professor of Radiology and Surgery

Division of Interventional Radiology

University of Virginia Health System

Saher Sabri, M.D.

• Speakers Bureau: W.L.Gore & Associates, Abbott

Disclosures

W.L. Gore- Speaker

RTO Indications

To treat encephalopathy

GV bleed with contraindication to TIPS

( ex. Encephalopathy)

Continued GV bleed after TIPS

optimization ( RTO vs antegrade GV

sclerosis)

? Isolated GV bleed. No EVs or ascites.

Outcomes- Technical success

568 BRTO patients-Meta-analysis

Technical success rate is 91%

Complete obliteration rate is 93%

Partial obliteration is more common in complex varices

( 3 or more afferent veins) Takaji et al (AJR 2011)

Technical and clinical failures were routinely treated

with endoscopic NBCA injection

Saad et al CVIR 2013

OUTCOMES- Rebleeding

The GV rebleed rate after successful BRTO procedure

was 3.2–8.7 %

For all types of variceal rebleed rate reached 19–31 %

The rate of exacerbation of existing EVs

1 year is 27–35 %

2 years 45–66 %

3 years 45–91 %

EV bleeding occurred in in 17–24 %

Aggressive surveillance for EVs is needed

Rebleeding TIPS vs BRTO - Sabri et al JVIR 2013

27 TIPS and 22 BRTO for GVs TIPS with embolization of afferent veins (coils and AVP)

Technical success 100% TIPS and 93% BRTO

Complications 4% TIPS 9% BRTO

Encephalopathy 15% TIPS , 0% BRTO

1 year Rebleeding from a GV source 11% TIPS ,

0% BRTO (p 0.2)

2 TIPS dysfunction and one continued

bleeding despite TIPS optimization

Outcome

Author Patients (n) Technical success

(%)

Rebleeding rate

(%)

Complete

obliteration rate

(%)

Cho et al 49 84 0 100

Hiraga et al 34 97 3 91

Kitamoto et al 24 96 9 88

Arai et al 11 100 9 91

Ninoi et al 78 87 0 95

Kanagawa et al 32 100 0 97

Sabri et al 22 91 0 89

Updated UVA 70 94 2 92

Gown et al

(PARTO)

73 100 2 98

PARTO (Gwon et al JVIR 2015)

73 patients ( 57 GV bleeds and 16 HE)

Technical success 100%

AVP II ( 8-22 mm)- 70 only had one plug

Rebleeding 1/73

Complete obliteration at 3 months 98.6%

All HE had resolution of symptoms and decrease in Ammonia

level (p<.001)

ZERO complications

PARTO

Chang et al. (Korean J Rad) 19 pts . 95% tech success

Acute complications included fever (n = 2), fever and

hypotension (n = 2; one diagnosed adrenal insufficiency), and

transient microscopic hematuria (n = 3)

Obliteration rate 84%

Kim at al CVIR Jan 2016

Retrospective . 95 patients ( follow up available

on 70 )

BRTO with EO in 49 patients. BRTO with STS

foam in 25. PARTO in 21

Technical success was 95% (94% BRTO, 100%

PARTO)

Procedure time of PARTO was significantly

shorter than those of other two BRTO

procedures (P<0.017).

More complications with EO , including one

mortality from DIC.

Kim at al CVIR Jan 2016

3 cases of failure to obliterate GVs in BRTO with EO

group. None with STS

4 cases of failure with PARTO. (including 2 cases of

rebleeding )

At 1 YEAR 81 % obliteration rate for PARTO

Statistical difference of gastric varices recurrence

between two BRTO procedures and PARTO (P<0.05).

Conclusion: BRTO using STS foam and PARTO are better

than BRTO using EO in terms of complication or

procedure time. However, PARTO showed frequent

recurrence of gastric varices during the long-term

follow-up compared to BRTO.

OUTCOMES- Portal HTN Exacerbation

Development of ascites (0–44 %)

hepatic hydrothorax (0–8 %)

Hypertensive gastropathy (5–13 %)

In our experience 4/70 ( 6%) required

subsequent TIPS to treat complications of

portal HTN

Tanihata et al showed that 58 % of patients

have > 5 mmHg increase in PSG ( 58%) and

were associated with EV exacerbation

Effect of RTO on liver function

The bilirubin rises significantly (P = .007) within days

after RTO

The MELD score significantly improved 3-4 months

post-RTO (from 14.1 to 10.7, P = .0008).

Effect is transient and most patients return to baseline

by 6-9 months

The Child Pugh score did not change significantly (from

7.6 to 6.7, P = .063).

Ascites worsened in 31% of patients

Saad et al Vasc Endovasc Surgery 2013

RTO for Encephalopathy

65 patients reported in the literature

Immediate response is 86-100%

Long term improvement in HE 100%

Serum Ammonia levels of 127. mmol/L

decreased significantly to 28 mmol/L within

1 week after the procedure (P = .002)

( Gwon et at Radiology 2013)

Complications

Pulmonary complications.

Decrease in PaO2 and A-A gradient ( Arai et

al )

PE ( Sabri et al)

Venous thrombosis

Partial PV or SV thrombosis up to 15% ( Cho

et al)

Partial renal Vein thrombosis ( 7%)

Balloon rupture 8.7% ( Park et al)

Stroke from air embolus( R-L shunt)

TIPS & RTO combination

TIPS may have a protective effect on portal HTN

after RTO ( 5-10% of RTO pts will require TIPS at

some point)

TIPS placement may prevent PV thrombosis post

RTO with diminutive PVs

In Encephalopathic patients, can we replace a

large portosystemic shunt with a small

controllable shunt (TIPS)?

Scenarios

GV with EV or ascites and no encephalopathy:

TIPS +/- GV sclerosis( RTO or antegrade)

GV without EVS or ascites and encephalopathy:

RTO

GV with EV or ascites and encephalopathy:

??TIPS, NBCA , banding and medical management

GV without EVS or ascites and no

encephalopathy: I think RTO