Accelerated Balloon-Retrograde Transvenous Obliteration (a-BRTO): a Real-World Analysis of Results in the Management of Gastric Variceal (GV) Bleeding at a Tertiary Gastrointestinal Bleeding Centre in Spain

Aims Gastric Variceal (GV) bleeding represents a significant clinical challenge due to its high mortality rate, which has been reported to be as high as 45% at six months, despite the fact that it is less common than esophageal varices. Therapeutic options, which combine endoscopic and interventional radiology approaches, are scarce, complex, and limited to specialised centres, hindering robust evidence to guide clinical decisions. This study evaluates the clinical outcomes of accelerated-BRTO (a-BRTO), a modified technique that reduces the balloon occlusion time from the conventional 4-24 hours, thereby minimising complications. The results aim to improve the applicability and safety of this promising approach to the management of GV bleeding.

Methods A descriptive and retrospective study was conducted at the Reina Sofía University Hospital, a tertiary gastrointestinal bleeding centre in southern Spain. Clinical and technical outcomes of all a-BRTO performed by an Interventional Radiology Unit over the past nine years (2016-2024) were evaluated. In addition, technical and clinical complications that occurred during and after the procedure, as well as the time to rebleeding and mortality, if any, were evaluated using descriptive statistical tools and Kaplan-Meier analysis [1] [2] [3] [4] [5].

Results Of the 20 patients who underwent a-BRTO, 16 (80%) were male, with a median age of 64 years (IQR 38-80) and a Charlson Comorbidity Index of 6.5 (IQR 3-14). Most patients (95%) had hepatic portal hypertension, 65% had alcohol-related liver disease, and 25% were on anticoagulants or antiplatelets. Median Meld-Na Score was 11 (IQR 6-24). Index bleeding occurred a median of 6.8 years after cirrhosis diagnosis, requiring blood transfusions in 85% of patients (median 2 units per-patient). At gastroscopy, 45%, 50%, and 5% of GOV2, IGV1, and IGV2 varices were identified, respectively. The a-BRTO procedure was successfully performed in 16 (80%) cases, with four technical complications (20%), with one intra-procedural death. Balloon occlusion lasted a median of 75 minutes (IQR 30-180). Over a median follow-up of 15 months (0-82), no additional procedure-related deaths occurred. Four rebleeding episodes were observed (three from GV, median time of 90 days), without related mortality. Cirrhosis decompensation occurred in 30% of patients, including encephalopathy (15%), ascites (10%), and hydrothorax (5%), with minimal thrombotic complications reported.

Conclusions The a-BRTO technique proved to be both effective and safe for the secondary prophylaxis of GV bleeding, with 3 (18.8%) cases of GV rebleeding observed during the follow-up period. Technical complications occurred in 4 (20%) patients, with one procedure-related death reported. Despite the adequate nine-year study period, the number of procedures performed was notably low, highlighting the importance of referring these patients to experienced centres to achieve the best possible clinical outcomes.

Publication History

Article published online:
27 March 2025

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