Balloon-occluded retrograde transvenous obliteration seals off bleeding-prone gastric varices from within the draining vein — without lowering overall portal pressure the way TIPSS can.
Gastric varices are dilated, fragile veins that form in the stomach lining as a consequence of portal hypertension — most often from cirrhosis — and carry a serious risk of sudden, heavy bleeding. Unlike oesophageal varices, gastric varices frequently drain through a large, naturally occurring shunt vessel — most commonly a gastrorenal shunt connecting the varix to the left renal vein and, from there, into the systemic circulation — rather than draining primarily back into the portal system. This shunt anatomy is what makes BRTO possible: by accessing and temporarily blocking this draining vein, it becomes possible to fill the varix complex itself with a sclerosant and seal it off from within, working from the outflow side rather than the arterial or portal side of the problem.
A catheter is advanced from a vein in the neck or groin into the gastrorenal shunt, and a balloon at the catheter tip is inflated to occlude the shunt's outflow. With outflow blocked, a sclerosant — most often a foamed detergent sclerosant, sometimes combined with coils or a gel-foam plug in modern variants of the technique — is injected through the catheter to fill the gastric varix and its feeding and draining channels. The balloon is left inflated for an extended period, often several hours, to allow the sclerosant to remain in contact with the vein wall and thrombose the entire varix complex, rather than washing out into the systemic circulation before it can take effect.
A gastrorenal or gastrocaval shunt identified on cross-sectional imaging — a prerequisite for the technique.
Particularly when endoscopic treatment has failed, isn't feasible, or carries a high risk of rebleeding.
Where TIPSS would control the varices but carries a meaningful risk of worsening liver function or encephalopathy.
A needle puncture is made in the neck or groin vein under sedation.
A catheter is guided into the draining shunt and a balloon blocks outflow from the varix.
A sclerosant fills the gastric varix and its feeding channels, confirmed on real-time imaging.
Most patients are observed overnight before going home the following day.
BRTO is most useful for patients with the specific combination of factors below, generally reviewed jointly by hepatology, gastroenterology, and interventional radiology:
Gastric varices with a suitable draining shunt — most often a gastrorenal or gastrocaval shunt identified on cross-sectional imaging, which is a prerequisite for the balloon-occlusion technique to work.
Active or prior gastric variceal bleeding, particularly when endoscopic treatment (such as glue injection) has failed, isn't feasible, or carries a high risk of rebleeding.
Poor liver reserve or a high risk of hepatic encephalopathy, where TIPSS would be effective at controlling the varices but carries a meaningful risk of diverting enough blood away from the liver to worsen liver function or trigger confusion and cognitive symptoms.
As a planned combination with TIPSS or splenic artery embolization in select patients, where BRTO controls the gastric varix directly while the second procedure manages overall portal pressure or reduces the risk of BRTO worsening oesophageal varices or ascites.
BRTO isn't the right choice for every patient with gastric varices — the absence of a suitable shunt vessel, dominant oesophageal variceal bleeding, or refractory ascites that would be worsened by increased portal pressure generally shift treatment toward TIPSS or endoscopic approaches instead, decided on a case-by-case basis.
Planning: cross-sectional imaging (CT venography) beforehand confirms the presence and course of a gastrorenal or other draining shunt, and maps the safest route for the catheter.
Access: under sedation, a needle puncture is made in the internal jugular vein in the neck or the femoral vein in the groin.
Catheterisation and balloon occlusion: a catheter is guided under X-ray guidance into the draining shunt vein, and a balloon at its tip is inflated to block outflow from the varix complex.
Sclerosant injection: a sclerosant, often as a foam, is injected through the catheter to fill the gastric varix and its feeding channels, confirmed on real-time imaging as it fills the varix rather than escaping into the systemic circulation.
Balloon dwell time: the balloon typically stays inflated for several hours — sometimes overnight — to give the sclerosant time to thrombose the varix completely before the balloon is deflated and removed.
Recovery: most patients are observed overnight in hospital, with the venous access site checked and general monitoring, before going home the following day.
TIPSS (transjugular intrahepatic portosystemic shunt) treats portal hypertension by creating a new channel that lowers pressure throughout the portal system, which controls gastric and oesophageal varices together but diverts some blood away from the liver — carrying a real risk of worsening liver function or triggering hepatic encephalopathy in susceptible patients. BRTO instead works locally, sealing off the gastric varix itself without creating a new shunt and without lowering overall portal pressure, which is why it tends to preserve liver function well and carries a lower encephalopathy risk.
The trade-off is that, because BRTO doesn't relieve portal pressure, it can worsen oesophageal varices or ascites in some patients by redirecting blood volume that used to drain through the treated shunt back into the portal system. This is why the choice between BRTO, TIPSS, endoscopic treatment, or a combination of these is individualised, weighing the pattern of varices, liver function, and prior encephalopathy against each option's specific trade-offs.
BRTO is generally well tolerated. The most common effects are transient — mild abdominal discomfort, and sometimes blood in the urine for a short period afterward, related to the renal vein being temporarily occluded during the procedure. Site-related risks, such as bruising or bleeding at the neck or groin puncture, are uncommon and usually minor. The specific risk to watch for after BRTO is a worsening of oesophageal varices or ascites, since blood that previously drained through the treated shunt is redirected back into the portal circulation — a risk factored into planning and follow-up rather than a surprise complication, and one reason follow-up endoscopy is part of standard aftercare.
Follow-up imaging — typically a contrast CT a few weeks after the procedure — confirms the gastric varix has thrombosed and shrunk, and follow-up endoscopy checks the varix directly and screens for any new or worsening oesophageal varices. Because BRTO changes flow patterns within the portal system rather than removing tissue, ongoing surveillance for oesophageal varices and ascites is a standard, expected part of aftercare for every patient, not a sign that the procedure hasn't worked.
Getting BRTO right depends on accurately mapping the shunt anatomy beforehand, achieving stable balloon occlusion, and judging how long to leave the sclerosant in contact with the vein wall — all while anticipating how the procedure will change pressure elsewhere in the portal system. Because gastric variceal bleeding sits at the intersection of liver disease, portal hypertension, and gastrointestinal bleeding risk, decisions about BRTO versus TIPSS versus endoscopic treatment, or a combination of these, are best made jointly by interventional radiology, hepatology, and gastroenterology, working from the same imaging and liver-function picture.
PARTO and CARTO are technique variants of the same retrograde transvenous obliteration procedure described above. Both treat gastric varices via the same gastrorenal (or similar) shunt route as classic BRTO — the difference is what the interventional radiologist uses to occlude the shunt's outflow: a vascular plug (PARTO) or embolisation coils (CARTO) in place of, or alongside, the balloon. They are not separate treatments requiring a different referral pathway; they are anatomy-driven refinements of BRTO, and the choice between them is typically made intraprocedurally based on the shunt's size and course.
What's different: instead of leaving a balloon inflated in the shunt for hours, the interventional radiologist deploys a vascular plug — a small mechanical device, such as an Amplatzer plug — directly at the shunt outflow. The plug creates occlusion immediately and permanently, with no need to wait through hours of balloon dwell time.
Why it's used: it solves the main weak point of classic BRTO — a balloon has to stay seated and inflated for hours, and in a shunt that is very large, short, or oddly shaped, the balloon can slip, deflate early, or fail to seal well. A plug doesn't have that problem — once placed, it's fixed.
Practical upside: shorter procedure time, less sedation time, and a lower risk of the balloon rupturing or migrating mid-procedure.
What's different: here, embolisation coils — tiny metal coils, sometimes packed with a gelatin sponge — are used to physically pack and block the shunt, instead of, or in addition to, the balloon.
Why it's used: coils are especially useful when the balloon alone can occlude the shunt temporarily during the procedure, but the operator wants a durable, mechanical backup so the balloon doesn't need to stay inflated for the full dwell period. A common pattern: the balloon occludes first, coils are packed in, and the balloon is then withdrawn while the coils hold the seal.
Practical upside: frees up the balloon and catheter sooner, and coils can be built up incrementally to handle shunts of different sizes better than a single balloon can.
PARTO and CARTO aren't separate procedures a patient would be referred for — they are technique variations within the BRTO umbrella. The choice between balloon-only, plug, coils, or a combination is made by the interventional radiologist based on what the shunt's anatomy looks like on imaging (size, length, tortuosity), and is often decided during the procedure itself rather than in advance. Capturing PARTO and CARTO as terms on this page has SEO/GEO value, since they are searched by patients and referring doctors who have come across the terms, but clinically and structurally they belong nested under the main BRTO service rather than as stand-alone treatment pages.
All three approaches share the same goal and the same access route — reaching the gastrorenal or other draining shunt from the neck or groin and occluding it so a sclerosant can fill and thrombose the gastric varix. Classic BRTO relies on a balloon left inflated for several hours, which works well in a shunt of suitable size and course but can be unreliable if the shunt is very large, short, or tortuous, since the balloon may not seat securely for that long. PARTO addresses this by deploying a vascular plug for immediate, stable occlusion, which can shorten procedure time and reduce the sedation burden on the patient. CARTO addresses it with coils, which can be built up to occlude shunts of varying size and are often used together with balloon occlusion early in the case, then left in place as the balloon is withdrawn. In practice, many operators use a combined approach — balloon occlusion first, with coils or a plug added to secure the result — choosing the specific technique based on shunt anatomy seen on pre-procedure imaging rather than a fixed rule.
The core risks and aftercare are the same as classic BRTO — transient discomfort, occasional blood in the urine from renal vein occlusion, and the possibility of worsened oesophageal varices or ascites from redirected portal flow, followed by the same follow-up imaging and endoscopy. PARTO and CARTO add a small, specific consideration: the implanted plug or coils are permanent metal devices left in the shunt, so as with any embolisation device, there is a small risk of device migration if it is not seated securely, which is why precise deployment and immediate imaging confirmation are part of the technique.
BRTO is used specifically to treat gastric varices — dilated, bleeding-prone veins in the stomach caused by portal hypertension — particularly when they drain through a gastrorenal or similar shunt vein, and especially in patients for whom TIPSS carries a higher risk of complications.
TIPSS lowers pressure throughout the whole portal system by creating a new shunt, which controls both gastric and oesophageal varices but diverts blood away from the liver. BRTO instead seals off the gastric varix directly without lowering overall portal pressure, which generally preserves liver function better but doesn't address oesophageal varices in the same way.
BRTO is highly effective at durably closing off the treated gastric varix and controlling bleeding from it. It doesn't treat the underlying portal hypertension driving the condition, so ongoing monitoring — and sometimes additional treatment for oesophageal varices or ascites — remains part of long-term care.
It can, in some patients — because BRTO redirects blood that used to drain through the treated shunt back into the portal circulation, it can increase pressure enough to worsen oesophageal varices or ascites. This risk is assessed beforehand and is one reason some patients are better served by TIPSS, a combined approach, or close follow-up after BRTO.
The procedure itself is done under sedation through a single neck or groin puncture, so there's no surgical incision. Most patients are observed overnight in hospital while the balloon dwell time and puncture site are monitored, and go home the following day.
PARTO (plug-assisted) and CARTO (coil-assisted) are variants of BRTO that use a vascular plug or embolisation coils, instead of or alongside the balloon, to block the shunt draining the gastric varix. They treat the same condition through the same access route and share the same goal — they're technique choices within the BRTO procedure, not separate treatments.
The choice is made by the interventional radiologist based on the size, length, and course of the draining shunt seen on pre-procedure imaging, and can also be decided during the procedure itself. Many cases use a combination — for example, balloon occlusion followed by coils to secure it — so patients are typically counselled on BRTO as a technique family rather than committed to one exact method in advance.
Book a consultation with Dr. Giragani, or send your scans for a specialist second opinion.