Standard endoscopic injection sclerotherapy with ethanolamine oleate or polidocanol has become accepted as the most useful treatment for esophageal varices (1–3). However, this technique is less effective and even risky in the treatment of gastric varices, especially fundal varices (4,5). Endoscopic injection of n-butyl-2-cyanoacrylate (NBCA), a tissue adhesive agent, is the only endoscopic treatment that has been shown to be effective for gastric varices (6–9). Several investigators have demonstrated the efficacy of this treatment in achieving initial hemostasis of gastric variceal bleeding (83%–100% of cases) (6,8,9). However, relatively high rates of rebleeding (20%–25% of cases) were also observed (6,9,10). Furthermore, this method carries a potential risk of migration of NBCA from the varices to the systemic venous circulation, especially in patients with fundal varices associated with a large gastrosystemic venous shunt. This migration of NBCA may result in fatal complications such as pulmonary embolism (11,12). Transjugular intrahepatic portosystemic shunt (TIPS) placement is effective in reducing portal pressure and has been widely used in patients with variceal bleeding or refractory ascites associated with portal hypertension (13,14). Some randomized studies comparing TIPS placement with endoscopic treatment for variceal bleeding have indicated significantly lower rebleeding rates following TIPS placement (approximately 10%–30% of cases) (15,16). However, TIPS placement has two main drawbacks: (a) a poor primary shunt patency rate (50%–60% of cases) and (b) development of postplacement hepatic encephalopathy, which occurs in about 20% of patients (13,14). It has been suggested that bleeding gastric varices associated with a large gastrorenal shunt occur at lower portosystemic pressure gradients than do bleeding esophageal varices (17,18). Some groups have reported that TIPS placement is less effective for gastric varices associated with a large gas-trorenal shunt (19,20). However, other investiga-tors did not find any difference in rebleeding rates between esophageal varices and gastric varices treated with TIPS placement (21,22). The clinical effectiveness of TIPS placement for gastric varices is still obscure. Other treatments have proved to be inconsistently effective or too invasive. Balloon-occluded retrograde transvenous obliteration (BRTO) has been the treatment of choice for gastric varices with a gastrosystemic venous shunt at many institutions in Japan (23–30). In standard BRTO, thrombi were created in the gastric varices with 5% ethanolamine oleate iopamidol (EOI) injected via a balloon catheter, a procedure that occludes the outlet of the gastrosystemic shunt. Since 1994, we have treated 60 cases of gastric varices with transcatheter techniques based on BRTO, and all patients were treated successfully. However, we have found that the use of standard BRTO in this context may be associated with several difficulties that can lead to unfavorable results. In such cases, additional techniques are required for successful treatment. In this article, we describe these additional techniques and our strategy for using them based on the anatomic classification system described in Part 1 (31).
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