Portal Hypertension · IR Playbook

Antegrade Transvenous Obliteration and Percutaneous Variceal Embolisation (BATO / PTVE)

Antegrade transvenous obliteration and percutaneous variceal embolisation are portal-side techniques in which the varix and its afferent feeding veins are entered from within the portal system — percutaneously through the liver or spleen, or through an existing TIPS — and packed with sclerosant, cyanoacrylate glue or coils. The mechanism is afferent devascularisation rather than efferent flow arrest: instead of sealing the systemic outflow and letting sclerosant dwell (as in BRTO), the operator occludes the left gastric, posterior gastric and short gastric veins that feed the varix, so the varix loses inflow and thromboses, which is why the procedure works when no gastrorenal shunt exists but does nothing to lower portal pressure and carries a high rate of recurrence unless the whole feeding plexus is obliterated. In the largest historical series of transhepatic embolisation the technique controlled acute bleeding reliably but recurrence was common; modern series using 2-octyl cyanoacrylate report gastric variceal rebleeding-free rates of about 88% at 3 and 5 years where obliteration was complete. The dominant procedure-specific risk is intraperitoneal haemorrhage from the transhepatic tract in a coagulopathic patient with ascites.

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