Portal Hypertension · IR Playbook

Retrograde Transvenous Obliteration of Gastric Varices (BRTO / PARTO / CARTO)

Retrograde transvenous obliteration is an endovascular technique in which a gastrorenal or gastrocaval shunt is occluded from its systemic end and the gastric varix complex is filled with sclerosant or embolic material until it thromboses. The mechanism is deliberate flow arrest: occluding the efferent shunt converts the varix from a high-flow conduit into a stagnant sump, so a sclerosant instilled retrogradely dwells against the endothelium long enough to cause thrombosis instead of washing into the systemic circulation — which is also why every complication of the procedure is either a consequence of sclerosant escape (pulmonary embolism, haemolysis, renal injury) or of the portal pressure that the obliterated shunt no longer decompresses (ascites, oesophageal variceal aggravation). Pooled technical success is approximately 96% and clinical success approximately 97%, with rebleeding generally under 10%. Unlike TIPS it does not create a portosystemic shunt, so hepatic encephalopathy improves rather than worsens.

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