AC Search
Document Navigator

Radiologic Management of Gastric Varices

Variant: 1   Cirrhotic patient with active bleeding from large high flow gastric varices, significant portal hypertension,and a MELD score of 14. CT demonstrates a large gastrorenal shunt.
Procedure Appropriateness Category
BRTO Usually Appropriate
Endoscopic management Usually Appropriate
TIPS Usually Appropriate
Partial splenic embolization May Be Appropriate
Surgical management May Be Appropriate

Variant: 2   Cirrhotic patient with bleeding from large high flow gastric varices with a MELD score of 20. CT demonstrates a large gastrorenal shunt.
Procedure Appropriateness Category
BRTO Usually Appropriate
Endoscopic management Usually Appropriate
TIPS May Be Appropriate
Partial splenic embolization May Be Appropriate
Surgical management May Be Appropriate

Variant: 3   Cirrhotic patient bleeding from small, low flow gastric varices and moderate ascites with a MELD score of 18. MRI does not demonstrate a gastrorenal shunt.
Procedure Appropriateness Category
Endoscopic management Usually Appropriate
TIPS Usually Appropriate
Partial splenic embolization May Be Appropriate
Surgical management May Be Appropriate
BRTO Usually Not Appropriate

Variant: 4   Cirrhotic patient bleeding from large, high flow gastric varices with hepatic encephalopathy and a MELD score of 18. MRI demonstrates a large gastrorenal shunt.
Procedure Appropriateness Category
BRTO Usually Appropriate
Endoscopic management Usually Appropriate
Partial splenic embolization May Be Appropriate
Surgical management May Be Appropriate
TIPS May Be Appropriate

Variant: 5   Cirrhotic patient bleeding from esophageal varices and gastric varices not amenable to endoscopic management with a MELD score of 13 and a hepatic wedge pressure of 22 mmHg. CT demonstrates a small gastrorenal shunt.
Procedure Appropriateness Category
TIPS Usually Appropriate
Surgical management May Be Appropriate
Partial splenic embolization May Be Appropriate
BRTO Usually Not Appropriate

Variant: 6   Cirrhotic patient bleeding from large high flow gastric varices with a MELD score of 12 and a hepatic wedge pressure of 10 mmHg. MRI demonstrates a large gastrorenal shunt.
Procedure Appropriateness Category
BRTO Usually Appropriate
Endoscopic management Usually Appropriate
TIPS Usually Appropriate
Partial splenic embolization May Be Appropriate
Surgical management May Be Appropriate

Variant: 7   Patient with gastric variceal bleeding, found to have chronic splenic vein occlusion on MRI.
Procedure Appropriateness Category
Splenic vein recanalization Usually Appropriate
Surgical management Usually Appropriate
Partial splenic embolization Usually Appropriate
Endoscopic management (sclerosis or cyanoacrylate injection) May Be Appropriate
BRTO Usually Not Appropriate
TIPS Usually Not Appropriate

Variant: 8   Patient with chronic intrahepatic and extrahepatic portal vein occlusion with cavernous transformation on CT with gastric variceal bleeding.
Procedure Appropriateness Category
Portal vein recanalization plus TIPS Usually Appropriate
Endoscopic management (sclerosis or cyanoacrylate injection) May Be Appropriate
Partial splenic embolization May Be Appropriate
Surgical management May Be Appropriate
BRTO Usually Not Appropriate

Panel Members
Charles Y. Kim, MDa; Jason W. Pinchot, MDb; Osmanuddin Ahmed, MDc; Aaron R. Braun, MDd; Brooks D. Cash, MDe; Barry W. Feig, MDf; Sanjeeva P. Kalva, g; Erica M. Knavel Koepsel, MDh; Matthew J. Scheidt, MDi; Kristofer Schramm, MDj; David M. Sella, MDk; Clifford R. Weiss, MDl; Eric J. Hohenwalter, MDm.
Summary of Literature Review
Introduction/Background
Special Therapy Considerations
Discussion of Procedures by Variant
Variant 1: Cirrhotic patient with active bleeding from large high flow gastric varices, significant portal hypertension,and a MELD score of 14. CT demonstrates a large gastrorenal shunt.
Variant 1: Cirrhotic patient with active bleeding from large high flow gastric varices, significant portal hypertension,and a MELD score of 14. CT demonstrates a large gastrorenal shunt.
A. BRTO
Variant 1: Cirrhotic patient with active bleeding from large high flow gastric varices, significant portal hypertension,and a MELD score of 14. CT demonstrates a large gastrorenal shunt.
B. Endoscopic management
Variant 1: Cirrhotic patient with active bleeding from large high flow gastric varices, significant portal hypertension,and a MELD score of 14. CT demonstrates a large gastrorenal shunt.
C. Partial splenic embolization
Variant 1: Cirrhotic patient with active bleeding from large high flow gastric varices, significant portal hypertension,and a MELD score of 14. CT demonstrates a large gastrorenal shunt.
D. Surgical management
Variant 1: Cirrhotic patient with active bleeding from large high flow gastric varices, significant portal hypertension,and a MELD score of 14. CT demonstrates a large gastrorenal shunt.
E. TIPS
Variant 2: Cirrhotic patient with bleeding from large high flow gastric varices with a MELD score of 20. CT demonstrates a large gastrorenal shunt.
Variant 2: Cirrhotic patient with bleeding from large high flow gastric varices with a MELD score of 20. CT demonstrates a large gastrorenal shunt.
A. BRTO
Variant 2: Cirrhotic patient with bleeding from large high flow gastric varices with a MELD score of 20. CT demonstrates a large gastrorenal shunt.
B. Endoscopic management
Variant 2: Cirrhotic patient with bleeding from large high flow gastric varices with a MELD score of 20. CT demonstrates a large gastrorenal shunt.
C. Partial splenic embolization
Variant 2: Cirrhotic patient with bleeding from large high flow gastric varices with a MELD score of 20. CT demonstrates a large gastrorenal shunt.
D. Surgical management
Variant 2: Cirrhotic patient with bleeding from large high flow gastric varices with a MELD score of 20. CT demonstrates a large gastrorenal shunt.
E. TIPS
Variant 3: Cirrhotic patient bleeding from small, low flow gastric varices and moderate ascites with a MELD score of 18. MRI does not demonstrate a gastrorenal shunt.
Variant 3: Cirrhotic patient bleeding from small, low flow gastric varices and moderate ascites with a MELD score of 18. MRI does not demonstrate a gastrorenal shunt.
A. BRTO
Variant 3: Cirrhotic patient bleeding from small, low flow gastric varices and moderate ascites with a MELD score of 18. MRI does not demonstrate a gastrorenal shunt.
B. Endoscopic management
Variant 3: Cirrhotic patient bleeding from small, low flow gastric varices and moderate ascites with a MELD score of 18. MRI does not demonstrate a gastrorenal shunt.
C. Partial splenic embolization
Variant 3: Cirrhotic patient bleeding from small, low flow gastric varices and moderate ascites with a MELD score of 18. MRI does not demonstrate a gastrorenal shunt.
D. Surgical management
Variant 3: Cirrhotic patient bleeding from small, low flow gastric varices and moderate ascites with a MELD score of 18. MRI does not demonstrate a gastrorenal shunt.
E. TIPS
Variant 4: Cirrhotic patient bleeding from large, high flow gastric varices with hepatic encephalopathy and a MELD score of 18. MRI demonstrates a large gastrorenal shunt.
Variant 4: Cirrhotic patient bleeding from large, high flow gastric varices with hepatic encephalopathy and a MELD score of 18. MRI demonstrates a large gastrorenal shunt.
A. BRTO
Variant 4: Cirrhotic patient bleeding from large, high flow gastric varices with hepatic encephalopathy and a MELD score of 18. MRI demonstrates a large gastrorenal shunt.
B. Endoscopic management
Variant 4: Cirrhotic patient bleeding from large, high flow gastric varices with hepatic encephalopathy and a MELD score of 18. MRI demonstrates a large gastrorenal shunt.
C. Partial splenic embolization
Variant 4: Cirrhotic patient bleeding from large, high flow gastric varices with hepatic encephalopathy and a MELD score of 18. MRI demonstrates a large gastrorenal shunt.
D. Surgical management
Variant 4: Cirrhotic patient bleeding from large, high flow gastric varices with hepatic encephalopathy and a MELD score of 18. MRI demonstrates a large gastrorenal shunt.
E. TIPS
Variant 5: Cirrhotic patient bleeding from esophageal varices and gastric varices not amenable to endoscopic management with a MELD score of 13 and a hepatic wedge pressure of 22 mmHg. CT demonstrates a small gastrorenal shunt.
Variant 5: Cirrhotic patient bleeding from esophageal varices and gastric varices not amenable to endoscopic management with a MELD score of 13 and a hepatic wedge pressure of 22 mmHg. CT demonstrates a small gastrorenal shunt.
A. BRTO
Variant 5: Cirrhotic patient bleeding from esophageal varices and gastric varices not amenable to endoscopic management with a MELD score of 13 and a hepatic wedge pressure of 22 mmHg. CT demonstrates a small gastrorenal shunt.
B. Partial splenic embolization
Variant 5: Cirrhotic patient bleeding from esophageal varices and gastric varices not amenable to endoscopic management with a MELD score of 13 and a hepatic wedge pressure of 22 mmHg. CT demonstrates a small gastrorenal shunt.
C. Surgical management
Variant 5: Cirrhotic patient bleeding from esophageal varices and gastric varices not amenable to endoscopic management with a MELD score of 13 and a hepatic wedge pressure of 22 mmHg. CT demonstrates a small gastrorenal shunt.
D. TIPS
Variant 6: Cirrhotic patient bleeding from large high flow gastric varices with a MELD score of 12 and a hepatic wedge pressure of 10 mmHg. MRI demonstrates a large gastrorenal shunt.
Variant 6: Cirrhotic patient bleeding from large high flow gastric varices with a MELD score of 12 and a hepatic wedge pressure of 10 mmHg. MRI demonstrates a large gastrorenal shunt.
A. BRTO
Variant 6: Cirrhotic patient bleeding from large high flow gastric varices with a MELD score of 12 and a hepatic wedge pressure of 10 mmHg. MRI demonstrates a large gastrorenal shunt.
B. Endoscopic management
Variant 6: Cirrhotic patient bleeding from large high flow gastric varices with a MELD score of 12 and a hepatic wedge pressure of 10 mmHg. MRI demonstrates a large gastrorenal shunt.
C. Partial splenic embolization
Variant 6: Cirrhotic patient bleeding from large high flow gastric varices with a MELD score of 12 and a hepatic wedge pressure of 10 mmHg. MRI demonstrates a large gastrorenal shunt.
D. Surgical management
Variant 6: Cirrhotic patient bleeding from large high flow gastric varices with a MELD score of 12 and a hepatic wedge pressure of 10 mmHg. MRI demonstrates a large gastrorenal shunt.
E. TIPS
Variant 7: Patient with gastric variceal bleeding, found to have chronic splenic vein occlusion on MRI.
Variant 7: Patient with gastric variceal bleeding, found to have chronic splenic vein occlusion on MRI.
A. BRTO
Variant 7: Patient with gastric variceal bleeding, found to have chronic splenic vein occlusion on MRI.
B. Endoscopic management (sclerosis or cyanoacrylate injection)
Variant 7: Patient with gastric variceal bleeding, found to have chronic splenic vein occlusion on MRI.
C. Partial splenic embolization
Variant 7: Patient with gastric variceal bleeding, found to have chronic splenic vein occlusion on MRI.
D. Splenic vein recanalization
Variant 7: Patient with gastric variceal bleeding, found to have chronic splenic vein occlusion on MRI.
E. Surgical management
Variant 7: Patient with gastric variceal bleeding, found to have chronic splenic vein occlusion on MRI.
F. TIPS
Variant 8: Patient with chronic intrahepatic and extrahepatic portal vein occlusion with cavernous transformation on CT with gastric variceal bleeding.
Variant 8: Patient with chronic intrahepatic and extrahepatic portal vein occlusion with cavernous transformation on CT with gastric variceal bleeding.
A. BRTO
Variant 8: Patient with chronic intrahepatic and extrahepatic portal vein occlusion with cavernous transformation on CT with gastric variceal bleeding.
B. Endoscopic management (sclerosis or cyanoacrylate injection)
Variant 8: Patient with chronic intrahepatic and extrahepatic portal vein occlusion with cavernous transformation on CT with gastric variceal bleeding.
C. Partial splenic embolization
Variant 8: Patient with chronic intrahepatic and extrahepatic portal vein occlusion with cavernous transformation on CT with gastric variceal bleeding.
D. Portal vein recanalization plus TIPS
Variant 8: Patient with chronic intrahepatic and extrahepatic portal vein occlusion with cavernous transformation on CT with gastric variceal bleeding.
E. Surgical management
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
References
1. Sharma BC, Varakanahalli S, Singh JP, Srivastava S. Gastric Varices in Cirrhosis vs. Extrahepatic Portal Venous Obstruction and Response to Endoscopic N-butyl-2-cyanoacrylate Injection. J Clin Exp Hepatol. 2017;7(2):97-101.
2. Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017;65(1):310-335.
3. Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology. 1992;16(6):1343-1349.
4. Deng H, Qi X, Guo X. Computed tomography for the diagnosis of varices in liver cirrhosis: a systematic review and meta-analysis of observational studies. [Review]. Postgrad Med. 129(3):318-328, 2017 Apr.
5. Zhu K, Meng X, Pang P, et al. Gastric varices in patients with portal hypertension: evaluation with multidetector row CT. J Clin Gastroenterol. 44(5):e108-15, 2010 May-Jun.
6. Ryan BM, Stockbrugger RW, Ryan JM. A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices. Gastroenterology. 2004;126(4):1175-1189.
7. Sarin SK. Long-term follow-up of gastric variceal sclerotherapy: an eleven-year experience. Gastrointest Endosc. 1997;46(1):8-14.
8. Qiao W, Ren Y, Bai Y, Liu S, Zhang Q, Zhi F. Cyanoacrylate Injection Versus Band Ligation in the Endoscopic Management of Acute Gastric Variceal Bleeding: Meta-Analysis of Randomized, Controlled Studies Based on the PRISMA Statement. Medicine. 94(41):e1725, 2015 Oct.Medicine (Baltimore). 94(41):e1725, 2015 Oct.
9. Kuramochi A, Imazu H, Kakutani H, Uchiyama Y, Hino S, Urashima M. Color Doppler endoscopic ultrasonography in identifying groups at a high-risk of recurrence of esophageal varices after endoscopic treatment. J Gastroenterol 2007;42:219-24.
10. Dariushnia SR, Haskal ZJ, Midia M, et al. Quality Improvement Guidelines for Transjugular Intrahepatic Portosystemic Shunts. J Vasc Interv Radiol. 2016;27(1):1-7.
11. Holster IL, Tjwa ET, Moelker A, et al. Covered transjugular intrahepatic portosystemic shunt versus endoscopic therapy + beta-blocker for prevention of variceal rebleeding. Hepatology. 63(2):581-9, 2016 Feb.Hepatology. 63(2):581-9, 2016 Feb.
12. Perarnau JM, Le Gouge A, Nicolas C, et al. Covered vs. uncovered stents for transjugular intrahepatic portosystemic shunt: a randomized controlled trial. J Hepatol. 2014;60(5):962-968.
13. Barange K, Peron JM, Imani K, et al. Transjugular intrahepatic portosystemic shunt in the treatment of refractory bleeding from ruptured gastric varices. Hepatology. 1999;30(5):1139-1143.
14. Chau TN, Patch D, Chan YW, Nagral A, Dick R, Burroughs AK. "Salvage" transjugular intrahepatic portosystemic shunts: gastric fundal compared with esophageal variceal bleeding. Gastroenterology. 1998;114(5):981-987.
15. Choi YH, Yoon CJ, Park JH, Chung JW, Kwon JW, Choi GM. Balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding: its feasibility compared with transjugular intrahepatic portosystemic shunt. Korean J Radiol. 2003;4(2):109-116.
16. Kim SK, Lee KA, Sauk S, Korenblat K. Comparison of Transjugular Intrahepatic Portosystemic Shunt with Covered Stent and Balloon-Occluded Retrograde Transvenous Obliteration in Managing Isolated Gastric Varices. Korean Journal of Radiology. 18(2):345-354, 2017 Mar-Apr.Korean J Radiol. 18(2):345-354, 2017 Mar-Apr.
17. Lo GH, Liang HL, Chen WC, et al. A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding. Endoscopy. 2007;39(8):679-685.
18. Ninoi T, Nakamura K, Kaminou T, et al. TIPS versus transcatheter sclerotherapy for gastric varices. AJR Am J Roentgenol. 2004;183(2):369-376.
19. Rees CJ, Nylander DL, Thompson NP, Rose JD, Record CO, Hudson M. Do gastric and oesophageal varices bleed at different portal pressures and is TIPS an effective treatment? Liver. 2000;20(3):253-256.
20. Sabri SS, Abi-Jaoudeh N, Swee W, et al. Short-term rebleeding rates for isolated gastric varices managed by transjugular intrahepatic portosystemic shunt versus balloon-occluded retrograde transvenous obliteration. J Vasc Interv Radiol. 2014;25(3):355-361.
21. Lakhoo J, Bui JT, Lokken RP, Ray CE Jr, Gaba RC. Transjugular Intrahepatic Portosystemic Shunt Creation and Variceal Coil or Plug Embolization Ineffectively Attain Gastric Variceal Decompression or Occlusion: Results of a 26-Patient Retrospective Study. Journal of Vascular & Interventional Radiology. 27(7):1001-11, 2016 07.J Vasc Interv Radiol. 27(7):1001-11, 2016 07.
22. Jiang Q, Wang MQ, Zhang GB, Wu Q, Xu JM, Kong DR. Transjugular intrahepatic portosystemic shunt combined with esophagogastric variceal embolization in the treatment of a large gastrorenal shunt. World J Hepatol. 2016;8(20):850-857.
23. Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Transjugular retrograde obliteration for chronic portosystemic encephalopathy. Abdom Imaging. 2000;25(6):567-571.
24. Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Eight years of experience with transjugular retrograde obliteration for gastric varices with gastrorenal shunts. Surgery. 2001;129(4):414-420.
25. Chikamori F, Kuniyoshi N, Shibuya S, Takase Y. Combination treatment of transjugular retrograde obliteration and endoscopic embolization for portosystemic encephalopathy with esophageal varices. Hepatogastroenterology. 2004;51(59):1379-1381.
26. Fukuda T, Hirota S, Sugimura K. Long-term results of balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy. J Vasc Interv Radiol. 2001;12(3):327-336.
27. Hirota S, Matsumoto S, Tomita M, Sako M, Kono M. Retrograde transvenous obliteration of gastric varices. Radiology. 1999;211(2):349-356.
28. Park KS, Kim YH, Choi JS, et al. [Therapeutic efficacy of balloon-occluded retrograde transvenous obliteration in patients with gastric variceal bleeding]. Korean J Gastroenterol. 2006;47(5):370-378.
29. Takuma Y, Nouso K, Makino Y, Saito S, Shiratori Y. Prophylactic balloon-occluded retrograde transvenous obliteration for gastric varices in compensated cirrhosis. Clin Gastroenterol Hepatol. 2005;3(12):1245-1252.
30. Yamagami T, Kato T, Hirota T, Yoshimatsu R, Matsumoto T, Nishimura T. Infusion of 50% glucose solution before injection of ethanolamine oleate during balloon-occluded retrograde transvenous obliteration. Australas Radiol. 2007;51(4):334-338.
31. Chikamori F, Shibuya S, Takase Y, Ozaki A, Fukao K. Transjugular retrograde obliteration for gastric varices. Abdom Imaging. 1996;21(4):299-303.
32. Arai H, Abe T, Shimoda R, Takagi H, Yamada T, Mori M. Emergency balloon-occluded retrograde transvenous obliteration for gastric varices. J Gastroenterol. 2005;40(10):964-971.
33. Ferral H, Patel NH. Selection criteria for patients undergoing transjugular intrahepatic portosystemic shunt procedures: current status. J Vasc Interv Radiol. 2005;16(4):449-455.
34. Saad WE, Sabri SS. Balloon-occluded Retrograde Transvenous Obliteration (BRTO): Technical Results and Outcomes. Semin Intervent Radiol. 2011;28(3):333-338.
35. Cho SK, Shin SW, Lee IH, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices: outcomes and complications in 49 patients. AJR Am J Roentgenol. 2007;189(6):W365-372.
36. Kumamoto M, Toyonaga A, Inoue H, et al. Long-term results of balloon-occluded retrograde transvenous obliteration for gastric fundal varices: hepatic deterioration links to portosystemic shunt syndrome. J Gastroenterol Hepatol. 2010;25(6):1129-1135.
37. Matsumoto A, Hamamoto N, Nomura T, et al. Balloon-occluded retrograde transvenous obliteration of high risk gastric fundal varices. Am J Gastroenterol. 1999;94(3):643-649.
38. Miyamoto Y, Oho K, Kumamoto M, Toyonaga A, Sata M. Balloon-occluded retrograde transvenous obliteration improves liver function in patients with cirrhosis and portal hypertension. J Gastroenterol Hepatol. 2003;18(8):934-942.
39. Yamamoto A, Nishida N, Morikawa H, et al. Prediction for Improvement of Liver Function after Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Varices to Manage Portosystemic Shunt Syndrome. J Vasc Interv Radiol. 27(8):1160-7, 2016 Aug.
40. Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori Y, Okino Y. Transcatheter obliteration of gastric varices: Part 2. Strategy and techniques based on hemodynamic features. Radiographics. 2003;23(4):921-937; discussion 937.
41. Chang IS, Park SW, Kwon SY, et al. Efficacy and Safety of Balloon-Occluded Retrograde Transvenous Obliteration with Sodium Tetradecyl Sulfate Liquid Sclerotherapy. Korean Journal of Radiology. 17(2):224-9, 2016 Mar-Apr.Korean J Radiol. 17(2):224-9, 2016 Mar-Apr.
42. Choi SY, Won JY, Kim KA, Lee DY, Lee KH. Foam sclerotherapy using polidocanol for balloon-occluded retrograde transvenous obliteration (BRTO). Eur Radiol. 2011;21(1):122-129.
43. Gwon DI, Kim YH, Ko GY, et al. Vascular Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Varices and Hepatic Encephalopathy: A Prospective Multicenter Study. J Vasc Interv Radiol. 26(11):1589-95, 2015 Nov.
44. Gwon DI, Ko GY, Yoon HK, et al. Gastric varices and hepatic encephalopathy: treatment with vascular plug and gelatin sponge-assisted retrograde transvenous obliteration--a primary report. Radiology. 268(1):281-7, 2013 Jul.
45. Itou C, Koizumi J, Hashimoto T, et al. Balloon-Occluded Retrograde Transvenous Obliteration for the Treatment of Gastric Varices: Polidocanol Foam Versus Liquid Ethanolamine Oleate. AJR Am J Roentgenol. 2015;205(3):659-666.
46. Jang SY, Kim GH, Park SY, et al. Clinical outcomes of balloon-occluded retrograde transvenous obliteration for the treatment of gastric variceal hemorrhage in Korean patients with liver cirrhosis: a retrospective multicenter study. Clin Mol Hepatol. 2012;18(4):368-374.
47. Kitamoto M, Imamura M, Kamada K, et al. Balloon-occluded retrograde transvenous obliteration of gastric fundal varices with hemorrhage. AJR Am J Roentgenol. 2002;178(5):1167-1174.
48. Kobayakawa M, Kokubu S, Hirota S, et al. Short-Term Safety and Efficacy of Balloon-Occluded Retrograde Transvenous Obliteration Using Ethanolamine Oleate: Results of a Prospective, Multicenter, Single-Arm Trial. Journal of Vascular & Interventional Radiology. 28(8):1108-1115.e2, 2017 Aug.J Vasc Interv Radiol. 28(8):1108-1115.e2, 2017 Aug.
49. Koizumi J, Hashimoto T, Myojin K, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices: use of CT-guided foam sclerotherapy to optimize technique. AJR Am J Roentgenol. 2012;199(1):200-207.
50. Mukund A, Deogaonkar G, Rajesh S, Shasthry SM, Sarin SK. Safety and Efficacy of Sodium Tetradecyl Sulfate and Lipiodol Foam in Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) for Large Porto-Systemic Shunts. Cardiovasc Intervent Radiol. 2017;40(7):1010-1016.
51. Ninoi T, Nishida N, Kaminou T, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices with gastrorenal shunt: long-term follow-up in 78 patients. AJR Am J Roentgenol. 2005;184(4):1340-1346.
52. Sabri SS, Swee W, Turba UC, et al. Bleeding gastric varices obliteration with balloon-occluded retrograde transvenous obliteration using sodium tetradecyl sulfate foam. J Vasc Interv Radiol. 2011;22(3):309-316; quiz 316.
53. Akahoshi T, Hashizume M, Tomikawa M, et al. Long-term results of balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding and risky gastric varices: a 10-year experience. J Gastroenterol Hepatol. 2008;23(11):1702-1709.
54. Arai H, Abe T, Takagi H, Mori M. Efficacy of balloon-occluded retrograde transvenous obliteration, percutaneous transhepatic obliteration and combined techniques for the management of gastric fundal varices. World J Gastroenterol. 2006;12(24):3866-3873.
55. Chikamori F, Kuniyoshi N, Kawashima T, Takase Y. Gastric varices with gastrorenal shunt: combined therapy using transjugular retrograde obliteration and partial splenic embolization. AJR Am J Roentgenol. 2008;191(2):555-559.
56. Hong CH, Kim HJ, Park JH, et al. Treatment of patients with gastric variceal hemorrhage: endoscopic N-butyl-2-cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 2009;24(3):372-378.
57. Kiyosue H, Matsumoto S, Onishi R, et al. [Balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices: therapeutic results and problems]. Nihon Igaku Hoshasen Gakkai Zasshi. 1999;59(1):12-19.
58. Koito K, Namieno T, Nagakawa T, Morita K. Balloon-occluded retrograde transvenous obliteration for gastric varices with gastrorenal or gastrocaval collaterals. AJR Am J Roentgenol. 1996;167(5):1317-1320.
59. Sonomura T, Sato M, Kishi K, et al. Balloon-occluded retrograde transvenous obliteration for gastric varices: a feasibility study. Cardiovasc Intervent Radiol. 1998;21(1):27-30.
60. Park JK, Saab S, Kee ST, et al. Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) for Treatment of Gastric Varices: Review and Meta-Analysis. Dig Dis Sci. 2015;60(6):1543-1553.
61. Okugawa H, Maruyama H, Kobayashi S, Yoshizumi H, Matsutani S, Yokosuka O. Therapeutic effect of balloon-occluded retrograde transvenous obliteration for gastric varices in relation to haemodynamics in the short gastric vein. Br J Radiol 2009;82:930-5.
62. Kim ES, Park SY, Kwon KT, et al. [The clinical usefulness of balloon occluded retrograde transvenous obliteration in gastric variceal bleeding]. Taehan Kan Hakhoe Chi. 2003;9(4):315-323.
63. Park SJ, Chung JW, Kim HC, Jae HJ, Park JH. The prevalence, risk factors, and clinical outcome of balloon rupture in balloon-occluded retrograde transvenous obliteration of gastric varices. J Vasc Interv Radiol. 2010;21(4):503-507.
64. Shimoda R, Horiuchi K, Hagiwara S, et al. Short-term complications of retrograde transvenous obliteration of gastric varices in patients with portal hypertension: effects of obliteration of major portosystemic shunts. Abdom Imaging. 2005;30(3):306-313.
65. Jogo A, Nishida N, Yamamoto A, et al. Factors associated with aggravation of esophageal varices after B-RTO for gastric varices. Cardiovasc Intervent Radiol. 2014;37(5):1243-1250.
66. Saad WE, Wagner CC, Lippert A, et al. Protective value of TIPS against the development of hydrothorax/ascites and upper gastrointestinal bleeding after balloon-occluded retrograde transvenous obliteration (BRTO). Am J Gastroenterol. 2013;108(10):1612-1619.
67. Chikamori F, Kuniyoshi N, Kawashima T, Takase Y. Short-term portal hemodynamic effects of partial splenic embolization for hypersplenism. Hepatogastroenterology. 2007;54(78):1847-1849.
68. Buechter M, Kahraman A, Manka P, et al. Partial spleen embolization reduces the risk of portal hypertension-induced upper gastrointestinal bleeding in patients not eligible for TIPS implantation. PLoS ONE [Electronic Resource]. 12(5):e0177401, 2017.PLoS ONE. 12(5):e0177401, 2017.
69. Duan X, Zhang K, Han X, et al. Comparison of percutaneous transhepatic variceal embolization (PTVE) followed by partial splenic embolization versus PTVE alone for the treatment of acute esophagogastric variceal massive hemorrhage. J Vasc Interv Radiol. 2014;25(12):1858-1865.
70. Waguri N, Hayashi M, Yokoo T, et al. Simultaneous combined balloon-occluded retrograde transvenous obliteration and partial splenic embolization for portosystemic shunts. J Vasc Interv Radiol. 2012;23(5):650-657.
71. Ohmoto K, Yoshioka N, Tomiyama Y, et al. Improved prognosis of cirrhosis patients with esophageal varices and thrombocytopenia treated by endoscopic variceal ligation plus partial splenic embolization. Dig Dis Sci. 2006;51(2):352-358.
72. Bernades P, Baetz A, Levy P, Belghiti J, Menu Y, Fekete F. Splenic and portal venous obstruction in chronic pancreatitis. A prospective longitudinal study of a medical-surgical series of 266 patients. Dig Dis Sci. 1992;37(3):340-346.
73. Orloff MJ, Hye RJ, Wheeler HO, et al. Randomized trials of endoscopic therapy and transjugular intrahepatic portosystemic shunt versus portacaval shunt for emergency and elective treatment of bleeding gastric varices in cirrhosis. Surgery. 2015;157(6):1028-1045.
74. Henderson JM, Boyer TD, Kutner MH, et al. Distal splenorenal shunt versus transjugular intrahepatic portal systematic shunt for variceal bleeding: a randomized trial. Gastroenterology. 2006;130(6):1643-1651.
75. Su AP, Zhang ZD, Tian BL, Zhu JQ. Transjugular intrahepatic portosystemic shunt versus open splenectomy and esophagogastric devascularization for portal hypertension with recurrent variceal bleeding. Hepatobiliary Pancreat Dis Int. 2017;16(2):169-175.
76. Cheng Z, Li JW, Chen J, Fan YD, Guo P, Zheng SG. Therapeutic effects of laparoscopic splenectomy and esophagogastric devascularization on liver cirrhosis and portal hypertension in 204 cases. J Laparoendosc Adv Surg Tech A. 2014;24(9):612-616.
77. Feng LS, Chen XP. Combined splenocaval or mesocaval C shunt and portoazygous devascularization in the treatment of portal hypertension: analysis of 150 cases. Hepatobiliary Pancreat Dis Int. 2006;5(1):70-73.
78. Reverter E, Tandon P, Augustin S, et al. A MELD-based model to determine risk of mortality among patients with acute variceal bleeding. Gastroenterology. 2014;146(2):412-419 e413.
79. Spengler EK, Hunsicker LG, Zarei S, Zimmerman MB, Voigt MD. Transjugular intrahepatic portosystemic shunt does not independently increase risk of death in high model for end stage liver disease patients. Hepatol Commun. 2017;1(5):460-468.
80. Saad WE, Wagner CC, Al-Osaimi A, et al. The effect of balloon-occluded transvenous obliteration of gastric varices and gastrorenal shunts on the hepatic synthetic function: a comparison between Child-Pugh and model for end-stage liver disease scores. Vasc Endovascular Surg. 2013;47(4):281-287.
81. Miraglia R, Maruzzelli L, Tuzzolino F, Petridis I, D'Amico M, Luca A. Transjugular Intrahepatic Portosystemic Shunts in Patients with Cirrhosis with Refractory Ascites: Comparison of Clinical Outcomes by Using 8- and 10-mm PTFE-covered Stents. Radiology. 2017;284(1):281-288.
82. Quintini C, D'Amico G, Brown C, et al. Splenic artery embolization for the treatment of refractory ascites after liver transplantation. Liver Transpl 2011;17:668-73.
83. Madoff DC, Wallace MJ, Ahrar K, Saxon RR. TIPS-related hepatic encephalopathy: management options with novel endovascular techniques. Radiographics. 2004;24(1):21-36; discussion 36-27.
84. Yoshida H, Mamada Y, Taniai N, et al. Long-term results of partial splenic artery embolization as supplemental treatment for portal-systemic encephalopathy. Am J Gastroenterol 2005;100:43-7.
85. Choi YS, Lee JH, Sinn DH, et al. Effect of balloon-occluded retrograde transvenous obliteration on the natural history of coexisting esophageal varices. J Clin Gastroenterol. 2008;42(9):974-979.
86. Watanabe K, Kimura K, Matsutani S, Ohto M, Okuda K. Portal hemodynamics in patients with gastric varices. A study in 230 patients with esophageal and/or gastric varices using portal vein catheterization. Gastroenterology 1988;95:434-40.
87. Xu CE, Zhang SG, Yu ZH, et al. Combined devascularization and proximal splenorenal shunt: is this a better option than either procedure alone? J Hepatobiliary Pancreat Surg. 2004;11(2):129-134.
88. Ono Y, Matsueda K, Koga R, et al. Sinistral portal hypertension after pancreaticoduodenectomy with splenic vein ligation. Br J Surg. 2015;102(3):219-228.
89. Liu Q, Song Y, Xu X, Jin Z, Duan W, Zhou N. Management of bleeding gastric varices in patients with sinistral portal hypertension. Dig Dis Sci. 2014;59(7):1625-1629.
90. Sato T, Yamazaki K, Akaike J, Toyota J, Karino Y, Ohmura T. Clinical and endoscopic features of gastric varices secondary to splenic vein occlusion. Hepatol Res. 2008;38(11):1076-1082.
91. Janne d'Othee B, Walker TG, Marota JJ, Waltman AC, Greenfield AJ, Koizumi J. Splenic venous congestion after balloon-occluded retrograde transvenous obliteration of gastric varices. Cardiovasc Intervent Radiol 2012;35:434-8.
92. Saad WE, Kitanosono T, Koizumi J, Hirota S. The conventional balloon-occluded retrograde transvenous obliteration procedure: indications, contraindications, and technical applications. Tech Vasc Interv Radiol 2013;16:101-51.
93. Luo X, Nie L, Wang Z, Tsauo J, Tang C, Li X. Transjugular endovascular recanalization of splenic vein in patients with regional portal hypertension complicated by gastrointestinal bleeding. Cardiovasc Intervent Radiol. 37(1):108-13, 2014 Feb.
94. Wang Q, Xiong B, Zheng C, Liang M, Han P. Splenic Arterial Embolization in the Treatment of Severe Portal Hypertension Due to Pancreatic Diseases: The Primary Experience in 14 Patients. Cardiovascular & Interventional Radiology. 39(3):353-8, 2016 Mar.Cardiovasc Intervent Radiol. 39(3):353-8, 2016 Mar.
95. Sakorafas GH, Sarr MG, Farley DR, Farnell MB. The significance of sinistral portal hypertension complicating chronic pancreatitis. Am J Surg. 2000;179(2):129-133.
96. Loftus JP, Nagorney DM, Ilstrup D, Kunselman AR. Sinistral portal hypertension. Splenectomy or expectant management. Ann Surg. 1993;217(1):35-40.
97. Uflacker R. Applications of percutaneous mechanical thrombectomy in transjugular intrahepatic portosystemic shunt and portal vein thrombosis. Tech Vasc Interv Radiol 2003;6:59-69.
98. Thornburg B, Desai K, Hickey R, et al. Portal Vein Recanalization and Transjugular Intrahepatic Portosystemic Shunt Creation for Chronic Portal Vein Thrombosis: Technical Considerations. Tech Vasc Interv Radiol. 2016;19(1):52-60.
99. Luo J, Li M, Zhang Y, et al. Percutaneous transhepatic intrahepatic portosystemic shunt for variceal bleeding with chronic portal vein occlusion after splenectomy. Eur Radiol 2018;28:3661-68.
100. Luo X, Wang Z, Tsauo J, Zhou B, Zhang H, Li X. Advanced Cirrhosis Combined with Portal Vein Thrombosis: A Randomized Trial of TIPS versus Endoscopic Band Ligation Plus Propranolol for the Prevention of Recurrent Esophageal Variceal Bleeding. Radiology 2015;276:286-93.
101. Han GH, Meng XJ, Yin ZX, et al. [Transjugular intrahepatic portosystemic shunt and combination with percutaneous transhepatic or transsplenic approach for the treatment of portal vein thrombosis with or without cavernomatous transformation]. Zhonghua Yi Xue Za Zhi 2009;89:1549-52.
102. Walser EM, Soloway R, Raza SA, Gill A. Transjugular portosystemic shunt in chronic portal vein occlusion: importance of segmental portal hypertension in cavernous transformation of the portal vein. J Vasc Interv Radiol. 2006;17(2 Pt 1):373-378.
103. Wils A, van der Linden E, van Hoek B, Pattynama PM. Transjugular intrahepatic portosystemic shunt in patients with chronic portal vein occlusion and cavernous transformation. J Clin Gastroenterol. 2009;43(10):982-984.
104. Marot A, Barbosa JV, Duran R, Deltenre P, Denys A. Percutaneous portal vein recanalization using self-expandable nitinol stents in patients with non-cirrhotic non-tumoral portal vein occlusion. Diagn Interv Imaging 2018.
105. Qi X, Han G, Yin Z, et al. Transjugular intrahepatic portosystemic shunt for portal cavernoma with symptomatic portal hypertension in non-cirrhotic patients. Dig Dis Sci 2012;57:1072-82.
106. Klinger C, Riecken B, Schmidt A, et al. Transjugular portal vein recanalization with creation of intrahepatic portosystemic shunt (PVR-TIPS) in patients with chronic non-cirrhotic, non-malignant portal vein thrombosis. Z Gastroenterol 2018;56:221-37.
107. Borghei P, Kim SK, Zuckerman DA. Balloon occlusion retrograde transvenous obliteration of gastric varices in two non-cirrhotic patients with portal vein thrombosis. Korean J Radiol. 2014;15(1):108-113.
108. Miyaaki H, Ichikawa T, Nakao K, et al. Portal hypertensive gastropathy with portal thrombosis successfully treated with partial splenic embolization. Clin J Gastroenterol. 2009;2(3):218-221.
109. Wang RY, Wang JF, Liu Q, Ma N, Chen WX, Li JL. Combined Rex-bypass shunt with pericardial devascularization alleviated prehepatic portal hypertension caused by cavernomatous transformation of portal vein. Postgrad Med. 2017;129(7):768-776.
110. Zhang H, Zhang N, Li M, Jin W, Pan S. Surgical treatment of portal vein cavernous transformation. World J Surg. 2004;28(7):708-711.
Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.