Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) is a minimally invasive treatment for gastric varices—enlarged veins in the stomach lining caused by high blood pressure in the portal vein system. Patients seek this procedure to prevent internal bleeding. The total time commitment involves preparation, the intervention performed by an interventional radiologist, and recovery. Understanding the timeline requires separating the time spent in the procedure room from the overall logistical time commitment.
Defining the BRTO Procedure and its Goal
BRTO is an advanced, image-guided technique used to manage gastric varices, often associated with a large gastrorenal shunt. These varices result from portal hypertension, forcing blood to reroute through collateral veins. The goal is to permanently block these high-risk veins to eliminate the danger of rupture and hemorrhage.
The process begins by accessing a systemic vein, typically in the neck or groin, and guiding a catheter to the vein draining the gastric varices. A small balloon on the catheter is inflated to temporarily occlude the blood flow through the shunt. This occlusion allows a liquid sclerosant agent, such as ethanolamine oleate or sodium tetradecyl sulfate, to be injected directly into the varices.
Trapping the sclerosant within the varices chemically irritates the vein walls, causing them to scar and clot, permanently obliterating the blood vessel. This redirection of blood flow back into the liver’s portal system may also improve liver function. Technical success relies on complete and sustained contact between the sclerosant and the variceal walls.
The Procedure Timeline: Time in the Interventional Suite
The time a patient spends inside the interventional suite for the BRTO procedure generally ranges from two to four hours. This duration covers the active time the interventional radiology team works under imaging guidance while the patient is under sedation or general anesthesia. The process starts with gaining vascular access, inserting a catheter into a large vein, typically the femoral vein in the groin or the internal jugular vein in the neck.
Following access, the radiologist guides the catheter under fluoroscopic imaging to the target shunt and inflates the balloon. A venogram is then performed, injecting contrast dye to map the variceal anatomy and confirm the balloon’s position. The longest phase of the procedure is the injection of the sclerosant agent into the varices.
The sclerosant must remain in contact with the variceal walls for a designated period to ensure complete chemical ablation. In some protocols, the balloon may remain inflated for several hours (up to 20 hours) to ensure the agent is fully retained. Modern techniques often use adjunctive materials to shorten this waiting period. Once the varices are filled and the agent has worked, the balloon is deflated, and the catheter is removed.
Pre-Procedure Preparation and Immediate Post-Procedure Care
The overall time commitment for BRTO extends beyond the two to four hours in the procedure room, beginning with preparation on the day of the intervention. Patients must fast for at least eight hours prior to the procedure to reduce anesthesia risks. The pre-procedure phase requires arriving at the facility at least 90 minutes early for check-in, paperwork, and anesthesia evaluation.
During this preparatory time, patients undergo blood work to check coagulation status and liver function. An intravenous line is placed for fluids and medication administration. This preparation ensures the patient is medically optimized before being transported to the interventional suite.
Following the procedure, the patient is moved to a Post-Anesthesia Care Unit (PACU) for immediate monitoring as they wake up from sedation or anesthesia. This recovery period typically lasts between one and two hours, during which nurses monitor vital signs and the puncture site for bleeding. After stabilization, the patient is transferred to a hospital floor for continued observation.
BRTO is not an outpatient procedure; a hospital stay is required to monitor for sclerosant side effects and changes in portal venous pressure. The typical hospital stay is between one and three days. This extended monitoring is necessary because shunt obliteration can cause a sudden, temporary increase in portal pressure, potentially exacerbating other varices or affecting fluid balance.
Variables That Can Extend the Procedure Duration
The two to four-hour timeline is an average, and several anatomical and technical factors can extend the procedure duration. The complexity of the patient’s venous anatomy is a primary variable, especially the configuration of the gastrorenal shunt and the gastric varices. Patients with multiple feeder veins require extra time identifying and selectively catheterizing each vessel.
The discovery of significant collateral vessels during the initial venogram can add substantial time, as these vessels must be sealed to prevent the sclerosant from escaping into the systemic circulation. This often necessitates the deployment of adjunctive embolization materials, such as metallic coils or Gelfoam. Shunt size is another factor, as a large shunt can make it challenging to achieve a complete seal with the balloon, requiring multiple adjustments.
Patient instability during the procedure, though uncommon, can lead to delays as the medical team pauses the intervention to stabilize blood pressure or heart rhythm. If technical success is not achieved in a single session due to the volume or complexity of the varices, the patient may require a second, staged BRTO procedure later. These variables emphasize that the procedure time is highly individualized based on the patient’s specific vascular network.