Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) is a minimally invasive technique used to treat gastric varices, which are enlarged veins in the stomach caused by high blood pressure in the portal vein system (portal hypertension). BRTO effectively treats these varices by obliterating the veins that supply them. The procedure involves accessing the enlarged veins through a catheter and injecting a specialized agent to cause them to scar and close off. While the intervention itself is relatively short, the overall time commitment for the patient extends from preparation through long-term follow-up imaging.
Procedure Overview and Preparation
The preparation phase starts with a consultation with the interventional radiologist to review the patient’s medical history and current status. This is followed by diagnostic steps to accurately map the internal anatomy, which can take several days or weeks to schedule and complete.
Pre-procedure imaging, typically a Computed Tomography (CT) scan or Magnetic Resonance Imaging (MRI), is necessary to identify the specific portosystemic shunt, such as a gastrorenal or gastrocaval shunt, that is supplying the varices. Blood work is also performed within 24 hours of the procedure to assess liver and kidney function and coagulation factors. On the day of the procedure, patients are asked to arrive at the hospital at least 90 minutes early to complete check-in, finalize consent forms, and have an intravenous (IV) line placed. This preparation ensures the patient is clinically ready and all logistical requirements are met before the therapeutic phase begins.
The BRTO Timeframe: Step-by-Step Duration
The BRTO procedure takes place in the interventional radiology suite and typically lasts between two to four hours, covering the time the patient is under sedation or general anesthesia. The procedure begins with the Access and Catheterization phase, where a catheter is inserted, usually through a vein in the neck or groin, and navigated to the target shunt under image guidance.
The next step involves Balloon Inflation and Angiography. A balloon at the tip of the catheter is inflated to temporarily block the blood flow in the shunt, and contrast dye is injected to fully map the complex network of gastric varices. The final and most time-intensive phase is the Sclerosant Injection and Embolization. A specialized sclerosing agent is injected into the varices to cause inflammation and eventual scarring, which obliterates the vessels.
The time required for the sclerosing agent to work, often called the “dwell time,” is a major variable in the procedure’s duration, sometimes lasting 30 minutes or more before the balloon is deflated. The overall time in the suite is influenced by anatomical complexity, such as the size and number of varices, and the presence of collateral vessels that may also need to be embolized. Once imaging confirms blood flow has stopped in the treated vessels, the balloon is deflated, and the catheter is removed.
Immediate Post-Procedure Monitoring
Immediately following the procedure, patients are moved to a recovery area for close observation. This monitoring period is focused on managing any immediate side effects and ensuring patient stability. Patients must maintain strict bed rest for four to six hours to minimize the risk of bleeding at the access site in the groin or neck.
The monitoring process involves frequent checks of vital signs, including blood pressure and heart rate, to ensure stability. Pain management is initiated during this time, as patients may experience discomfort related to the sclerosant injection. Most institutions require an overnight hospital stay for BRTO patients to ensure recovery and allow for continued monitoring of potential complications. Discharge criteria include stable vital signs and the ability to walk without assistance.
Recovery and Long-Term Follow-up Schedule
The time commitment extends beyond the hospital stay, encompassing the patient’s recovery and the long-term surveillance schedule. Patients are advised to avoid strenuous activity, heavy lifting, and intense exercise for four to six weeks following the procedure to allow the body to heal completely. A return to light daily activities, such as office work or household chores, is often possible within one to two weeks, depending on the patient’s overall health.
Long-term follow-up confirms the success of the obliteration and monitors for potential complications. The first follow-up imaging, typically a contrast-enhanced CT scan, is scheduled approximately one to three months after the BRTO procedure. This scan confirms that the gastric varices are completely closed off and assesses the status of the surrounding vessels. Patients also undergo periodic endoscopic surveillance and clinical assessments every six months to one year to check for recurrence or the worsening of other varices, such as those in the esophagus.