Why Is BRTO Recommended for Bleeding Gastric Varices with a Gastrorenal Shunt?

May 25, 2026 · Pouyan Golshani, MD, Interventional Radiologist

It’s 2 AM in the emergency department, and your patient with known cirrhosis is hypotensive with active hematemesis. After initial resuscitation, an urgent CT angiogram confirms the source: large, high-flow gastric varices fed by a prominent gastrorenal shunt. The patient’s Model for End-Stage Liver Disease (MELD) score is 14. Gastroenterology has been consulted for emergent endoscopy, but you know a definitive, durable treatment is needed. The interventional radiology team needs a consult, and you must consider the best approach. This article details the clinical workflow for this specific scenario, explaining why Balloon-occluded Retrograde Transvenous Obliteration (BRTO) is rated as Usually appropriate by the American College of Radiology (ACR).

Who Fits This Clinical Scenario?

This guidance applies specifically to a cirrhotic patient with active, high-flow bleeding from gastric varices, significant portal hypertension, and a moderate MELD score (e.g., 14). The critical, defining feature for this workflow is the presence of a large, spontaneous portosystemic shunt—most commonly a gastrorenal shunt—identified on prior cross-sectional imaging like a contrast-enhanced CT. This anatomical finding is the key determinant that makes BRTO a primary consideration.

This article does not apply to patients with slightly different presentations, which would trigger a different management pathway:

Higher MELD Score (e.g., >18-20): A patient with a MELD score of 20 has more advanced liver dysfunction, which increases the procedural risk and may alter the choice between BRTO and a Transjugular Intrahepatic Portosystemic Shunt (TIPS).
Prominent Hepatic Encephalopathy: If the patient has significant pre-existing hepatic encephalopathy, a procedure like TIPS that shunts more portal blood away from the liver would be relatively contraindicated.
No Demonstrable Shunt: If CT imaging does not show a clear gastrorenal or other large portosystemic shunt, the technical approach for BRTO is not feasible, and other options like TIPS or antegrade obliteration become the focus.
Splenic Vein Thrombosis: Gastric varices can be caused by splenic vein occlusion (so-called “sinistral” or left-sided portal hypertension) without cirrhosis. This is a distinct pathophysiology requiring a different treatment strategy, often splenectomy.

What Diagnoses Are You Working Up in This Scenario?

In this scenario, the primary diagnosis of bleeding gastric varices is already established. The clinical workup is focused on characterizing the underlying pathophysiology and anatomy to guide intervention. The goal is to stop the hemorrhage and prevent re-bleeding, which carries a high mortality risk.

Bleeding Gastric Varices Secondary to Portal Hypertension: This is the principal diagnosis. In cirrhosis, scarring obstructs normal blood flow through the liver, causing pressure to back up into the portal venous system. This portal hypertension forces blood into alternative, lower-pressure pathways (portosystemic shunts), leading to the formation of dilated, fragile vessels (varices) in the stomach and esophagus. Gastric varices, particularly large ones (GOV2 or IGV1 types), are prone to rupture and massive hemorrhage.

Spontaneous Gastrorenal Shunt: This is not a separate diagnosis but a critical anatomical finding. It represents a major pathway for portal blood to bypass the liver, flowing from the gastric veins (often via the short gastric or posterior gastric veins) directly into the left renal vein and then the systemic circulation. While this shunt decompresses the portal system to some degree, it is also the primary outflow for the gastric varices. Its presence is what makes a retrograde (i.e., via the renal vein) approach like BRTO technically possible and highly effective.

Underlying Decompensated Cirrhosis: The MELD score of 14 indicates moderate liver dysfunction. The active bleeding is a sign of decompensation. Management must address not only the acute hemorrhage but also the underlying liver disease, including coagulopathy, ascites, and potential for hepatic encephalopathy, which will influence the choice of intervention.

Why Is BRTO the Recommended Study for This Presentation?

For a patient with bleeding gastric varices and a large gastrorenal shunt, the ACR panel rates Balloon-occluded Retrograde Transvenous Obliteration (BRTO) as Usually appropriate. This procedure is a direct, targeted therapy that leverages the patient’s specific shunt anatomy to obliterate the varices.

During BRTO, an interventional radiologist accesses the venous system (typically via the femoral vein), navigates a catheter into the inferior vena cava, and then into the left renal vein to engage the gastrorenal shunt. A balloon is inflated within the shunt to occlude outflow, and a sclerosant agent is injected retrogradely to fill and thrombose the gastric varices. The balloon remains inflated for a period to allow the sclerosant to work before being deflated and removed. This technique directly eliminates the varices with high technical and clinical success rates for preventing re-bleeding.

The key advantage of BRTO in a patient with a MELD score of 14 is that it does not worsen portal hypertension—in fact, it may transiently increase it by closing a major outflow shunt. Crucially, it preserves hepatopetal (toward the liver) portal flow, avoiding the risk of inducing or worsening hepatic encephalopathy, a significant concern with alternative treatments.

How Do Alternatives Compare?

TIPS: A Transjugular Intrahepatic Portosystemic Shunt is also rated Usually appropriate. TIPS works by creating a new pathway for blood to flow from the portal vein directly to the hepatic vein, decompressing the entire portal system. While effective at controlling bleeding, it shunts blood away from the liver, which can precipitate or worsen hepatic encephalopathy. For a patient with a MELD of 14, this risk is moderate but significant, making the targeted approach of BRTO often preferable if the anatomy is suitable.
Endoscopic Management: Injection of tissue adhesives like cyanoacrylate glue is also Usually appropriate and is the standard first-line therapy for acute stabilization. However, for large, high-flow varices connected to a large shunt, the glue can embolize systemically, and re-bleeding rates after a single session can be substantial. Endoscopy is critical for initial hemostasis but is often used as a bridge to a more definitive treatment like BRTO or TIPS.

Both BRTO and TIPS are fluoroscopically-guided procedures that involve radiation exposure and the use of iodinated contrast. The ACR does not provide specific relative radiation level (RRL) estimates for these interventional procedures, as doses are highly variable depending on patient anatomy and procedural complexity.

What’s Next After BRTO? Downstream Workflow

The post-procedure workflow focuses on confirming treatment success, monitoring for complications, and managing the patient’s underlying liver disease.

If BRTO is technically successful: The patient is typically monitored in an intensive or intermediate care unit. The primary goals are to manage any post-procedural pain, monitor for complications like hemoglobinuria from sclerosant-induced hemolysis, and manage fluid status. A follow-up contrast-enhanced CT or MRI is often performed within 1-3 months to confirm complete thrombosis and obliteration of the treated gastric varices. The patient’s gastroenterology or hepatology team will continue to manage their cirrhosis and screen for the development of new or recurrent esophageal varices, which can sometimes occur due to shifts in portal pressure.

If BRTO is technically unsuccessful: In a small number of cases, the interventional radiologist may be unable to cannulate the gastrorenal shunt or achieve stable balloon occlusion. If the patient remains at high risk for re-bleeding, the next logical step is to proceed with TIPS, which is also rated Usually appropriate and does not depend on the same shunt anatomy for access.

If bleeding recurs despite BRTO: This is uncommon but can occur if the varices were incompletely obliterated or if new varices develop. The workup would involve repeat endoscopy and cross-sectional imaging to identify the source. Depending on the findings, treatment could involve repeat BRTO, antegrade obliteration techniques, or TIPS.

Pitfalls to Avoid (and When to Get Help)

Navigating this clinical scenario requires careful coordination and awareness of potential missteps. Common pitfalls include:

Underestimating the MELD Score: A MELD of 14 is not benign. It signifies moderate liver dysfunction and carries procedural risks. The decision between BRTO and TIPS should be made in consultation with hepatology and interventional radiology.
Delaying Definitive Therapy: While endoscopic management is a critical first step for stabilization, it should not be considered the final treatment in a patient with high-risk anatomy. A prompt consult to Interventional Radiology is essential.
Ignoring Worsening Ascites or Esophageal Varices: By occluding a major portosystemic shunt, BRTO can transiently increase portal pressure. This may lead to worsening ascites or the enlargement of esophageal varices, which must be monitored and managed aggressively post-procedure.
Lack of Multidisciplinary Communication: The optimal management of a patient with a major variceal bleed requires close collaboration between the emergency department, gastroenterology, interventional radiology, and critical care teams.

If the patient develops worsening encephalopathy, refractory ascites, or signs of liver failure after the procedure, immediate escalation to the hepatology and critical care teams is warranted.

Frequently Asked Questions

Why choose BRTO over TIPS for a patient with a MELD score of 14?

While both are rated ‘Usually appropriate,’ BRTO is often preferred in this scenario because it directly obliterates the varices without shunting blood away from the liver. This avoids the risk of worsening hepatic encephalopathy, which is a significant concern even with a moderate MELD score of 14. TIPS decompresses the entire portal system but at the cost of reduced liver perfusion.

What is the role of endoscopy if BRTO is the planned definitive treatment?

Endoscopy is the crucial first-line intervention for acute stabilization. In a patient with active, life-threatening hematemesis, emergent endoscopy with injection of a tissue adhesive like cyanoacrylate glue is performed to achieve initial hemostasis. BRTO is then performed as a more durable, definitive treatment to prevent re-bleeding, often within a few days of stabilization.

Can BRTO be performed if a patient does not have a gastrorenal shunt?

No, a classic BRTO procedure requires a suitable portosystemic shunt (most commonly gastrorenal or gastrocaval) to provide a retrograde venous access route to the gastric varices. If no such shunt exists, alternative approaches like TIPS or percutaneous antegrade obliteration would be considered.

How does the presence of significant ascites affect the decision to perform BRTO?

Significant, uncontrolled ascites is a relative contraindication for BRTO. Because BRTO occludes a major decompressive shunt, it can cause a temporary increase in portal pressure, which can acutely worsen ascites. The patient’s volume status and ascites should be medically optimized before the procedure, and in some cases, TIPS may be a better option as it actively reduces portal pressure.

How would a much higher MELD score, such as 22, change the management plan?

A MELD score of 22 indicates severe liver dysfunction and significantly higher procedural mortality risk. In such a patient, the risks of any invasive procedure are elevated. While TIPS is often used as a bridge to liver transplantation, the risk of post-TIPS encephalopathy and liver failure is very high. BRTO might be considered a lower-risk alternative in terms of liver function, but the decision would require a careful, multidisciplinary discussion about the patient’s overall prognosis and candidacy for transplant.

Reviewed by Pouyan Golshani, MD, Interventional Radiologist — May 26, 2026