significant efferent collateral vessels are embolized using coils, and/or gelfoam and sclerosant.occlusive balloon is inflated to occlude the shunt, then contrast injected upstream of the occlusion (retrograde venography) to further evaluate variceal anatomy and identify major collateral vessels.the target shunt (typically gastro-renal shunt via left renal vein) catheterized using with selective catheter (e.g.a 6 to 12-French vascular sheath placed.systemic venous access obtained via femoral vein approach, alternatively via internal jugular vein approach. The classic BRTO procedure is as follows: afferent & efferent gastric variceal anatomy.CT imaging - ideally immediately preceding BRTO intervention.standard laboratory studies, including liver enzymes and coagulation panel.The techniques employed are typically adapted depending on specific portosystemic anatomy and operator experience and preference. balloon-occluded antegrade transvenous obliteration (BATO).coil-assisted retrograde transvenous obliteration (CARTO).vascular plug-assisted retrograde transvenous obliteration (PARTO).The classic BRTO procedure has been largely supplanted by modified techniques which involve shorter procedure times. prophylaxis against re-bleeding in the setting of primary endoscopic therapy.active hemorrhage, after failed endoscopic treatment.
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