Pathophysiological management of gastric varices: From hemodynamics to targeted therapies

Table 3 Hemodynamics of gastric varices based on cross-sectional imaging classification, along with their preferred and alternative interventions

Type		Venous anatomy	Venographic/hemodynamic findings ⇨ key issue	Preferred intervention	Alternative intervention	Key technical notes during RTO
Efferent venous pattern
A	Single draining shunt (usually gastrorenal; rarely gastrocaval); no collaterals		Complete opacification of the varix on balloon-occluded venography	Standard BRTO	PARTO/CARTO/EUS-guided	Deep microcatheter placement ⇨ inject sclerosant till minimal afferent filling
B1/B2	Single shunt + small/multiple collateral veins		Incomplete opacification due to preferential collateral flow ⇨ Collateral “leak”	Modify the flow to isolate the varix by coil/plug embolization	EUS-guided	Balloon beyond collaterals; deep positioning ⇨ flow-directed embolization ⇨ microcatheter beyond collaterals ⇨ sclerosant
B3	Single shunt + large collateral veins		Poor opacification until collaterals are controlled ⇨ Significant collateral drainage	Pre-embolize collaterals ⇨ BRTO	EUS-guided	Selective catheterization ⇨ coil embolization ⇨ repeat venography
C1	Two shunts (gastrorenal + small gastrocaval)		Partial opacification due to the second shunt ⇨ Additional minor outflow	Eliminate second shunt ⇨ treat as B3	BATO/PTO/trans-TIPS access/EUS-guided	Coil embolization of the gastrocaval shunt via microcatheter
C2	Two large shunts (gastrorenal + gastrocaval)		Incomplete opacification due to dual drainage ⇨ Major dual outflow	EUS-guided/BATO/PTO/trans-TIPS access	Combined BRTO approaches for dual shunt control	Dual balloon occlusion (gastrorenal + IJV gastrocaval) ⇨ then sclerosant
D	No shunt		No large draining shunt ⇨ No retrograde access possible	TIPS (± embolization)	BATO/PTO/EUS-guided	-
Afferent venous pattern
Type 1	Single afferent vein supplying gastric varix		Sclerosant stagnates with minimal reflux into the afferent vein ⇨ Risk of excessive reflux into the portal vein if over-injected	Standard BRTO	EUS-guided	Endpoint = minimal afferent vein filling; avoid forceful injection
Type 2	Two afferent veins (left + posterior gastric veins)		Reflux preferentially into the lower-pressure vein ⇨ Partial obliteration due to persistent higher-pressure inflow	Staged BRTO is often required after coil/glue embolization of feeders	BRTO + TIPS if associated esophageal varices present/EUS-guided	Endpoint = reflux in one vein; repeat the session for the remaining varix
Type 3	Separate afferent vein drains directly into the shunt (no variceal communication)		Sclerosant preferentially flows into this vein ⇨ portal reflux ⇨ Ineffective variceal filling + risk of portal spill	BRTO + Selective embolization of the aberrant afferent vein	EUS-guided	Deep microcatheter positioning; embolize extra afferent (transhepatic/transjugular) if needed

EUS: Endoscopic ultrasound; BRTO: Balloon-occluded retrograde transvenous obliteration; PARTO: Plug-assisted retrograde transvenous obliteration; CARTO: Coil-assisted retrograde transvenous obliteration; RTO: Retrograde transvenous obliteration; BATO: Balloon-occluded antegrade transvenous obliteration; PTO: Percutaneous transhepatic obliteration; TIPS: Transjugular intrahepatic portosystemic shunt.