AASLD Practice Guidance on the Use of TIPS, Variceal Embolization, and Retrograde Transvenous Obliteration in the Management of Variceal Hemorrhage

Recently published AASLD (American Association for the Study of Liver Diseases) practice guidance, which was developed by consensus of an expert panel is a comprehensive one on the use of interventional radiology endovascular techniques in the management of hemorrhage from esophageal, gastrofundal, and ectopic varices [1]. This guidance addresses the recent advancements in the interventional procedures including transjugular intrahepatic portosystemic shunt (TIPS), variceal embolization, and retrograde transvenous obliteration (RTO). Moreover, this document reviews the anatomy of portosystemic collaterals and clinical use of these endovascular treatments. Although TIPS is a common procedure for variceal hemorrhage, I would like to address on the RTO procedures in this commentary. RTO is a promising treatment for the prevention of recurrent hepatic encephalopathy (HE) and bleeding of gastric varices (GVs). Furthermore, RTO may help restore portal blood flow to improve the liver function and survival in patients with cirrhosis and preserved liver function. Plug-assisted retrograde transvenous obliteration (PARTO) has been widely performed since 10 years ago, which uses of vascular plug and gelfoam [2]. PARTO deceases the procedure time and prevents procedure-related complications as it does not require an indwelling balloon catheter and sclerosing agents. Except embolization of prominent efferent vein using microcoils in a few cases, the procedure time could be markedly shortened because hand-cut gelfoam sponges (1–2 mm) themselves is used, and their larger size is usually sufficient to embolize efferent veins such as left inferior phrenic and paravertebral veins during shunt embolization. It also eliminates the need of sclerosing agents, thereby avoiding its complications. Not only has this advance been associated with high technical and clinical success, but the method is also simper, easier, and safer to perform. Although limited by a lack of clinical data, PARTO has the potential to be a treatment of choice for portosystemic shunt (PSS) associated with GVs and HE. …