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BRTO for Pediatric Patients: Special Considerations and Outcomes

12 July 2024

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) is a minimally invasive procedure primarily used to treat gastric varices associated with portal hypertension. While the procedure is well-established in adults, its application in pediatric patients presents unique challenges and considerations. This blog explores the special considerations and outcomes of BRTO in children, highlighting its benefits, risks, and the latest advancements in pediatric care.

Understanding BRTO: A Brief Overview

What is BRTO?
BRTO is a procedure designed to manage gastric varices by occluding the blood flow to these abnormal veins using a balloon catheter. The balloon blocks the vein, and a sclerosant is injected to obliterate the varices, effectively reducing the risk of bleeding.

Indications for BRTO in Pediatrics
In pediatric patients, BRTO is typically indicated for those with portal hypertension resulting from conditions such as liver cirrhosis, congenital liver diseases, or post-surgical complications. These conditions can lead to the development of gastric varices, which pose a significant risk of life-threatening bleeding.

Portal hypertension is the primary indication for BRTO in pediatric patients. This condition occurs when there is increased blood pressure within the portal venous system, often due to liver cirrhosis, congenital liver diseases, or post-surgical complications. Elevated pressure in the portal vein can lead to the development of gastric varices—enlarged veins in the stomach that are at risk of bleeding.

Special Considerations in Pediatric BRTO

Anatomical and Physiological Differences
Children have smaller and more delicate vascular structures compared to adults. This requires meticulous planning and precision during the BRTO procedure. The equipment used must be appropriately sized for pediatric patients, and the procedure must be tailored to their unique anatomical and physiological characteristics.

Sedation and Anesthesia
Administering sedation and anesthesia in pediatric patients requires special expertise. Anesthesiologists must carefully balance the need for effective sedation with the child’s safety and comfort. The choice of sedative agents and dosages must be adjusted according to the child’s age, weight, and overall health condition.

Psychological Considerations
Undergoing a medical procedure can be particularly stressful for children and their families. It’s crucial to provide psychological support and clear communication throughout the treatment process. Child life specialists can help prepare children for the procedure through age-appropriate explanations and coping strategies.

Radiation Exposure
Minimizing radiation exposure is a significant concern in pediatric patients. Techniques such as using the lowest possible radiation dose, employing non-radiation imaging modalities when feasible, and shielding non-target areas are essential to protect the child’s long-term health.

Procedure and Technique Adjustments

Tailoring the Technique
The BRTO technique in pediatric patients often requires adjustments to accommodate their smaller size. Specialized pediatric catheters and balloons are used, and the volume of sclerosant injected is carefully calculated based on the child’s body size and the size of the varices.

Imaging and Guidance
High-quality imaging is crucial for the success of BRTO. In pediatric patients, real-time ultrasound, fluoroscopy, and MRI can be used to guide the procedure accurately. These imaging modalities help ensure precise catheter placement and effective variceal obliteration while minimizing complications.

Post-Procedure Monitoring
Close monitoring after the procedure is essential to detect any immediate complications and assess the effectiveness of the treatment. Pediatric patients may require extended observation to ensure they are stable and to provide timely intervention if any issues arise.

Outcomes of BRTO in Pediatric Patients

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) is a promising and effective treatment for pediatric patients with gastric varices due to portal hypertension. This procedure, which involves the occlusion of blood flow to varices and injection of a sclerosant to obliterate them, has shown significant benefits in children. This section delves into the outcomes of BRTO in pediatric patients, examining its efficacy, safety, long-term results, and overall impact on the quality of life.

Efficacy of BRTO in Children

High Success Rates BRTO has demonstrated high success rates in controlling gastric varices in pediatric patients. Studies and clinical reports indicate that the procedure can effectively obliterate varices and prevent rebleeding in a majority of cases. For children with portal hypertension, BRTO offers a crucial intervention that significantly reduces the risk of life-threatening variceal bleeding.

Improved Portal Hemodynamics One of the primary goals of BRTO is to improve portal hemodynamics by reducing portal hypertension. The procedure successfully decreases the pressure within the portal venous system, alleviating the strain on varices and reducing the likelihood of their rupture. This hemodynamic improvement is particularly beneficial for children, as it can stabilize their condition and prevent further complications.

Safety and Complications

Low Complication Rates BRTO is generally considered a safe procedure with a low rate of severe complications, especially when performed by experienced interventional radiologists. The minimally invasive nature of the procedure contributes to its safety profile, reducing the risks associated with more invasive surgical interventions. Common complications, such as minor bleeding or transient abdominal pain, are typically manageable and do not significantly impact the patient’s recovery.

Management of Potential Risks While serious complications are rare, they can include infection, allergic reactions to the sclerosant, or accidental damage to surrounding structures. However, these risks are mitigated through careful procedural planning, the use of advanced imaging techniques, and close post-procedural monitoring. The benefits of BRTO in preventing severe variceal bleeding generally outweigh the potential risks, making it a viable option for many pediatric patients.

Long-Term Outcomes

Sustained Variceal Obliteration Long-term outcomes for pediatric patients undergoing BRTO are generally positive, with sustained variceal obliteration observed in many cases. This long-term effectiveness is crucial for children, as it reduces the need for repeated interventions and allows them to lead more normal lives without the constant threat of variceal bleeding.

Reduction in Hospitalizations Successful BRTO significantly reduces the frequency of hospitalizations due to variceal bleeding. This reduction not only improves the child’s quality of life but also decreases the emotional and financial burden on their families. Long-term follow-up studies have shown that children who undergo BRTO experience fewer emergency visits and hospital admissions compared to those managed with other treatments alone.

Quality of Life Improvements BRTO has a substantial positive impact on the quality of life for pediatric patients. By effectively managing variceal bleeding and reducing the complications associated with portal hypertension, children can engage more fully in daily activities, attend school regularly, and participate in social and physical activities. This improvement in quality of life extends to their families, who experience less anxiety and stress related to their child’s health.

Case Studies and Clinical Evidence

Case Study 1: Congenital Liver Disease
A 10-year-old patient with congenital liver disease and severe portal hypertension underwent BRTO to treat life-threatening gastric varices. The procedure was successful, with no immediate complications. Follow-up imaging showed complete obliteration of the varices, and the patient remained free of bleeding episodes for over two years.

Case Study 2: Post-Surgical Complications
An 8-year-old patient developed gastric varices following liver surgery. BRTO was performed to prevent bleeding. The procedure required careful adjustment of the technique to accommodate the child’s small size. The patient experienced significant improvement, with no variceal bleeding reported in the following year.

Clinical Studies
Several clinical studies have demonstrated the safety and efficacy of BRTO in pediatric patients. A review of cases from multiple centers reported high success rates in controlling gastric varices, with a low incidence of severe complications. These studies highlight the potential of BRTO as a valuable treatment option for children with portal hypertension and variceal bleeding.

Future Directions and Innovations

Advancements in Pediatric Equipment
Ongoing advancements in pediatric-specific medical equipment are improving the safety and effectiveness of BRTO. Innovations such as smaller, more flexible catheters and advanced imaging technologies are enhancing the precision of the procedure.

Research and Clinical Trials
Continued research and clinical trials are essential to further refine BRTO techniques for pediatric patients. Studies focusing on long-term outcomes, optimal dosages of sclerosant, and the development of new therapeutic agents will contribute to better treatment protocols.

Integration with Comprehensive Care
BRTO should be integrated into a comprehensive care plan for pediatric patients with liver disease. This approach includes regular monitoring, nutritional support, and management of underlying conditions. A multidisciplinary team, including hepatologists, interventional radiologists, anesthesiologists, and child life specialists, ensures holistic care.

Conclusion

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) offers a promising solution for managing gastric varices in pediatric patients with portal hypertension. While the procedure requires special considerations and adjustments, its benefits in terms of efficacy, safety, and quality of life improvements are significant. Continued advancements in technology and research will further enhance the role of BRTO in pediatric care, providing hope and better outcomes for young patients and their families.

What is BRTO?

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) is a specialized interventional radiology procedure used primarily to manage gastric varices, particularly in patients with portal hypertension. Portal hypertension is a condition characterized by increased blood pressure within the portal venous system, often due to liver cirrhosis or other liver diseases. This procedure helps reduce the risk of variceal bleeding, which can be life-threatening.

Understanding BRTO: A Comprehensive Overview

Definition and Purpose
BRTO is a minimally invasive procedure designed to treat gastric varices by occluding the veins that supply them, thereby preventing bleeding. It is most commonly used in patients with portal hypertension who are at risk of or have experienced bleeding from gastric varices. The procedure involves the use of a balloon catheter to block the vein and a sclerosant to obliterate the varices.

Anatomy Involved
The primary anatomical structures involved in BRTO include the gastric varices, the portal venous system, and the shunt that connects these veins to systemic circulation. Gastric varices are enlarged veins in the stomach that develop due to increased pressure in the portal vein, often as a result of liver disease. These varices can rupture and bleed, posing a significant health risk.

Indications for BRTO

Gastric Varices
The primary indication for BRTO is the presence of gastric varices, particularly in patients with portal hypertension. Gastric varices are less common but more difficult to treat than esophageal varices. They are prone to bleeding, which can be severe and life-threatening.

Refractory or Recurrent Variceal Bleeding
BRTO is indicated for patients who have experienced recurrent or refractory variceal bleeding despite other treatments such as endoscopic band ligation or sclerotherapy. It is also used as a preventive measure in high-risk patients to prevent the initial episode of bleeding.

Pre-Transplant Bridging Therapy
For patients awaiting liver transplantation, BRTO can serve as a bridging therapy to control variceal bleeding and stabilize the patient’s condition, making them better candidates for transplantation.

Portal Hypertensive Gastropathy
In addition to treating gastric varices, BRTO may be used to manage portal hypertensive gastropathy, a condition where the stomach lining is damaged due to elevated portal pressure. By reducing portal hypertension, BRTO can help alleviate this condition.

The BRTO Procedure: Step-by-Step

Pre-Procedure Preparation
Before undergoing BRTO, patients typically undergo a series of diagnostic tests, including imaging studies such as CT scans, MRI, or ultrasound, to assess the anatomy and severity of the varices. Blood tests are also conducted to evaluate liver function and overall health. Patients may receive sedation and local anesthesia during the procedure to ensure comfort.

Insertion of the Balloon Catheter
The procedure begins with the insertion of a balloon catheter into the appropriate vein, usually the left renal vein, which connects to the gastric varices through a shunt. The catheter is advanced under imaging guidance to the site of the varices.

Balloon Occlusion
Once the catheter is in place, the balloon is inflated to occlude the vein, blocking blood flow to the varices. This occlusion is crucial as it isolates the varices, making them more susceptible to the sclerosant.

Injection of the Sclerosant
After occlusion, a sclerosant (a chemical that induces scarring) is injected into the varices through the catheter. The sclerosant causes the varices to collapse and become obliterated, preventing future bleeding. The balloon remains inflated during this process to ensure the sclerosant stays localized.

Post-Procedure Monitoring
Following the procedure, the balloon is deflated and the catheter is removed. Patients are monitored for several hours to ensure there are no immediate complications such as bleeding or infection. Most patients can go home the same day, although some may require an overnight stay for observation.

Benefits of BRTO

Effective Control of Variceal Bleeding
BRTO is highly effective in controlling and preventing variceal bleeding. By obliterating the gastric varices, the procedure significantly reduces the risk of life-threatening bleeding episodes.

Minimally Invasive Nature
As a minimally invasive procedure, BRTO involves less risk and shorter recovery times compared to surgical options. Patients typically experience less pain and fewer complications, allowing for a quicker return to normal activities.

Improvement in Portal Hypertension
BRTO can improve portal hypertension by reducing the blood flow through varices and decreasing overall portal pressure. This improvement can alleviate symptoms and reduce the complications associated with portal hypertension.

Long-Term Efficacy
Studies have shown that BRTO provides long-term efficacy in managing gastric varices, with many patients experiencing sustained benefits and reduced need for further interventions.

Limitations and Risks of BRTO

Potential Complications
While BRTO is generally safe, potential complications include bleeding, infection, allergic reactions to the sclerosant, and accidental damage to surrounding structures. Careful procedural planning and close monitoring can mitigate these risks.

Patient Selection
Not all patients with gastric varices are suitable candidates for BRTO. The procedure is most effective in patients with well-preserved liver function and isolated gastric varices. Patients with extensive liver disease or multiple varices may require alternative treatments.

Post-Procedure Care
Patients require careful post-procedure care and monitoring to ensure the success of the treatment and manage any potential complications. Regular follow-up visits and imaging studies are essential to monitor for recurrence of varices or other issues.

Clinical Outcomes and Research

Success Rates
Clinical studies have demonstrated high success rates for BRTO in controlling gastric varices and preventing rebleeding. The procedure’s effectiveness, combined with its minimally invasive nature, makes it a valuable option for managing this condition.

Long-Term Outcomes
Long-term outcomes for patients undergoing BRTO are generally positive, with sustained control of varices and improved quality of life. Regular follow-up and comprehensive care are essential to maintaining these benefits.

Ongoing Research
Ongoing research continues to explore ways to enhance the effectiveness and safety of BRTO. Advances in imaging technology, sclerosant formulations, and procedural techniques hold promise for improving outcomes and expanding the indications for BRTO.

Conclusion

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) is a highly effective and minimally invasive procedure for managing gastric varices, particularly in patients with portal hypertension. By providing targeted treatment and reducing the risk of variceal bleeding, BRTO significantly improves patient outcomes and quality of life. As research and clinical practice continue to evolve, BRTO will remain a critical tool in the management of portal hypertension and its complications.

Our Doctors

Dedicated IR Center for Vascular Problems in Madhya Pradesh

DR. SHAILESH GUPTA
MD, PDCC (INTERVENTIONAL RADIOLOGY) Consultant & Co-Director CVIC (Center Of Vascular & Interventional Care)

DR. ALOK KUMAR UDIYA
MD Radiology, PDCC (Neurointervention Radiology), PDCC ( HPB Intervention Radiology) FINR (Switzerland) & EBIR
Endovascular Surgeon & Consultant Interventional Neuroradiologist at Care CHL Hospital, Indore Co-director CVIC( center for vascular and interventional care)

DR. NISHANT BHARGAVA
Consultant Intervention Radiologist
MD Radiology, PDCC ( Neurointervention Radiology), FINR ( Fellowship in Neurointervention Radiology)
Co-director CVIC(Center for Vascular and Interventional Care)