Interventional Radiology in the Treatment of Gastric Varices

November 18 07:45 2025 Print This Article

What are Gastric Varices? 

Portal circulation comprises a complex network of blood vessels that transport blood from the organs of the digestive system to the liver. Certain conditions, such as cirrhosis, splenic vein blockage or portal vein thrombosis, increase the pressure in the portal vein, causing the blood vessels in the stomach to become enlarged, known as gastric varices. These gastric varices can be life-threatening as they can rupture and cause bleeding.

How does this matter to you as a patient:

• Bleeding gastric varices cause a considerable drop in blood pressure, shock, vomiting of blood or black stools.
• Even when the bleeding is under control, the presence of gastric varices indicates a serious underlying condition (e.g., portal hypertension) that requires continuous monitoring and care.
• Treatment strategies are complicated and often require a multidisciplinary team comprising hepatologists, gastroenterologists, interventional radiologists and so on.

This article focuses on interventional radiology (IR) treatments for gastric varices, including what they are, how they work and what you need to know as a patient.

How Can IR Help?

IR is a minimally invasive procedure performed by radiologists using wires, small catheters, and imaging guidance (e.g. X-ray, fluoroscopy, ultrasound, computed tomography [CT], etc.) instead of open surgery. IR is an option for gastric varices to help stop bleeding, address the underlying portal hypertension, and reduce recurrence.

Primary IR Procedures Used for Gastric Varices

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

A connection between a branch of the portal vein (which brings in blood from the intestines) and the hepatic vein (inside the liver and carries blood out of it) is made using a catheter to divert the high pressure in the portal system into the systemic circulation, thereby lowering the overall portal pressure. Briefly, a thin tube/catheter is inserted in the neck and is guided to the liver. Using imaging guidance, a metal stent is placed to form a connection between the hepatic vein and portal vein. This method is useful for variceal bleeding that is unresponsive to endoscopic treatment. However, this method has been controversial as diverting the blood flow is associated with hepatic encephalopathy (liver dysfunction [inability to filter toxins from the blood] leads to brain dysfunction).

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO)

Patients with gastric varices have a gastrorenal shunt (a connection between the stomach and kidney veins), causing the blood to flow in the wrong direction. This is a procedure that uses a balloon catheter and sclerosant (a substance that causes scarring of the vein and closes it) to block the varices. The catheter is guided to the varices by accessing the vein in the thigh or the neck. The sclerosing agent is injected, and the balloon is inflated to obliterate the varix. Following the removal of the balloon and the sclerosing agent, the varix is effectively closed and bleeding is stopped.

Unlike TIPS, BRTO effectively improves liver function by increasing blood flow through the liver, thereby enhancing its toxin-filtering capacity. BRTO can occasionally raise the pressure in other veins, such as in the oesophagus. Some other side effects of this procedure include blood in the urine, abdominal pain or fluid around the lungs. Rare but life-threatening issues include irregular heart rhythm and shock.

Advancements in retrograde transvenous obliteration have overcome some of the problems associated with balloon catheters and sclerosing agents. In plug-assisted retrograde transvenous obliteration (PARTO), the balloon catheter is replaced with a vascular plug and the sclerosing agent is replaced with the gelfoam slurry. This method provides the same effectiveness as BRTO, without the complications mentioned above for BRTO.

The plug size in PARTO is limited; thus, it cannot be used for varices with large shunts. Another advancement called CARTO (coil-assisted retrograde transvenous obliteration) was developed. In this procedure, vascular embolization coils replace the vascular plugs; thus, there is no limitation of size.

Why choose IR Over Standard Endoscopy?

• Endoscopic therapies have been the traditional first-line treatment for gastric varices. However, their unique anatomy and considerable blood flow make endoscopy therapy less effective, as the risk of profuse bleeding and rebleeding is very high. The risk of pulmonary embolism is also high, as the glue used for gastric varices tends to leak due to high blood flow. The endoscopic injection of the glue increases the risk of ulcer formation, which consequently increases rebleeding risk.
• IR procedures are minimally invasive, improving patient outcomes and achieving complete and superior obliteration of gastric varices. IR can be used in combination with endoscopy. For example, endoscopy therapy can be used for an acute bleeding episode to stabilise the patient. For improving long-term patient outcomes and reducing rebleeding risk, the patient can be referred to IR.

What This Means for You as a Patient?

These therapies are effective in stopping rebleeding from gastric varices in suitably selected patients. They are increasingly becoming a standard for treating gastric varices in high-risk patients and in those where endoscopy fails as a treatment modality. The choice of IR as a treatment modality for gastric varices will depend on your unique anatomy, bleeding risk, liver condition, as well as overall physical fitness.

How Does the Procedure Work? 

In this section, we briefly describe the procedure, including the pre-procedural preparation and post-procedural care.

Preparation

• A cross-sectional imaging (CT or MRI) or Doppler ultrasound will be performed for portal vein anatomy assessment, to identify the varices and any shunts (e.g. a gastrorenal shunt), which are the pathways used in IR.
• The overall health will be assessed by performing liver and kidney function tests and coagulation tests.
• The gastroenterologist will present the alternatives (endoscopy, medication, TIPS), as well as the pros/cons of IR.

The Procedure

• Depending on the condition of the patient, either moderate sedation or general anaesthesia will be given.
• A catheter will be inserted via a vein in the neck or groin. The catheter is guided into the relevant shunt or vein using fluoroscopy or X-rays that drain the varix (for BRTO) or into the portal system (for TIPS).
• In the case of BRTO, a balloon is inflated to block outflow, followed by the release of a sclerosant or metal wires into the variceal vein to obliterate it.
• Then, the balloon is deflated and the catheter is removed, and a closure device or pressure is applied at the entry site.

Post-Procedure

• Hospitalisation usually lasts from 1 to 3 days as doctors monitor the patient for infection, bleeding or liver/kidney function problems.
• A follow-up CT scan is performed to ensure the varix is obliterated.
• Continuous follow-up is essential as there is a risk of new varices emerging due to the persistent portal hypertension. The gastroenterologist will continue to monitor and manage any pre-existing liver disease, bleeding or portal hypertension.

Risks and Limitations

As no procedure is risk-free, it is important to be well informed. The possible risks involved in IR procedures are as follows:

• Bleeding at the site of vein access (thigh or neck)
• Infection
• Ascites can worsen, or blocking a shunt can increase portal pressure, causing fluid accumulation
• As IR can alter blood flow dynamics, it can worsen any pre-existing liver disease.
• If contrast dye is used, it can cause contrast-related kidney injury in patients with reduced kidney function.

Integration of IR into the Treatment Plan for Gastric Varices

Treating gastric varices involves a multimodal strategy. The steps below indicate how IR fits in the treatment plan for gastric varices.

• If bleeding is present, then the bleeding needs to be stopped using the first-line treatment strategy of endoscopy plus medications (vasoactive drugs or beta-blockers).
• The doctors assess the overall condition of the patient, the anatomy and any underlying liver disease. If bleeding recurs or the endoscopy procedure fails, then IR is the treatment of choice.
• The intervention is decided based on the patient’s condition. For example, BRTO may be preferred if the patient has a large gastrorenal shunt and gastric varices, while TIPS can be used for generalized portal hypertension and both oesophageal and gastric varices.
• As the risk for portal hypertension continues to remain, the patient must undergo regular endoscopic screening for varices, imaging and laboratory tests to assess for ascites, encephalopathy and liver function tests, continue to take medications and maintain a healthy lifestyle to manage any underlying liver disease.

Summary

Gastric varices develop in patients with liver disease or portal hypertension. Endoscopy and pharmacological therapy are considered the first-line treatment for gastric varices. If these options fail, IR procedures such as TIPS or BRTO are attempted. They are minimally invasive, directly target the varices, and can be integrated with the overall portal hypertension care plan.

Advancements, such as PARTO and CARTO, have overcome some of the complications of BRTO, improving patient outcomes. However, IR techniques require certain considerations, such as the type of shunt involved, suitable patient anatomy, manageable liver disease and an experienced team with knowledge of the risks and follow-up requirements.

If you or a loved one are dealing with gastric varices or related liver conditions, expert care is vital. Kauvery Hospital, with branches in Chennai, Hosur, Salem, Tirunelveli, and Trichy, offers advanced interventional radiology and multidisciplinary treatment to ensure the best possible outcomes for patients.

What Patients Want to Know About Gastric Varices Treatment 

What are gastric varices and why do they form?

Gastric varices are enlarged veins in the stomach caused by high pressure in the portal vein, usually due to liver disease like cirrhosis or vein blockages.

How serious is bleeding from gastric varices?

Bleeding is a medical emergency. It can cause vomiting of blood, black stools, low blood pressure and shock, needing immediate hospital care.

How does interventional radiology treat gastric varices?

IR uses minimally invasive treatments like TIPS, BRTO, PARTO and CARTO to stop bleeding, reduce pressure and prevent future episodes.

What is the difference between TIPS and BRTO treatment?

TIPS reduces overall portal pressure by creating a new pathway in the liver, while BRTO blocks the abnormal vein draining the varices. BRTO suits patients with a gastrorenal shunt.

When is IR recommended over endoscopy?

IR is recommended when bleeding continues despite endoscopy or when the risk of recurrence is high due to the anatomy and high blood flow of gastric varices.

What can patients expect after an IR procedure?

Most patients stay in the hospital for 1–3 days for monitoring, imaging follow-up and assessment of liver or kidney function.

Can gastric varices come back after treatment?

Yes, because portal hypertension may persist. Regular scans, endoscopy and liver care are essential to prevent new varices.

Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai (Alwarpet, Radial Road & Vadapalani), Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and paediatric trauma care.

Chennai Alwarpet – 044 4000 6000 • Chennai Radial Road – 044 6111 6111 • Chennai Vadapalani – 044 4000 6000 • Trichy – Cantonment – 0431 4077777 • Trichy – Heartcity – 0431 4077777 • Trichy – Tennur – 0431 4022555 • Maa Kauvery Trichy – 0431 4077777 • Kauvery Cancer Institute, Trichy – 0431 4077777 • Hosur – 04344 272727 • Salem – 0427 2677777 • Tirunelveli – 0462 4006000 • Bengaluru – 080 6801 68011