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Unlocking portals: navigating patient selection, TIPS techniques, and embolization strategies in portal hypertension

Unlocking portals: navigating patient selection, TIPS techniques, and embolization strategies in portal hypertension

Dr. Chris Molvar
Dr. Bulent Arslan
Dr. Merve Ozen

Drs. Chris Molvar, Bulent Arslan, and Merve Ozen discuss the complexities IRs face when treating portal hypertension, specifically regarding patient selection, TIPS techniques, and the art of embolization.

Episode Transcript

Introduction (00:00):

Recorded live from the Cook booth at SIR and featuring leading experts in the field of interventional radiology discussing a wide range of IR-related topics. This is the Cook@ SIR podcast series.

Dr. Chris Molvar (00:17):

Welcome to what is sure to be an informative and provocative podcast. This program is coming to you live from a soundproof studio at the SIR annual meeting in Salt Lake City. My name is Chris Mulvar. I’ll be your host, your moderator, and an opinionated participant. I’m joined by colleagues Bulent Arslan and Merve Ozen and we’re gathering today to discuss portal hypertension, specifically looking at patient selection, TIPS techniques, and variceal embolization strategies over the next 30 or so minutes. The discussion will have something for everybody.


For those just learning about IR’s role in portal hypertension to experts in the field. In doing so, the topics will be diverse, engaging, rooted in evidence and typical practice, but also allowing room for expression of opinion. Merve and Bulent, please introduce your practice settings and then we’ll get into the discussion.

Dr. Merve Ozen (01:28):

Hi, thank you so much for having me. I’m an interventional radiologist and until last Friday I was working at the University of Kentucky almost for four years. Now I’m moving to Arizona to work at the Mayo Clinic.


At the University of Kentucky there is a lot of liver-disease patients whom needs TIPS placement and oncologic treatments. So, we do a lot of TIPS placement and the RTO cases, and I was trained with Dr. Arslan at the Rush University and it’s an honor to be with him here today.

Dr. Bulent Arslan (02:14):

Thank you so much, Merve, for nice comments. I have been practicing a little over 20 years now, and I’m at Rush for the past 12 years. And we have a very clinical-oriented, strong program that I believe that all kind of academic and private practices should be. We take our patients very seriously, and we own them. We admit them. We kind of take care of pretty much everything related to their care after we— if we are doing a procedure on them and that helped us to create a good portal program. Portal hypertension and portal interventions are one of my passions.


I do have a couple others, I’m not unidirectional, but portal is definitely the most complex IR field in my mind. It encloses going through the liver, doing shunts, a lot of crazy things when necessary and embolization it’s very comprehensive and difficult field. The hemodynamics are different than anywhere else in the body. In the veins, you just want everything to go to the heart and the arteries go peripheral. Portal is not quite like that. There are a lot of nuances, so that’s why I like the field. And I’m happy to be here and I’m honored to be part of this podcast.

Dr. Chris Molvar (03:41):

Yeah, my practice settings are pretty similar to what you guys have mentioned, and I’ve had an interest, a focus, in portal hypertension over about the last decade. I’ve been in practice for about 15 years. I work in the western suburbs of Chicago at Loyola University, and we are a transplant center. An awful lot of this work is built around a program.


Certainly the entry of these patients into our medical system is largely through hepatologists and then it’s collaborative care on what are we doing, how are we managing portal hypertension, and is there an embolization strategy that’s going to be part of it?


Our first mentioned topic here is patient selection. I’m interested in your guys’ practice. What’s the most likely reason you’re placing a TIP shunt? What’s the most common indication that that patient ends up on your table in your clinic?

Dr. Merve Ozen (04:43):

Most common indication is usually in an inpatient setting for bleeding patients. Outpatient presentation is usually for ascites or for preventative TIPS placement, and for inpatients if the patient is actively bleeding, our approach will be different, how we assess the patient, sometimes even with the higher MALT scores, which requires multidisciplinary approach and comprehensive discussion with the family members. But outpatient setting is more like a one-to-one discussion with the patient for ascites and also for patients who are in between, they’re bleeding intermittently.


Are there any other resource of bleeding like do we need to do a BRTO? Not all the patients come up with a good liver workup, so we want to make sure they see a pathologist and transplant surgeons before we see them and plan for a procedure.

Dr. Chris Molvar (05:54):

What do you think? You put more TIPS in for ascites or more for bleeding?

Dr. Bulent Arslan (06:00):

I think bleeding is a little more than ascites in our practice, just like Merve’s, but they’re not like massive hemorrhages. I used to see that a lot, patient bleeding on the floor, et cetera. Your shoes get red, you’re trying to stop. We used to get relatively more often. That I think medical management has improved a little bit. That is not happening quite as often. We still get one or two a year, but most of the patients we deal with are patients bleeding from certain either esophageal varices, endoscopies not working—obviously, one of the number one indications for gastric varices or even sometimes rectal, other ectopic varices—on and off slowly, they can’t control. The medications, the blockers, are not helping, and we end up doing a semi-electively, in the next two, three days, place the TIPS on them. And the ascites, we still do quite a bit for ascites as well, and there are some other indications too. So I would say bleeding is still number one.

Dr. Chris Molvar (07:04):

I would give you a little different answer that I probably do most of these for ascites. You come in as outpatient. This is sort of by volume. I do more for fluid management than I do for bleeding. Just an interesting kind of trend between two centers that are not all that far from each other. There are certainly some trends where there is consideration of early TIPS intervention for ascites. Ascites with some sarcopenia. I feel like some of that is driving that volume of doing more of this work in the setting of ascites on outpatients compared to the bleeding inpatient.


I also think we’ve certainly recognized over about a five-year period this kind of work for clot. Portal thrombus. Is that something you guys see? Where mitigation of portal clot, let’s say prior to transplant or failed anticoagulation, some progression, that there’s an interest now in flow-related resorption of that clot. How do you create that flow, put into TIPS, and get that outflow channel? Gives you an opportunity to stretch the vein, maybe do a thrombectomy if you need to. Are you guys picking up on that signal also?

Dr. Merve Ozen (08:33):

Yeah, of course. So whenever we receive a consult, we discuss the potential options with the gastroenterology team and see if this will benefit for the patient, if the patient is a transplant candidate, and how we can reconstruct the portal vein. And I’ve seen amazing cases with Dr. Arslan. Most of our cases were very complex, and with that experience, I was able to offer that option for our patients. But these cases are complex, and it requires maybe more than one operator, which could be one of your trainee, and lots of devices, anesthesia. And we need to discuss the risks with the patient—and some patients are very compliant and some are not—and we need to set the expectations.


Most of the time, there is a high expectation of, okay, I’m going to go into this procedure, get this done, and with portal recanalization, things may get very complex. And we need to make sure there is a risk of being unsuccessful and high risk for bleeding, which will require additional interventions. We may need to go back and try again or use a different access.

Dr. Bulent Arslan (10:06):

Yeah, I mean that’s a very interesting question, but it’s a loaded question. There’s a clot and there are various clots. And I mean the cases we’re referring to is a lot of clots, chronic, et cetera. The things kind of out of hand. And then, again, compliments back you, she is one of my trainees that has become expert in the portal interventions early in her career. I hope I had something to do with it. But our usual protocol is if somebody has a clot, we start them on anticoagulation.


As you know better than anybody, some of them are chronic, some of them are acute. The chronic clot usually it’s not easy to get rid of. It is wall adherent, non-occlusive, this or that. They won’t go away, but you want to make sure that they don’t progress. So as long as they can get their anticoagulation without contraindications long-term, we will observe them and see how things go.


But if they’re progressing, then that’s a different story or if they’re coming with a large clot burden that’s not clearing up, then you do interventions try to remove the clot, if it’s part of this removal. If it’s some of this old clot, we may end up placing a stent, this or that, without kind of closing the door for transplant. We have this, usually a multi-specialty, discussion every week for each patient. And then there are times that we will do thrombectomy if anticoagulation is not giving us a good result.


There are times we will end up putting a TIPS to make sure the flow continues. And there is— I think I would say among the patients that we do have to do intervention on for portal clot, more than half ends up getting TIPS to maintain flow. Because in that closed system, if you don’t have an outflow or if you have bidirectional flow, there are some shunts, there’s these—


Our approach is to close as much shunt as possible, leave a TIPS so there’s laminar flow in the direction that is supposed to happen and then hopefully progression won’t happen and patient will eventually get their transplant.

Dr. Chris Molvar (12:19):

Yeah, I think we really prioritize a patent portal vein prior to transplant, and we work pretty hard to achieve that. Often, anticoagulation just doesn’t seem like enough. The wall adherence stuff that’s chronic, is that really going to go away with blood thinners? Yeah, it’s more you just support a lack of progression, but that end-to-end anastomosis is viewed with a lot of priority and hence whatever we can do prior to transplant to make the transplant safer—we spend a lot of time in technically complex cases with that goal in mind.


Non-cirrhotic portal hypertension, do you do much of this? I’ll tell you, I personally don’t, but I feel like it’s another one of these— There’s a signal out there about who else should we make these portal intervention procedures available for and where do non-cirrhotics fit in to what you’re seeing?

Dr. Bulent Arslan (13:27):

I’m going to jump onto this one by the way, because non-cirrhotics are something I like to do a lot. They usually don’t have portal hypertension though. They usually have an occlusion in their splenic or SMV, et cetera, that due to either pancreatitis, inflammation, surgery, whatever the reason, they’re a little bit more complex. And then if they’re cirrhotic, obviously, the goal is they’re usually hopefully going to go to transplant.


The goal is to recanalize the portal vein, create a TIPS, leave a non-stented portal vein segment so they can get their transplants. But if they’re non-cirrhotic, it changes from patient to patient. The goal is you treat them. We had a session actually yesterday, very good session. Riad has a huge series on that. We do the similar procedures in our center, and access is a problem in these, because usually have to use alternative access, splenic, mesenteric, et cetera.


And the goal is initially to treat their symptoms which they present with either bleeding or ascites. And they become— the last one that I recently treated, we actually had a common patient that we treated by SMV recanalization. We went up and had to use an RF wire, because nothing else I had—back end of the wires—nothing would pass through this really hard occlusion and then it ended up being okay.


I lost couple of years of my life, but it worked out great and the patient is doing actually pretty good right now, had only one drainage after the procedure. He used to get drains that had a huge umbilical hernia. He had drains every week. Now in the past six months or so, even longer now, only one drain. The CT shows everything is widely patent. So that’s the whole different— I’m going to use the word animal.


And again, if they’re symptomatic, definitely there’s also a discussion do you really want them to become symptomatic? Because when they become symptomatic, that may mean that they’re going to bleed, and when they bleed, there’s a percentage of these patients that may not come out. I think this requires clinical evaluation, sitting down with a patient. The way I look at it is like treating an aneurysm.


Somebody has a six centimeter aneurysm; they’re not symptomatic, they’re walking around, but if they rupture—which they eventually will, there’s percentages every year—then there’s a good chance they’re going to die. So you have this bleeding problem potentially in these patients. I don’t know why treat the same way because there are people who say don’t touch non-symptomatic patients. I’m not sure if I agree with that. I think patients should at least have understanding of the potential risks without treatment and the risks of the treatment.


And it also depends on the anatomy. If it’s a very complex treatment with a low risk of bleeding, maybe wait. But if it’s a simple treatment with a potentially durable long-term result— I mean if it was my dad, I would want to kind of get him out of it. That’s my perspective. What do you think Merve?

Dr. Merve Ozen (16:52):

I think most of the other specialties don’t know exactly what we do, especially for these kinds of procedures. They don’t know if we can treat these patients. So as an interventional radiologist, I think our goal should be showing what we can do, especially in tumor boards. I recommend all the new graduate fellows and residents to be friends with their hepatologists and transplant surgeons and gastroenterologists.


So with these one-to-one conversations, you can help these patients because sometimes we don’t get the consults, and we can review every patient even for a liver biopsy and see what we can offer for the patient. But most of the time I don’t think a lot of gastroenterologists and hepatologists know what Dr. Arslan can do. Like magic.


So my goal is to have good relationship with my other colleagues from other specialties, to show what we can do for these patients, because these are very complex procedures.

Dr. Chris Molvar (18:04):

Great. Let’s move a little on from patient selection into some of the technical aspects. And as we’ve mentioned, this is a technically demanding procedure. They’re time-consuming, there are baked in risks associated with it. Do you have, let’s say, a strong preference in the kit you use?


Is it always the same kit? Are you a blended user, variety of kits? Do you look at the imaging to then decide or, “Yeah, it’s just I want a certain kit on a Monday and a different one on a Thursday.” How do you unpack that?

Dr. Merve Ozen (18:42):

I think we were spoiled trainees in Rush. We had every device possible and so we get to use and try every device, and once I graduated, I saw that the real world is not like that. And I like to know the advantages and disadvantages of every, for instance, every TIPS set. There are cases that you can prefer Rösch-Uchida over a Colapinto to get access into the portal vein.


But so since I started my new job, I learned how to do ICE-guided TIPS, and in those cases, due to the— So if you’re doing a CO2 venogram, and you’re accessing with one sharp stick, that’s quick. But when you’re doing ICE-guided TIPS, you may need to take some time to find your angle and advance your needle. So I realized that sometimes with Colapinto needle, it may take some piece, because it’s a more slow advancement.


So even though I see my needle within the portal vein, I don’t get enough flow. So I may need to use a wire or just do a little flush. With Rösch-Uchida with the needle inside the cannula, it’s easier for me to do that part, but I pay close attention not to introduce any air during that step. So I recommend all the newly graduate trainees to try and just use whatever you have available.


There’s no one magical device that is preferred over one other, but sometimes you just need to use whatever is available. For denser livers, Colapinto may be easier, but for instance, for NASH or if you’re using ICE, you may prefer Rösch-Uchida.

Dr. Chris Molvar (20:51):

Do you use either ICE or CO2 or do you have a preference there that “My standard kit involves an ICE probe?”

Dr. Merve Ozen (21:01):

I started doing CO2, and the more I learned about ICE, now I don’t even ask the technologist prep the CO2, I can see everything. I know where I’m sticking, and it takes— There are some cases it takes only 35 minutes to do the whole tips. So ICE.

Dr. Chris Molvar (21:24):

Are you controlling both the ICE probe and the needle? It’s a vampire stick in the right internal jugular vein and you’re touching both or do you use the groin? Do you use two operators?

Dr. Merve Ozen (21:43):

I do the vampire stick. I like to just be in contact with my trainee or technologist on my right side. Sometimes I need to adjust it myself, because every ultrasound access you want to see the ultrasound yourself and advance the needle. It could be difficult in some cases if the liver is very dense, and usually what I do is if I’m scrubbed in with one of my trainees, we sit down and we just do a preparation: And this is how you’re going to advance it, this is how I’m going to advance it.


So we have a plan before the procedure, but sometimes I like to just advance, stop and sometimes I use towels and stabilize my probe and then advance it. It all depends on the anatomy. If I need to have a very anterior throw, then I will probably need someone to just turn the probe with me. So it depends on the anatomy and the case.

Dr. Chris Molvar (22:46):

What do you think Bulent? What do you do for portal vein visualization?

Dr. Bulent Arslan (22:49):

Yeah, I mean I do apologize. When Merve was there, we weren’t doing ICE at all, you know, the old-fashioned way. We started doing ICE as well. We’re actually, I’m not per se doing it. The only reason I’m doing it is to educate the residents because I think ICE is a shorter learning curve than the conventional way of doing it. And it makes me lose time even though ICE people may claim otherwise. I mean, I have done one TIPS in 25 minutes, so it takes 25 minutes to prep the ICE in our place.


So that’s another discussion, probably debate. And in terms of needles, I pretty much use mostly combination. Rösch-Uchida probably number one right now. I used to only use Colapinto. I did start using Rösch-Uchida about 10 years ago, and it’s working fine, but it is not as robust as the Colapinto. I’ve even had a couple of cases when portal vein wall is very thick, inflamed, that buried the Colapinto into the wall and I use the Rösch-Uchida needle.

Dr. Chris Molvar (24:00):

Yeah, to fenestrate it.

Dr. Bulent Arslan (24:01):

To create a kind of channel through that area and use a V18 and things like that. So I think both needles are helpful. Just like Merve said, you need to know when to use which one depending on the anatomy. And there are other sets out there, which I have tried. They have, in certain scenarios, maybe some advantages, et cetera.


But they’re all complex and they also have a lot of issues that, over the years which I happen to find out, because I like to try new things and then still go with what works best. And I would say about 80, 90% of access get us Rösch-Uchida or Colapinto right now.

Dr. Chris Molvar (24:40):


Dr. Bulent Arslan (24:41):

And then even though they’re old, they’re simple, they work.

Dr. Chris Molvar (24:45):

Yeah. I presume your preferred cannulation of a hepatic vein is the right hepatic vein and then you look for the right portal vein. Does that change with ICE? Is the middle better with ICE and this is coming from a— I never use ICE. The only time I’ve used it was with DIPS placements and I feel like those have really fallen out of favor in the last five years or so. It’s better to struggle to get a TIPS in than to put in a DIPS.


It’s sort of been my opinion on it, but I wonder whether your visualization technique drives hepatic vein preferences or maybe not. Is it always right to right as a first choice and the middle as a second? Or does any of that “I’ve got an ICE probe versus I’ve got CO2,” change your thinking?

Dr. Merve Ozen (25:41):

That’s a very good question. I think about that a lot, because with ICE, I’m able to see the portal vein better from the middle hepatic vein. I know it’s unconventional. We are trained to go from right to right, and we also did a study on where to access the portal vein, which one gives more patency or which is more successful? The more I start using ICE, I realize there’s so much variations in the hepatic vein anatomy.


I think in 30% of the patients that I’ve seen, there is a prominent middle hepatic vein and smaller right hepatic vein. In those cases, it gives a very nice access with ICE, but again, it requires prior evaluation with the CT or MRI to find the best track. I will still stick with right to right and if some patients need additional TIPS, like double barrel TIPS, then you can continue with a middle to right or middle to left access.

Dr. Chris Molvar (26:54):


Dr. Bulent Arslan (26:55):

Yeah. I mean I agree with everything Merve said. One thing that I also kind of worry about it, there’s no science to it. I don’t think there’s any studies, but the way I look at it is the right lobe of the liver and cirrhotic patient is a lost lobe. Left lobe is what the functional lobe, and then you don’t want these patients to tank, et cetera— kind of continue to have function. So I try to stay on the right.

Dr. Chris Molvar (27:22):

You don’t like the middle to left?

Dr. Bulent Arslan (27:24):

I don’t like the middle. I don’t like the left, but I have done left to left, left to different variations. Pretty much all of them I have done except from left to right. That would be a little challenging. We did that in the pigs though, right? Okay. Anyway, so I try to leave the TIPS on the right lobe, if feasible, but you have to look at your vessels too, right?


Every TIPS we do imaging, it’s like I think you should never ever do a TIPS without good pre-procedure imaging, and it needs to be relatively recent, hopefully within a month or so, ideally. I’ll tell you one case that one of my colleagues was pushed into getting a TIPS because patient wasn’t stable to go to CT, this or that. Brought him down, he tried, he couldn’t get into the portal vein and then called me.


I tried a couple of times, I was like, “I don’t know what’s wrong. There’s something wrong with this.” And the patient got better. Let’s stop this. We’ll bring him back again. He was kind of more controlled. Got a CT scan afterwards, same day, a couple of hours later, and this right was gone. I mean it wasn’t thrombus or whatever. If it was thrombus, you could get into it. There was no right lobe. The portal vein, maybe like a few centimeter, one, two millimeter flicker towards that area.


So if it’s thrombosis, you can get into the portal vein and still re-canalize it. This was an atrophic right that wasn’t accessible. So we brought the patient back to the left to left TIPS. So one case we didn’t do imaging, we ended up with—

Dr. Chris Molvar (29:06):

Yeah, that’s regrettable.

Dr. Bulent Arslan (29:07):

A nonsense problem that could have been harmful to the patient. Fortunately, it went well. But that’s one thing I’m going to say. Look at your imaging plan, know where everything is, create a three-dimensional image in your head and then work with that. Use the ICE if you’re comfortable with.

Dr. Chris Molvar (29:23):

I agree. I think that’s a huge part of it and that cognitive fusion of taking the cross-sectional imaging and turn it into what you see in the fluoroscopy unit is where you separate your early from more mature users, and I am of the opinion that even a non-contrast CT, and the time difference here may be marginal, but even in a critically ill patient, you can understand a fair bit even without any contrast.


Often, the hepatic veins are visible and you could see where the portal veins are. You’re not certain about patency, but you know anatomically where they are in relation to the hepatic veins.

Dr. Merve Ozen (30:02):

I also want to see—sorry to interrupt—but I also want to see the varices. Where are they coming from? Am I going to embolize them? So I think to have a target, it’s not just placing a stent, but those patients need a BRTO. Are we going to do both procedures at the same time? Is there an inflow? So I think good imaging is a must.

Dr. Chris Molvar (30:25):

And maybe we’ll take that as a segue to our last topic here with embolization. I’m wondering what patients get TIPS and embolization? Let’s say TIPS plus antegrade embolization. Who gets that? Anybody with a varix that looks like it’s going to compete with flow or that varix has to have bled or that’s an audible, and you’re not sure until you put the shunt in and do a venogram? Where do you sit on that with TIPS and antegrade embolization?

Dr. Bulent Arslan (30:58):

So Merve made a huge point. I mean this imaging is going to help you with that as well. At least you’ll know. You’ll be aware of what else is there, because if you have a huge shunt that’ll compete with your TIPS, that’s a problem. And that question you’re asking is— I’ve been into meetings like four hours, just multiple experts kind of fighting with each other. We’re not going to be able to answer this, but I’ll give you my two dime. I think it depends is the right answer. It depends on the patients. It depends on the symptoms.


It depends on what you’re trying to do, patient’s underlying liver status, liver function, and history or existing encephalopathy versus bleeding versus ascites, combination of those things. Because TIPS is— not TIPS. Portal interventions in general, embolization plus recanalization, whatever it is, it’s a very fine balance.


There are certain things that you do is going to push the patient towards one side of the scale, certain things to the other side. If you have BRTO or even antegrade occlusion of the shunts, et cetera, that’s going to make you more likely to get ascites, because you’re increasing the portal pressure, right? That’s depending on—

Dr. Chris Molvar (32:11):

Yeah, nothing comes for free.

Dr. Bulent Arslan (32:12):

Exactly. Nothing comes for free. It’ll help with the encephalopathy and maybe even the liver function a little bit. When you do the TIPS you’ll decompress everything, so your risk of bleeding is going to go away, but then going to your ascites is going to go away, because you don’t have that extra pressure. But then you may become encephalopathic, your liver may fail.


So it’s a very fine balance. So depending on what symptoms the patient’s coming in, you need to kind of put everything together, look at your imaging like Merve said, and assess the patient and decide on— And I have to tell you, there are patients that, with an existing shunt, I just placed a small TIPS, because their problem is with the shunt bleeding. And then the shunt, if it was a gastrorenal, I would probably embolize that, take care of the bleeding was from gastric, because that’s a more definitive way of taking care of the bleeding.


But if the shunt is somewhere else and then you’re just trying to decompress the system a little bit more because patient has an umbilical shunt for example, I may not embolize that at that point. Because you embolize that, how much flow— that’s taking away how much flow? The TIPS— you’re going to try to kind of fine tune it like crazy, and you just have to look at where you’re at symptomatically and choose the procedure that’s going to bring you where it’s going to benefit the patient.

Dr. Chris Molvar (33:33):

Sure. How about devices Merve, antegrade embolization, is it coils, you obliterate those patients? How complicated do you make it?

Dr. Merve Ozen (33:47):

I think there is no one way doing the embolization. It’s an art. I love it. So it depends on the flow. First of all, if I have a high-flow varix, and I can consider balloon occlusion and cyclical therapy, if those varices are very bulky torches, I like to use some gel foam and wait a little bit until those are obliterated. And if I can put some coils on the way out or some plug that will, I think, help the patient not to have a rebleed. Sometimes pressure gives a little clue on how patients are going to do after the procedure.


If I’m able to lower down the pressure 50% or more, I know if those varices are going to respond well to the TIPS, but the pressure is not going well or if I have to have a smaller diameter TIPS due to encephalopathy or any heart issues, then I will go and be more aggressive with the varices because I can’t really decrease the gradient a lot. And I am more on the— if I see a varix, I want to embolize it, because I think we need to cure the culprit.


These varices are submucosal, and they can bleed anytime even with a little irritation. And the TIPS is going to help them. But if they’re there, and if they’re causing intermittent bleeding, I think we need to address that.

Dr. Chris Molvar (35:40):

Sure. What do you do for retrograde obliterations? You got the full complement, you’ll do BRTO, PARTO, CARTO, and if you do, what’s the driver for “I’m going to use a balloon versus I’m going to use a macroembolic?”

Dr. Bulent Arslan (35:56):

Yeah, I mean I have done it all. We actually started BRTO when I was at University of Virginia in 2007. We were, I think, one of the first sites. There may be another academic center that did it at the same time or I don’t remember. And it’s like one of my fellow who became an attendant came up with it, who read this article from Asia, and then had this patient that you couldn’t put TIPS in, but bleeding from gastric varices.


So I said, “Go ahead and do it.” And he did it and then we all started doing it. So we used to use a balloon at the time, put it up for 24 hours, use the sclerosant, patient ICU. Come back next day, hope that things won’t fly away. And then we went down to four hours, people went down to two hours, but at two hours I think there’s some mishaps happen.


I never tried that, but some people did and things were kind of flying away and then they stopped doing it. Then obviously PARTO and CARTO came. I initially liked the CARTO, because what I would do is I would in a very large one, for example, that are relatively harder to do, you could just sclerose and then you had the balloon lumen and just shove a bunch of kind of coils through that. So you would occlude mechanically, robustly. And then you could take the balloon up and, still kind of a little scary, but I never had anyone fly away, and that’s because once you thrombose everything and then you put the— the flow is gone, so it’s going to be okay. But PARTO is the easiest. You just get a second access, you deploy your— And the embolic, instead of just using foam Sotradecol, you want to mix some gel foam, the pyrrole, et cetera, to kind of make it thicker so they don’t go through the plug.


And that’s what we have been doing. We get two access usually and put one microcatheter all the way up into the gastric varices, and our second one is a 9 French sheath for the deployment of the plug. And we just deploy the plug and then starts the sclerosing from top down. And that’s been working great. Most procedures are under hour, or 90 minutes at most, and no failures, no problems, no PEs.

Dr. Chris Molvar (38:15):

That’s exactly what I do. Just about all of ours are PARTO with a plug, with gel foam. I do find it helpful to pre-mix your gel foam, that if it looks like this is—you’re going to need 50 cc’s or you’re going to need a 100 cc’s—having that pre-mixed I think is very helpful as the contrast column is somewhat evanescent, you can sort of lose it if you’re spending time pairing things, sort of passing it through a three-way.

Dr. Merve Ozen (38:50):

Dr. Arslan, do you prefer IJ access or femoral access for your BRTOs?

Dr. Bulent Arslan (38:56):

I do femoral. I mean I’ve done IJ too, but I just feel there are a lot of cases that, coming from IJ, makes certain parts of the procedure easier, but I just like to— I don’t care about the difficulty of catheterizing, etc. It is fun for me.


Working in the groin is always easier for me. Patient’s head is not there. I’m a little kind of OCD about sterility, you know, the hair. I just want a nice clean area that without kind of restriction that I can work. So I’ll do the femoral whenever there’s an option.

Dr. Chris Molvar (39:35):

I’d give you the same answer. It’s femoral. IJ is problem-solving. I don’t want to work near the head. I don’t want to work in air. I’d rather have everything resting on the table and almost always, if you can cannulate the shunt and you progressively stiffen the wire, maybe coaxial sheath, it’s almost always achievable working from the groin.

Dr. Merve Ozen (39:59):

How about anesthesia? Do you always have anesthesia for BRTOs?

Dr. Bulent Arslan (40:04):

I don’t know if it’s necessary or not, but we always do. It makes my life easier. And then we almost— I should also say, even though I said femoral—on almost all of our portal interventions right now, because they’re usually not very straightforward, we have IJ, femoral, and abdomen prepped. Because you never know what you’re going to need, and then prepping in the middle of the procedure is difficult. So my techs are now regularly doing— I go in the room, they’re all prepped. It’s like you don’t have to worry about it.

Dr. Merve Ozen (40:37):

I have one more question. I know I’m not the host, but do your gastroenterologists see the patients and access the varices endoscopically prior seeing you?

Dr. Bulent Arslan (40:50):

Well, they all get endoscopy prior. That’s kind of a routine practice. That’s when the patient comes to us and they try to band them. That’s another question. I want to get your opinion too, Chris. Like patients have esophageal varices, right? They all get screened, they all get banding, et cetera, treated preemptively. They have gastric varices, they haven’t bled. What do you do?

Dr. Chris Molvar (41:13):

Yeah, I mean we do lean on the endoscopists for high-risk features. We will run with a high-risk feature in favorable anatomy and treat it.

Dr. Bulent Arslan (41:23):

Can you explain on the high-risk feature?

Dr. Chris Molvar (41:26):

To me, you see red wale signs mentioned. I’m not exactly sure what that is, but that feature probably along with the size of that varix would be potential triggers to get into the kind of prophylactic bleeding mitigation. It’s definitely a bit of a gray zone, but your mortality rates with left-sided portal hypertension bleeding, gastric variceal bleeding, super high.


So you are riding that risk curve if you’ve got endoscopically identified varices, if you’ve got a CT pathway to treat them, looks like you could do a retrograde occlusion and you pick up some hint of we don’t like the endoscopic features on this. I think that’s a reasonable patient to treat.

Dr. Bulent Arslan (42:24):

Yeah, I mean, again, I don’t know how many hepatologists are kind of, “Hey, this doesn’t look good. Let’s treat.” Even though patient never bled, et cetera. I feel like even though we trained our hepatologists very well, so they know that we can do any procedure for them, they don’t ask us to do it right now. They just tell them. They have to decide if the patient is going to be okay with that procedure or not.


That’s where they’re kind of at. I feel like, I think in Asia, the practice is a little different. When they see gastric varices, they have a much lower threshold to embolize them, just like the endoscopists. And this is the debate, because how is it okay to treat esophageal varices preemptively to prevent bleeding? But when you have gastric varices—when you have a high risk of dying, right, stomach acid, et cetera, whatever—you just wait and see if they bleed? And guess what? When they bleed, at the best scenario, 10% of them is never going to make it and shouldn’t the patients at least hear that?


Again, we’re going back to the same other kind of conversation. Shouldn’t they hear it and then choose it themselves? But what’s the risk of BRTO? How many patients did you kill with BRTO, Merve?

Dr. Merve Ozen (43:42):

Zero. I hope. I’ve never killed—

Dr. Bulent Arslan (43:44):

Okay. How about you, Chris?

Dr. Chris Molvar (43:44):


Dr. Bulent Arslan (43:45):

Yeah. Right. I mean it’s a complex procedure, but it is safe. And then worst case that’s going to happen, there’s hundreds of patients series in Asia. You get prominence of esophageal varices, which takes two, three years. You may get ascites. Which, if that happens, you can place the small TIPS, whatever, and then manage under control instead of leaving an abnormal thing that exposes the patient to a potential death. Yeah, that’s my personal opinion, but—

Dr. Merve Ozen (44:15):

I agree a hundred percent. Gastric varices, they could be mortal and if we see them, especially if there’s a red wale sign, BRTO will be beneficial. And then we can always bring the patient back to a trans-jugular gradient measurement, see how the pressure is doing, and then potentially plan for a TIPS placement.

Dr. Chris Molvar (44:43):

Yeah. Let me take a minute here to close the session, unless you guys have anything else you’d like to get in here.

Dr. Bulent Arslan (44:54):

Oh, let me think. You covered everything.

Dr. Merve Ozen (44:59):

I would like to say something for the trainees and new attendings. If you haven’t trained with good portal training, I think it’s very important to read some of the guidelines. One is the AASLD guideline. It has a extensive indication and contraindication assessment information that is very, very helpful. And I always talk to Dr. Arslan whenever I have a difficult case.


Reach out to your mentors and be friends with your hepatologist, gastroenterologists, and transplant colleagues. And whenever you need to build these relationships, sometimes you need to give your own time, answer questions when you’re on vacation. So those things are very important when you’re building your practice.

Dr. Bulent Arslan (45:59):

Yeah, actually that’s a great point, Merve. Outstanding. That gave me an idea to mention one more thing. It’s like I think portal system is the hardest thing that we do and I also feel like we’re lucky now the training is— that IR-DR training become a lot more robust. So I feel my trainees are actually out there relatively comfortable getting started, but it is a challenge for a lot of young junior attendings. Not only the technical parts of it, clinical parts of it as well. There’s a lot to discuss that are unknown,


Excuse me. To remedy that. That’s been one thing that in my mind for many, many years, even at SIR or other meetings, the space for portal is relatively limited because there is not as many people who masters— almost in every institution, maybe one or two people only because the rest doesn’t want to deal with it.


So to break that and maybe to help people who are interested and go, we decided to do a dedicated portal integration meeting, which is going to happen in September 27—29 in Chicago, and you guys are going to be experts in that meeting and there’s going to be a lot more, we’ll have about 50 faculty from around the US and world.


It’s going to be a three-day meeting, portal interventions only. So if anyone is listening to the— interested in getting a really robust learning and maybe some of those things that we can’t answer here in 10 minutes, potentially could be answered. I just wanted to remind everyone who has a passion for portal work.

Dr. Chris Molvar (47:42):


Dr. Merve Ozen (47:43):

I also want to thank Cook Medical for their support for portal hypertension education or fellows education.

Dr. Chris Molvar (47:51):

Yeah. These procedures, TIPS, variceal embolization. They’re technically demanding in already complex patients. I’m hopeful that our audience has taken away some pearls about picking the right patient, about optimizing your procedure technique.


Cook has a very generous Vista education program, including large animal courses, which allow for hands-on training in TIPS and embolization. And I think it’s a great addition to mastering this important skill set.

Dr. Bulent Arslan (48:27):

I mean, you and I have been working on that for a while now. I think it is one of the best courses ever.

Dr. Chris Molvar (48:33):

I agree.

Dr. Bulent Arslan (48:34):

That exists not only in this but in anything because what can beat doing the actual procedure on a very human-like anatomy? And then the only thing that we keep saying on that course is “Keep the pig alive.”

Dr. Merve Ozen (48:49):

I did my first TIPS there. Yeah, I did.

Dr. Bulent Arslan (48:53):

Awesome. That’s great.

Dr. Merve Ozen (48:54):

It was very helpful. The most exciting course ever.

Dr. Chris Molvar (48:58):

Well, thank you to Cook Medical. Thank you to Bulent and Merve for this stimulating discussion.

Dr. Bulent Arslan (49:05):

Thank you as well. Chris,

Dr. Merve Ozen (49:07):

Thank you so much.

Dr. Bulent Arslan (49:07):

It’s always a pleasure. And thank you to Cook on my behalf as well. They’re doing great in educating not only us, but also our trainees.