Vascular Anatomy and the Morphologic and Hemodynamic Classifications of Gastric Varices and Spontaneous Portosystemic Shunts Relevant to the BRTO Procedure

The pathologic anatomy and hemodynamics of the left-sided portal circulation that is associated with gastric varices (GVs) are complex and highly variable. Understanding the pathologic anatomy and hemodynamics associated with GVs is important for clinical management decisions and for the technical descriptive details of the balloon-occluded retrograde transvenous obliteration (BRTO) and balloon-occluded antegrade transvenous obliteration procedures. A reflection of the considerable variability in anatomy, pathology, and hemodynamics is the numerous descriptive and categorical classifications that have been described in the past 2 decades. This article reviews the detailed descriptive gross anatomy, radiographic anatomy, and portosystemic venous hemodynamics that are associated with GVs and that can be encountered during the BRTO or balloon-occluded antegrade transvenous obliteration procedure(s) or both. Definitions are also set to clarify this detailed anatomy that received limited description in the prior literature. Moreover, all the classifications that have been described (to the best of the author's knowledge) that are relevant to the BRTO procedure are detailed in the article.