Nonendoscopic management of gastric varices

The endovascular approach to management of gastric varices can be a complex process with both complimentary and competing techniques. Optimal treatment involves a multidisciplinary approach with hepatologists, endoscopists, diagnostic radiologists and interventional radiologists. A thorough understanding of the patients liver function and anatomy is essential to determine the appropriate course of endovascular therapy. Preferred endovascular procedural management has changed dramatically in the past 30 years and is variable depending on operator experience and regional differences. This manuscript will cover our approach to gastric variceal management using transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), variants of TIPS and BRTO, and an algorithm outlining an approach to determine appropriate management techniques.