Pathophysiological management of gastric varices: From hemodynamics to targeted therapies

Table 1 Classification of gastric varices based on venographic and angiographic findings

Classification	Basis	Types/grades	Key features	Clinical relevance
Hirota classification	BRTO findings	Grade 1-5	Grade 1-2: Good opacification, minimal collaterals. Grade 3 Partial opacification with collaterals. Grade 4-5: Poor/no opacification, extensive collaterals or large shunt	Predicts the feasibility and success of BRTO; higher grades = lower success
Fukuda classification	Dominance of afferent (feeding) veins on angiography	Type 1-4	Type 1 Left gastric vein dominant. Type 2 mixed (LGV + posterior/short gastric). Type 3 complex bilateral supply. Type 4 right-sided dominance	Helps identify inflow patterns and guides selective embolization
Matsumoto classification	Flow dynamics in gastrorenal shunt and LGV	Type 1-2	Type 1 portosystemic flow present. Type 2 portosystemic flow absent. Subtypes based on flow in LGV: A (hepatopetal)/B (hepatofugal)	Predicts worsening of esophageal varices after BRTO (higher risk in Type 1B)

BRTO: Balloon-occluded retrograde transvenography; LGV: Left gastric vein.

Table 2 Differentiation of efferent/shunt-dominant or afferent/inflow-dominant varices based on various features

Parameter	Efferent (shunt)-dominant varices	Afferent (inflow)-dominant varices
Primary driver	Low-resistance outflow (drain-driven)	High inflow (supply-driven)
Key imaging feature (CT/MR)	Large single shunt (e.g., gastrorenal/gastrocaval)	Multiple feeders, no dominant shunt
Collateral pattern	Limited collaterals, dominant drainage pathway	Dense collateral network
EUS findings	Prominent draining channel, rapid flow toward the shunt	Multiple perforators/feeding vessels, complex flow
Flow dynamics	High-flow toward systemic circulation	Multidirectional or inflow-heavy flow
Portal hypertension features	Less prominent	Marked (ascites, collaterals)
Clinical clues	HE, preserved liver function	Ascites, decompensation, less HE

EUS: Endoscopic ultrasound; CT: Computed tomography; MR: Magnetic resonance; HE: Hepatic encephalopathy.

Table 3 Hemodynamics of gastric varices based on cross-sectional imaging classification, along with their preferred and alternative interventions

Type		Venous anatomy	Venographic/hemodynamic findings ⇨ key issue	Preferred intervention	Alternative intervention	Key technical notes during RTO
Efferent venous pattern
A	Single draining shunt (usually gastrorenal; rarely gastrocaval); no collaterals		Complete opacification of the varix on balloon-occluded venography	Standard BRTO	PARTO/CARTO/EUS-guided	Deep microcatheter placement ⇨ inject sclerosant till minimal afferent filling
B1/B2	Single shunt + small/multiple collateral veins		Incomplete opacification due to preferential collateral flow ⇨ Collateral “leak”	Modify the flow to isolate the varix by coil/plug embolization	EUS-guided	Balloon beyond collaterals; deep positioning ⇨ flow-directed embolization ⇨ microcatheter beyond collaterals ⇨ sclerosant
B3	Single shunt + large collateral veins		Poor opacification until collaterals are controlled ⇨ Significant collateral drainage	Pre-embolize collaterals ⇨ BRTO	EUS-guided	Selective catheterization ⇨ coil embolization ⇨ repeat venography
C1	Two shunts (gastrorenal + small gastrocaval)		Partial opacification due to the second shunt ⇨ Additional minor outflow	Eliminate second shunt ⇨ treat as B3	BATO/PTO/trans-TIPS access/EUS-guided	Coil embolization of the gastrocaval shunt via microcatheter
C2	Two large shunts (gastrorenal + gastrocaval)		Incomplete opacification due to dual drainage ⇨ Major dual outflow	EUS-guided/BATO/PTO/trans-TIPS access	Combined BRTO approaches for dual shunt control	Dual balloon occlusion (gastrorenal + IJV gastrocaval) ⇨ then sclerosant
D	No shunt		No large draining shunt ⇨ No retrograde access possible	TIPS (± embolization)	BATO/PTO/EUS-guided	-
Afferent venous pattern
Type 1	Single afferent vein supplying gastric varix		Sclerosant stagnates with minimal reflux into the afferent vein ⇨ Risk of excessive reflux into the portal vein if over-injected	Standard BRTO	EUS-guided	Endpoint = minimal afferent vein filling; avoid forceful injection
Type 2	Two afferent veins (left + posterior gastric veins)		Reflux preferentially into the lower-pressure vein ⇨ Partial obliteration due to persistent higher-pressure inflow	Staged BRTO is often required after coil/glue embolization of feeders	BRTO + TIPS if associated esophageal varices present/EUS-guided	Endpoint = reflux in one vein; repeat the session for the remaining varix
Type 3	Separate afferent vein drains directly into the shunt (no variceal communication)		Sclerosant preferentially flows into this vein ⇨ portal reflux ⇨ Ineffective variceal filling + risk of portal spill	BRTO + Selective embolization of the aberrant afferent vein	EUS-guided	Deep microcatheter positioning; embolize extra afferent (transhepatic/transjugular) if needed

EUS: Endoscopic ultrasound; BRTO: Balloon-occluded retrograde transvenous obliteration; PARTO: Plug-assisted retrograde transvenous obliteration; CARTO: Coil-assisted retrograde transvenous obliteration; RTO: Retrograde transvenous obliteration; BATO: Balloon-occluded antegrade transvenous obliteration; PTO: Percutaneous transhepatic obliteration; TIPS: Transjugular intrahepatic portosystemic shunt.

Table 4 Summary of meta-analyses comparing the various therapeutic modalities in the management of gastric varices

Ref.	Study type	Comparison	Sample size	Key efficacy outcomes	Safety outcomes	Key conclusion
Yu et al[55]	Meta-analysis	BRTO vs TIPS	435 (5 studies)	Similar success (91% vs 89%)	Rebleeding lower with BRTO (10.6% vs 18.7%); HE lower (0% vs 23%)	BRTO preferred; TIPS increases HE
Paleti et al[53]	Meta-analysis	BRTO vs TIPS	676 (7 studies)	No difference in technical success/hemostasis	Rebleeding ⇩ with BRTO (OR 0.30); HE ⇩ (OR 0.06); mortality ⇩ (OR 0.43)	BRTO superior to TIPS for rebleeding, HE, and survival
Wang et al[54]	Meta-analysis	BRTO vs TIPS	9 studies	Similar immediate hemostasis	Rebleeding higher with TIPS (RR 2.61); HE ⇧ with TIPS (RR 16.1)	BRTO provides better survival and lower rebleeding
Osman et al[56]	Network meta-analysis (RCTs)	BRTO vs TIPS vs ECI vs NSBB	647 (9 studies)	BRTO lowest rebleeding (RR 0.04 vs NSBB)	β-blockers worst outcomes	BRTO most effective for secondary prophylaxis
Giri et al[6]	Network meta-analysis	Multiple (radiological and endoscopic)	2783 (34 studies)	BRTO highest obliteration (SUCRA 95.1); EUS-C+G second (80.9)	Adverse events highest with TIPS; lowest with thrombin	BRTO and EUS superior to ECI; top-ranked therapies
Florencio de Mesquita et al[35]	Meta-analysis	EUS (coil + glue) vs ECI	445 (6 studies)	Rebleeding ⇩ with EUS (OR 0.22); reintervention ⇩ (OR 0.29) with EUS	No difference in embolism/mortality	EUS superior to ECI with similar safety
Mohammadpour et al[57]	Meta-analysis	EUS-coil + glue vs endoscopic modalities	579 (9 studies)	Higher obliteration (RR 1.18); rebleeding ⇩ (RR 0.36)	Adverse events ⇩ (RR 0.55)	EUS combination therapy superior to endoscopic options
Biswas et al[58]	Individual patient meta-analysis	BRTO/TIPS vs ECI	1240 (15 studies)	Rebleeding ⇩ with BRTO (sHR 0.15), TIPS (sHR 0.49)	Ascites ⇧ with BRTO; HE ⇧ with TIPS	Endovascular therapies superior to ECI

EUS: Endoscopic ultrasound; ECI: Endoscopic cyanoacrylate injection; BRTO: Balloon-occluded retrograde transvenous obliteration; TIPS: Transjugular intrahepatic portosystemic shunt; NSBB: Non-selective beta-blockers; RR: Risk ratio; OR: Odds ratio; HE: Hepatic encephalopathy.