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Occlusion balloon catheters of 5.2- or 6-French have been used for a few decades in various endovascular treatments of body trunk vascular lesions. However, these catheters may be difficult to place in cases of excessive vessel tortuosity, small vessels, and anatomic complexity. Recently, the introduction of the double lumen microballoon catheters for body trunk vascular lesions has allowed operators to advance them into more distal, smaller, and more tortuous vessels. Since the launch of the first generation microballoon catheters onto the market in Japan in 2011, the microballoon catheters have evolved and are now generally available for clinical use. The purpose of this article is to review the evolution and current clinical applications of the microballoon catheters in the field of interventional radiology.

Purpose: The purpose of this study was to evaluate changes in thrombosis in gastric varices., Material and Methods: Fourteen patients were studied who underwent balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices with a gastrorenal shunt. The B-RTO catheter was retained overnight in all patients. Balloon-occluded retrograde venography (B-RTV) was performed to evaluate the degree of thrombus formation. This evaluation was done twice during the overnight B-RTO procedure: A few hours after the procedure and on the following day. Investigated were the degree of thrombus formation observed by the first and second B-RTV, change in the degree of thrombus between the first and second B-RTV, and whether and how much sclerosing agent was administered on the second day., Results: The first B-RTV showed entire or partial enhancement of the gastric varix in seven (50%) cases and complete or almost complete lack of enhancement in the remaining seven cases. In four of the former seven cases, the second B-RTV showed entire or partial enhancement of the gastric varix, and the sclerosing agent was added. However, in the remaining ten cases, enhancement was almost or completely lacking., Conclusion: When complete thrombosis is shown on B-RTV obtained a few hours after B-RTO, the addition of a sclerotic agent would be unnecessary.

Purpose: To evaluate changes in imaging findings on CT during hepatic arteriography (CTHA) and CT during arterial portography (CTAP) by balloon occlusion of the treated artery and their relationship with iodized oil accumulation in the tumor during balloon-occluded transcatheter arterial chemoembolization (B-TACE)., Methods: Both B-TACE and angiography-assisted CT were performed for 27 hepatocellular carcinomas. Tumor enhancement on selective CTHA with/without balloon occlusion and iodized oil accumulation after B-TACE were evaluated. Tumorous portal perfusion defect size on CTAP was compared with/without balloon occlusion. Factors influencing discrepancies between selective CTHA with/without balloon occlusion and the degree of iodized oil accumulation were investigated., Results: Among 27 tumors, tumor enhancement on selective CTHA changed after balloon occlusion in 14 (decreased, 11; increased, 3). In 18 tumors, there was a discrepancy between tumor enhancement on selective CTHA with balloon occlusion and the degree of accumulated iodized oil, which was higher than the tumor enhancement grade in all 18. The tumorous portal perfusion defect on CTAP significantly decreased after balloon occlusion in 18 of 20 tumors (mean decrease from 21.9 to 19.1 mm in diameter; p = 0.0001). No significant factors influenced discrepancies between selective CTHA with/without balloon occlusion. Central area tumor location, poor tumor enhancement on selective CTHA with balloon occlusion, and no decrease in the tumorous portal perfusion defect area on CTAP after balloon occlusion significantly influenced poor iodized oil accumulation in the tumor., Conclusions: Tumor enhancement on selective CTHA frequently changed after balloon occlusion, which did not correspond to accumulated iodized oil in most cases.

Background: Balloon-occluded retrograde transvenous obliteration (B-RTO) has become known as an effective treatment for gastric varices with a gastrorenal shunt. However, the appropriate duration to maintain inflation of the catheter balloon for sufficient thrombosis has been unknown., Purpose: To evaluate retrospectively the factors related to the development of thrombus in gastric varices by evaluating the necessity of the addition of a sclerosing agent on the second day in overnight B-RTO., Material and Methods: Sixty-five patients who underwent B-RTO for gastric varices with a gastrorenal shunt were studied. The B-RTO catheter was retained overnight in all patients. Incidence of and factors influencing the necessity of additional injections of a sclerosing agent on the second day were investigated., Results: In all 65 patients (100%), B-RTO was technically successful and in 61 patients (93.8%) complete thrombosis of the gastric varices was achieved. In 46 of the 65 patients (70.8%), the sclerosing agent was added on the second day. Higher Child-Pugh score, in particular, lower serum albumin level, and higher prothrombin time-international normalized ratio (PT-INR) were significantly associated with the need for the addition of the sclerosing agent on the second day. Optimal cut-off values for the serum albumin level and PT-INR were 3.6 g/dL and 1.13, respectively., Conclusion: Liver function might influence the development of thrombosis of gastric varices in B-RTO. Serum albumin and PT-INR levels would provide information for deciding on the duration of retention of the B-RTO catheter to obtain sufficient therapeutic effectiveness., (© The Foundation Acta Radiologica 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Objective: To evaluate the technical feasibility and safety considerations of balloon-occluded transarterial chemoembolization (B-TACE) using a newly developed 1.8-French (Fr) tip microballoon catheter for hepatocellular carcinoma (HCC)., Material and Methods: Between February 2013 and May 2013, 31 patients (20 males, 11 females; age range 56-85 years) underwent B-TACE using a 1.8-Fr tip microballoon catheter for unresectable HCC. The technical success rate, procedural complications, and adverse events of B-TACE were retrospectively investigated., Results: A total of 31 patients were subjected to 70 sessions of B-TACE using a 1.8-Fr tip microballoon catheter. The level of B-TACE was sub-subsegmental in 11, subsegmental in 35, segmental in 14, lobar in five, and right inferior phrenic artery in five sessions. The overall technical success rate was 99% (69 out of 70 sessions). As procedural complications, rupturing of the microballoon (n = 3) and aneurysmal dilatation at the site of balloon occlusion (n = 2) were encountered. There were no significant differences in any parameters between blood biochemical examination before and between two to four weeks after the procedure., Conclusion: A 1.8-Fr tip microballoon catheter enables selective catheterization in patients with HCC and B-TACE using the 1.8-Fr tip microballoon catheter is a safe procedure.

Objective: The purpose of our investigation was to evaluate the usefulness of cone-beam computed tomography (CBCT) in balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices., Material and Methods: Between December 2010 and March 2011, four patients underwent B-RTO for gastric varices that occurred after portal hypertension. In all, after insertion of sclerotic agents, CBCT was used to observe distribution of the sclerotic agent in the gastric varices and afferent gastric veins. Investigated was whether the entire gastric varices and afferent gastric veins were confirmed by retrograde venography performed when the sclerotic agent was infused and by CBCT obtained after insertion of the sclerotic agent., Results: On CBCT obtained after insertion of the sclerotic agent, distribution of sclerotic agents in the gastric varices and afferent gastric veins was clearly visualized. On the other hand, retrograde venography was inferior in detecting the area of distribution of sclerotic agents and the afferent gastric veins., Conclusion: Application of CBCT is helpful to precisely evaluate the distribution of sclerotic agents in B-RTO.

Objective: To determine the safety and usefulness of a two-tiered approach to balloon-occluded retrograde transvenous obliteration (B-RTO) as a treatment for large gastric varices after portal hypertension., Materials and Methods: 50 patients were studied who underwent B-RTO for gastric varices between October 2004 and October 2011 in our institution. The B-RTO procedure was performed from the right femoral vein and the B-RTO catheter was retained until the following morning. Distribution of sclerotic agents in the gastric varices on fluoroscopy was evaluated in all patients on days 1 and 2. When distribution of sclerotic agents in the gastric varices on day 1 had been none or very scanty even though the volume of the sclerotic agent infused was above the acceptable level, a second infusion was administered on day 2. When distribution was satisfactory, the B-RTO catheter was removed., Results: In 8 (16%) patients, little or no sclerotic agent infused on day 1 was distributed in the gastric varices. However, on day 2, sclerotic agents were distributed in all gastric varices. Mean volume of ethanolamine oleate-iopamidol infused on day 1 was 24.6 mL and was 19.4 mL on day 2. Gastric varices were well obliterated with no recurrence. Complications caused by the sclerotic agent such as pulmonary edema or renal insufficiencies were not seen., Conclusion: When gastric varices are very large, a strategy involving thrombosis of only the drainage vein on the first day followed by infusing the sclerotic agent on the following day might be effective and feasible.

Purpose: To elucidate changes in hemodynamics after balloon occlusion of the splenic artery during balloon-occluded retrograde transvenous obliteration (B-RTO)., Materials and Methods: In eight patients who had B-RTO for a gastric varix, the balloon-occluded venous pressure of the drainage vein was measured, and balloon-occluded retrograde venography (B-RTV) was performed with and without occlusion of the splenic artery during B-RTO. The pressure and the degrees of the variceal complex visualized on B-RTV were compared between those with and without occlusion of the splenic artery., Results: In seven of the eight patients, balloon-occluded venous pressure of the drainage vein decreased after balloon occlusion of the splenic artery. A paired t test showed that the mean decrease from 21.88 mm Hg to 18.38 mm Hg was statistically significant (P = .0033). From findings of B-RTV, the variceal complex was more extensively visualized after occlusion of the splenic artery in seven of the eight patients., Conclusions: Balloon occlusion of the splenic artery during B-RTO for gastric varices can produce changes in hemodynamics related to gastric varices and has the potential to prompt the sclerosing agent to distribute more extensively and evenly in the gastric varix., (Copyright © 2012 SIR. Published by Elsevier Inc. All rights reserved.)

Objective: To retrospectively evaluate the frequency and risk factors for developing thrombus in a systemic vein such as the infrarenal inferior vena cava or the iliac vein, in which a balloon-occluded retrograde transvenous obliteration (B-RTO) catheter was indwelled., Materials and Methods: Forty-nine patients who underwent B-RTO for gastric varices were included in this study. The B-RTO procedure was performed from the right femoral vein, and the B-RTO catheter was retained overnight in all patients. Pre- and post-procedural CT scans were retrospectively compared in order to evaluate the development of thrombus in the systemic vein in which the catheter was indwelled. Additionally, several variables were analyzed to assess risk factors for thrombus in a systemic vein., Results: In all 49 patients (100%), B-RTO was technically successful, and in 46 patients (94%), complete thrombosis of the gastric varices was achieved. In 6 patients (12%), thrombus developed in the infrarenal inferior vena cava or the right common-external iliac vein. All thrombi lay longitudinally on the right side of the inferior vena cava or the right iliac vein. One of the aforementioned 6 patients required anticoagulation therapy. No symptoms suggestive of pulmonary embolism were observed. Prothrombin time-international normalized ratio and the addition of 5% ethanolamine oleate iopamidol, on the second day, were related to the development of thrombus., Conclusion: Development of a thrombus in a systemic vein such as the inferior vena cava or iliac vein, caused by indwelling of the B-RTO catheter, is relatively frequent. Physicians should be aware of the possibility of pulmonary embolism due to iliocaval thrombosis.

Objective: The purpose of our investigation was to determine the safety and usefulness of embolisation procedures in balloon occluded retrograde transvenous obliteration (BRTO) as treatment of gastric varices after portal hypertension., Materials and Methods: Between June 2004 and August 2009, 40 patients underwent BRTO for gastric varices that occurred after portal hypertension in our institution. When large collateral vessels of gastric varices had developed as drainage veins other than the gastro-renal shunt, these collateral vessels were embolised prior to BRTO., Results: Embolisation was performed for 18 collateral vessels in 16 cases before BRTO. Embolised collateral vessels were the left inferior phrenic vein (n = 14), intercostal vein (n = 3), and ascending lumbar vein communicating with the gastro-renal shunt (n = 1). Mean number of micro-coils used was 5.7 in left inferior phrenic veins, 4.7 in intercostal veins and 4 in the ascending lumbar vein. In 36 (90%) patients, contrast-enhanced abdominal CT after BRTO showed that the gastric varices were well obliterated. The rate of occurrence of cases in which the remnant of the enhanced area in the gastric varices was seen even after BRTO was statistically higher in cases requiring embolisation of collateral vessels than in those who did not (4/16 versus 0/24, P = 0.0199 according to Fisher's exact probability test). Recurrence of gastric varices was determined by endoscopy in 1 (2.5%) case necessitating embolisation of collateral vessels. There were no serious complications., Conclusion: Embolisation of collateral vessels before BRTO is a safe and useful procedure. However, especially in cases having collaterals sufficiently large to require embolisation, careful follow-up for recurrence of gastric varices is necessary., (© 2011 The Authors. Journal of Medical Imaging and Radiation Oncology © 2011 The Royal Australian and New Zealand College of Radiologists.)

We encountered a case of gastric varix without a gastrorenal shunt that drained through the left pericardiacophrenic vein, which entered the left brachiocephalic vein. For this case we successfully performed balloon occluded retrograde transvenous obliteration, in which sclerotic agents were infused via the left pericardiacophrenic vein approached from the left subclavian vein.

We encountered a patient with a gastric varix that drained through the left inferior phrenic vein, which directly entered the inferior vena cava at the point just inferior to the diaphragm. In this patient, gastrorenal shunt was not seen. Balloon-occluded retrograde transvenous obliteration of the gastric varix was performed, in which 50% glucose and 5% ethanolamine oleate-iopamidol were injected as sclerosing agents while the balloon was inflated in the left inferior phrenic vein. 1 week after the procedure, the disappearance of enhancement in the gastric varix was confirmed on contrast-enhanced multidetector row CT. Furthermore, a significant reduction in the size of the varix was confirmed on endoscopic examination 4 months later.

We report a 78-year-old woman who presented with repeated tarry stools, and having lower duodenal variceal bleeding caused by portal hypertension. Endoscopic therapy had been attempted, but was impossible because the endoscope could not be inserted into the lower duodenum. Thus, the lower duodenal variceal bleeding was treated with balloon-occluded retrograde transvenous obliteration in combination with embolization using microcoils. Complete hemostasis was achieved without complications, and neither the recurrence of varices nor rebleeding has occurred for the last 3 years. A review of the English-language literature reveals only 11 such cases. The world literature is reviewed.

The feasibility of infusion of 50% glucose solution before balloon-occluded retrograde transvenous obliteration (BRTO) to occlude collateral vessels draining gastric varices other than gastrorenal shunt was evaluated. In five patients with such collateral vessels, 50% glucose solution was infused from the balloon catheter inflated within the gastrorenal shunt. The degree of collateral vessels had decreased when BRTO was carried out so that sclerotic agents sufficiently occupied the gastric varices in all patients. In three patients, embolization of collateral vessels with coils was unnecessary. There were no complications. In conclusion, retrograde infusion of 50% glucose solution assists in effectively carrying out BRTO.

A 68-year-old woman was admitted to the authors' hospital for hepatic encephalopathy. Her laboratory data and computed tomography findings were not suggestive of liver cirrhosis. Superior mesenteric angiography revealed an extrahepatic portal-systemic shunt with a main cause of hepatic encephalopathy. Despite treatment with branched-chain amino acid, lactulose, and kanamycin, hyperammonemia was prolonged, and the portal-systemic shunt was therefore treated with balloon-occluded retrograde transvenous obliteration. After the procedure, hyperammonemia was improved, and there were no signs of recurrent portal-systemic encephalopathy.

We present a patient with gastric varices complicating portal hypertension caused by liver cirrhosis related to hepatitis C virus. The patient underwent balloon-occluded retrograde transvenous obliteration. The gastric varices almost completely disappeared, without any sclerotic agent being used, after iatrogenic injury of the gastrorenal shunt at the time of the interventional procedure.

We report a 70-year-old woman with hepatic encephalopathy due to an intrahepatic portosystemic venous shunt that was successfully occluded by percutaneous transcatheter embolization with n-butyl cyanoacrylate and microcoils.