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The Western philosophy (US/Europe) for addressing portal hypertension and its complications is to decompress the system, i.e. Gastric varices can bleed at lower portosystemic pressures compared to esophageal varices, possibly explaining the decreased efficacy of TIPS.4 The paucity of studies directly comparing BRTO to TIPS has generated controversy over therapeutic outcomes. However, limited data points to decreased efficacy of TIPS for treatment of gastric varices in terms of long-term re-bleeding rates and overall regression. TIPS has proven very effective in acutely controlling both esophageal and gastric variceal hemorrhage. Minimally invasive procedures such as endoscopic band ligation and injection sclerotherapy are well documented for bleeding esophageal varices but demonstrate decreased efficacy when treating gastric varices (particularly fundal GV).3 Thus, treatments such as balloon-occluded retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunt (TIPS) have become valuable options in controlling esophageal (when endoscopy has failed) and gastric variceal bleeding. 1) Although less common, bleeding gastric varices (GV) are associated with a poorer prognosis, more severe blood loss, higher re-bleeding rates, and higher mortality (45-50%).2

Gastroesophageal varices are a common sequelae of portal hypertension with esophageal varices being more common than gastric varices (70-80% vs 20-30%, respectively).