BRTO has an accepted role for treatment of GVs, espe­cially in patients with poor hepatic reserve (model for end­stage liver disease or MELD score exceeding 18), hepatic encephalopathy, and/or heart failure in whom TIPS is con­traindicated. BRTO indications include GVs that are actively, previously, or at high risk for bleeding. GV oblit­eration may be combined with other procedures depending on the particular clinical and anatomic scenario (Table39.2) or based on operator preference. Notably, BRTO of GVs can help resolve hepatic encephalopathy, if present, through physiologic portosystemic shunt closure. Contraindications to BRTO include lack of a gastrorenal shunt or other systemic access to GVs, as well as portal and/or splenic vein throm­bosis in the absence of alternative mesenteric or splenic venous outow (which risks mesenteric and splenic isch­emia and infarction). Pre-procedure patient evaluation includes a thorough history and physical exam, laboratory evaluation, and upper endoscopy to diagnose and conrm the presence of GVs. Triple-phase contrast-enhanced cross­sectional imaging is routinely obtained to delineate GV anatomy (including inow and outow vessels) (Fig.39.6) for pre-procedure planning.