![coil assisted retrograde transvenous obliteration coil assisted retrograde transvenous obliteration](https://americanjir.com/content/1/2018/2/1/img/AJIR-2-16-g003.png)
Despite multiple attempts, we were unable to get a stable position within the proximal shunt to deploy the Amplatz™ plug as the plug repeatedly landed into the larger variceal portion. The initial plan was to perform a PARTO by placing the Amplatz™ plug into the narrower segment of the dumbbell-shaped proximal varix. Triple phase CT showed a large splenorenal shunt, therefore decided to attempt BRTO for management of his encephalopathy. Case Report: 53-year-old patient with non-alcoholic steatohepatitis (NASH) cirrhosis with portal hypertension with refractory hepatic encephalopathy causing disabling symptoms and affecting his quality of life. Modified versions of BRTO such as Plug Assisted Retrograde Transvenous Obliteration (PARTO) and Coil Assisted Retrograde Transvenous Obliteration (CARTO) have been introduced to overcome the limitations of BRTO such as prolonged procedure time, high-acuity post-procedural care, risk of balloon rupture and sclerosant leakage. The procedure involves obliterating large portosystemic shunts by occluding the outflow tract by balloon catheter and injecting sclerosant into the varix. Abstract: Background: Balloon-occluded Retrograde Transvenous Obliteration (BRTO) is a well-established procedure for the management of refractory hepatic encephalopathy, performed by interventional radiology.