Purpose: Why and how to decide whether femoral or jugular approach should be used for shunt catheterization for a successful balloon-occluded retrograde transvenous obliteration (BRTO) procedure. Materials and Methods: Sixteen patients had undergone BRTO for variceal bleeding (11 cases) and encephalopathy (5 cases) with the femoral (13) and jugular approach (5). In two patients, both femoral and jugular approaches were used. There were four failed shunt catheterizations with the femoral or jugular approach two each. In all patients, the inferior vena cava (IVC) to shunt distance (ISD) was measured on the reformatted coronal computed tomography image. Results: The IVC to shunt distance (ISD) was between 2.0 and 3.5 cm in 13 patients and >3.5 cm in five. Two patients were having both proximal gastrorenal and distal splenorenal shunts. The ISD was >3.5 cm in two patients with failed initial femoral approach and < 3.5 cm in two other patients with failed initial jugular approach. In each of the four failures, the alternative approach resulted in obtaining a successful BRTO. Conclusion: The femoral approach is recommended for catheterization of the gastrorenal shunt for BRTO when the shunt joins the renal vein within 3.5 cm from the IVC. However, when the shunt is farther than 3.5 cm from the IVC, the jugular approach is suitable for a BRTO procedure.
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