The patient was a 35-year-old woman with history of Crohn's disease and a history of portal vein thrombosis and splenic infarction 5 years ago. She underwent a total abdominal colectomy and was admitted for persistent left upper quadrant pain 10 days after surgery. An abdominal-pelvis computed tomography (CT) scan 10 days after surgery showed interval development of main portal vein thrombosis with extension into both the right and left portal veins (Fig. 1A) and small isolated varices in the gastric fundus (Fig. 1B). She was discharged with Coumadin and Lovenox after control of pain. She was readmitted 2 weeks later for increasing left upper quadrant pain. The 2 week follow-up abdominal-pelvis CT scan showed an interval decrease in the size of the portal vein thrombosis but a new inferior mesenteric vein thrombosis (Fig. 1C) and an interval increase in the size of the gastric varices (Fig. 1D). The patient did not have any symptoms of upper gastrointestinal (GI) bleeding at admission.

Due to the portal and inferior mesenteric vein thrombosis, she was planned to continue on anticoagulation with Coumadin therapy. However, due to the presence of gastric varices, a significant risk of variceal bleeding existed with anticoagulation medication. Additionally, an interval increase in the size of the gastric varices was observed on the CT scan compared with previous scans. The primary care team wanted to treat these gastric varices with a minimally invasive procedure such as BRTO, although the size of the gastric varices was relatively small. Therefore, she was referred for the BRTO procedure for prophylactic embolization of the gastric varices considering the presence of a gastrorenal shunt. Laboratory data before the BRTO procedure was creatinine, 0.65 mg/dL; bilirubin, 0.1 mg/dL; aspartate transaminase (AST), 10 units/L; alanine transaminase (ALT), 7 units/L; albumin, 2.7 g/dL; and PT/INR, 18.5 sec/1.51.

The procedure was performed under moderate sedation with intravenous midazolam hydrochloride and fentanyl citrate. We initially accessed the right internal jugular vein and placed a 9 Fr sheath. An 8 Fr renal double curve guiding catheter (Vista Britetip IG; Cordis, Miami, FL, USA) was placed in the left renal vein. Then, a 6 Fr balloon wedge pressure catheter (Teleflex Medical, Arrow International Inc., Reading, PA, USA) was placed in the gastrorenal shunt, and balloon occluded retrograde venography was performed. A venogram showed filling of the small gastric varices (Fig. 1E). The sclerosant was administered with the occlusion balloon inflated, and the varices were filled under fluoroscopic guidance over 30 minutes. We used 4 mL of 3% sodium tetradecol sulfate as the sclerosant (Sotradecol; AngioDynamics, Queensbury, NY, USA) mixed with 2 mL lipiodol (Ethiodol; Savage Laboratories, Melville, NY, USA) and 6 mL of air. The spot image after embolization showed shrunken gastric varices with lipiodol uptake (Fig. 1F). The balloon occlusion catheter was left in place for 30 minutes. Then, no residual gastric varix was observed after some reflux of sclerosant agent into the coronary vein, and no retrograde flow into the renal vein was observed after deflating the occlusion balloon. Thus, we decided to remove the occlusion catheter and sheath.

The patient was started on anticoagulation treatment and was discharged home on Coumadin. The post-procedural course was uneventful with no evidence of upper GI bleeding. A follow-up upper endoscopy at 105 days post procedure showed complete resolution of the gastric varices. Follow up CT scans at 3 and 5 months post BRTO procedure showed complete resolution of the portal vein thrombosis and complete obliteration of the gastric varices (Fig. 1G).

The patient was a 51-year-old woman with necrotizing pancreatitis and extensive enterocutaneous fistulas also complicated by portal vein thrombosis with cavernous transformation and splenic vein thrombosis (Fig. 2A). She also had multiple episodes of upper GI bleeding for which she had undergone an upper GI endoscopy and ligation of the varices. She underwent splenic artery and gastroduodenal artery embolization due to recurrence of the upper GI bleeding. She was referred for a BRTO procedure due to continual upper GI bleeding even after multiple variceal ligations, splenic and gastroduodenal artery embolization, and persistence of multiple gastric varices on both upper GI endoscopy and CT imaging (Fig. 2B). Laboratory data before the BRTO procedure was creatinine, 0.6 mg/dL; bilirubin, 4.4 mg/dL; AST, 92 units/L; ALT, 59 units/L; albumin, 2.2 g/dL; and PT/INR, 19.1 sec/1.58.

The same BRTO technique that was described for the first case was used. A balloon occluded retrograde venogram showed filling of the gastric varices and multiple collateral veins including the inferior phrenic vein (Fig. 2C). Two collateral veins including the inferior phrenic vein were catheterized with a 2.7 Fr microcatheter (Progreat; Terumo Medical, Elkton, MD, USA) and embolized with multiple 6 mm and 4 mm microcoils (Nester coil; Cook Inc., Bloomington, IN, USA). A Gelfoam slurry was used to embolize multiple small collateral veins before administering the sclerosant. The sclerosant was administered with the occlusion balloon inflated, and the varices were filled under fluoroscopic guidance over 40 minutes. Six mL of 3% sodium tetradecol sulfate was used as the sclerosant (Sotradecol; AngioDynamics) mixed with 3 mL lipiodol (Ethiodol; Savage Laboratories) and 9 mL of air. A spot image after embolization showed shrunken gastric varices with lipiodol uptake (Fig. 2D). The balloon occlusion catheter was left in place overnight through the guiding catheter. The patient was monitored in the intensive care unit to assess the therapeutic response as well as delayed complications. A complete blood count and hepatic function panel were obtained to assess the therapeutic response the following morning. The sheath and catheters were removed the following morning after checking lipiodol uptake on plain abdominal radiography.

The patient's upper GI bleeding cleared within a few days after the procedure, and she was discharged. Follow-up upper endoscopy 65 days post procedure showed normal gastric mucosa. Additionally, follow-up CT scans at 6 months post BRTO procedure showed complete obliteration of gastric varices (Fig. 2E). However due to underlying necrotizing pancreatitis with multiple enterocutaneous fistulas and abdominal wounds, she expired 8 months post procedure due to complicated sepsis.