Trans-splenic Embolization of Peristomal Varices in the Setting of Non-cirrhotic Portal Hypertension: An Under-recognize
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LETTER TO THE EDITOR
Trans-splenic Embolization of Peristomal Varices in the Setting of Non-cirrhotic Portal Hypertension: An Under-recognized Technique Rangarajan Purushothaman1
•
George Koshy Vilanilam1 • R. Gaines Fricke2
Received: 21 March 2020 / Accepted: 23 April 2020 Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2020
To the Editor: In the current era of patients with multiple comorbidities, patients and physicians look to interventional radiologists to manage complex diseases. Portal venous disease in particular often requires minimally invasive intervention as these patients are often not good surgical candidates. We write this letter to emphasize the importance of transsplenic access for these interventions, in this case, transsplenic stomal varix embolization. A 40-year-old woman presented with anemia and bloody output from her ileostomy. She had a prior total colectomy for refractory gastrointestinal bleeding in the setting of superior mesenteric vein (SMV) thrombosis of unclear etiology, resulting in cavernous transformation of the portal vein (PV). She was on chronic anticoagulation, though had persistent bleeding despite reversal of anticoagulation. A CT mesenteric angiogram showed peristomal ectopic varices, secondary to non-cirrhotic portal hypertension (Fig. 1). Variceal embolization through trans-splenic access was planned, in view of SMV thrombosis and cavernous transformation of the portal vein. A centrally directed splenic vein branch was accessed with a 21G Chiba needle and was exchanged for a 6 F sheath over a wire. Mesenteric venogram revealed stenotic residual main portal vein with cavernous transformation and multiple collaterals and a
& Rangarajan Purushothaman [email protected] 1
Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
2
Department of Radiology, Radiology Associates, P.A., Little Rock, AR, USA
large varix supplying the ileostomy (Fig. 2). A microcatheter was negotiated into the distal end of the varix which was then embolized with coils. Post-embolization venogram showed the satisfactory results, and the splenic access tract was embolized using coils (Fig. 3). Her bleeding resolved, anemia improved, and she was discharged 3 days later. Liver cirrhosis and primary sclerosing cholangitis are the common etiologies for stomal varies. The mortality rate is 3–4% per bleeding episode [1]. Treatment options are transjugular intrahepatic portosystemic shunt (TIPS), transhepatic embolization, direct percutaneous embolization and balloon retrograde transvenous obliteration (BRTO). TIPS is the definitive treatment and reduces the likelihood of rebleeding by 78.5% [2, 3]. TIPS and transhepatic antegrade embolization were not options in our patient as the cause of portal hypertension was post-sinusoidal. Direct percutaneous embolization was not chosen as the feeding vein was deep, not visible on ultrasound, and had no compressible systemic v
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