CC BY-NC-ND 4.0 · Journal of Clinical Interventional Radiology ISVIR 2019; 03(01): 069-070
DOI: 10.1055/s-0039-1681118
Letter to the Editor
Indian Society of Vascular and Interventional Radiology

Endovascular Management of Ectopic Variceal Bleeding after Hepaticojejunostomy

Amitha Vikrama K. S.
1   Department of Interventional Radiology, Sakra World Hospital, Bangalore, Karnataka, India
,
Yugandhar Samireddypalle
1   Department of Interventional Radiology, Sakra World Hospital, Bangalore, Karnataka, India
,
Chinmaya Deepak
1   Department of Interventional Radiology, Sakra World Hospital, Bangalore, Karnataka, India
› Author Affiliations
Further Information

Publication History

Received: 09 August 2018

Accepted after revision: 13 November 2018

Publication Date:
22 April 2019 (online)

A 62-year-old woman with a prior history of cholangiocarcinoma, left hepatectomy, hepaticojejunostomy, and portal vein reconstruction in September 2017 presented with recurring episodes of melena since March, 2018. Endoscopy revealed gastric varices, and the patient underwent multiple sessions of endoscopic management of the varices. However, the episodes of melena continued. Contrast-enhanced computed tomography (CT) of the abdomen revealed occlusion of the main portal vein with multiple venous collaterals at the hepaticojejunostomy ([Fig. 1A, B]). She was referred to the Interventional Radiology department for further management. On examination, she was clinically stable with pulse rate of 78 beats/min and blood pressure of 138/70 mm Hg. Her liver function tests, renal function tests, and coagulation parameters were normal. Hemoglobin was 12 gm/dL. Portal vein recanalization followed by embolization of the varices was planned.

Zoom Image
Fig. 1 (A) Coronal reformatted CT image at the level of hepatic hilum demonstrating portal vein thrombosis extending from the portosplenic confluence to the porta (arrow). The intrahepatic right branch of portal vein is patent. (B) Coronal reformatted CT image demonstrating multiple ectopic jejunal varices at the hepaticojejunostomy (black arrow). The hypodense thrombus within the portal vein is also noted (white arrow). (C) Portography demonstrating occlusion of the main portal vein (white arrow). There is prominent left gastric vein (black arrow) probably feeding the gastric collaterals.

Percutaneous transhepatic access of a peripheral portal vein radicle of the segment VI was achieved using a micropuncture set (AccuStick, Boston Scientific). Portal venography revealed occlusion of the main portal vein and filling of left gastric vein ([Fig. 1C]). The occluded segment of the main portal vein was crossed using a 0.035-in guidewire (Terumo). Balloon angioplasty of the occluded portal vein was performed using a 6- × 40-mm balloon. This was followed by placement of a 10-mm × 60-mm self-expanding metallic stent (Absolute Pro; Abbott) ([Fig. 2A, B]). The stent was dilated using a 10- × 40-mm balloon. Postprocedure venography revealed satisfactory antegrade flow across the stent. There was filling of multiple venous collaterals at the hepaticojejunostomy from the jejunal tributaries of the superior mesenteric vein ([Fig. 2A]). The left gastric vein was no longer visualized. These venous collaterals were superselectively catheterized, and embolization was performed using 33% n-butyl-cyanoacrylate–Lipiodol mixture ([Fig. 2B]). Postembolization venography revealed good antegrade flow across the stent with no filling of the varices at the hepaticojejunostomy ([Fig. 2C]). The portal vein access tract was embolized using n-butyl-cyanoacrylate. There were no procedural or immediate postprocedural complications. The patient was discharged in a stable condition without any further complaints of melena. Follow-up Doppler at 1 week of the procedure revealed a patent portal vein with good hepatopetal flow.

Zoom Image
Fig. 2 (A) Poststenting portal venography demonstrating satisfactory antegrade flow across the portal vein. Multiple jejunal varices are seen supplied by the jejunal branches of the superior mesenteric vein (arrow). Note that the left gastric vein is not opacified. (B) Superselective embolization of the varices using 33% n-butyl-cyanoacrylate (arrow). (C) Postembolization portography demonstrating good antegrade flow across the main portal vein without any filling of the varices. The glue cast of the embolization can be seen (arrow).
 
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