Fig. 3. A 53-year-old man with underlying hepatitis C cirrhosis, ascites and large multifocal hepatocellular carcinoma (HCC) status post 2 × TACE (transcatheter arterial chemoembolization) with recurrent isolated gastric varices (GV). (A) Upper gastrointestinal endoscopy shows large GV around the gastric fundus with active oozing (arrow). (B) Axial venous phase computed tomography (CT) scan through the liver shows large necrotic HCC within the right lobe of the liver. (C) Coronal venous phase CT scan image through the liver shows a large necrotic HCC in S7 and S8 of the liver. Also note large enhancing GV around the gastric fundus (arrow) with gastrorenal shunt (dashed arrow). (D) Balloon occluded venogram of the gastro-renal shunt shows contrast filling of the GV (arrowhead) along with a draining inferior phrenic collateral vein (dashed arrow). (E) Repeat balloon occluded venogram following coil embolization of the inferior phrenic vein (arrow) shows filling of the more GV (arrowhead). This is followed by injection of sodium tetradecyl sulfate (Sotradecol; AngioDynamics, Queensbury, NY, USA) mixed with Lipiodol into the GV. (F) Abdominal radiograph on the next day following shows pooling of the dense Lipiodol (Ethiodol; Savage Laboratories, Melville, NY, USA) in the left upper quadrant around the gastric fundus.
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