Gastric fundal varices are increasingly recognized as a cause of gastrointestinal bleeding in patients with portal hypertension.¹ Among patients with cirrhosis and portal hypertension, portosystemic collaterals often form, with gastric varices accounting for 10% to 20% of these cases. Compared to esophageal varices, isolated gastric fundal varices are prone to more severe bleeding, display a higher rebleeding rate, are associated with greater difficulty achieving hemostatic control, and have higher morbidity and mortality.¹

The management of acute gastric variceal bleeding begins with endoscopy² following the initial resuscitation and stabilization of the patient. Glue treatment³ is the preferred method for managing fundal variceal bleeding, whereas band ligation is the recommended approach for bleeding at the gastroesophageal junction. However, this carries a risk of rebleeding, and complications may arise from the embolization of the sclerosant (n-butyl-2-cyanoacrylate or isobutyl-2-cyanoacrylate) to non-target organs,³ including pulmonary embolism and renal vein thrombosis. If endoscopy is unsuccessful in controlling variceal bleeding, radiological interventions such as TIPS and BRTO are recommended.³ TIPS, a minimally invasive procedure frequently performed to decompress the portal venous system, is considered the primary strategy for managing gastric variceal bleeding in Western countries.³ However, this approach leads to hepatic encephalopathy in 20% to 30% of patients and is not always effective in controlling isolated gastric variceal bleeding. In contrast, BRTO is the preferred treatment in Eastern nations (such as Japan and Korea)⁴ due to its high efficacy in controlling bleeding gastric varices and lower incidence of hepatic encephalopathy. BRTO is also recommended for the treatment of refractory hepatic encephalopathy.⁵

A 65-year-old man with a history of nonalcoholic steatohepatitis-related cirrhosis was admitted to the emergency room with a 5-day history of melena and one episode of hematemesis. He had been receiving medical treatment for cirrhosis for the past 5 years. An endoscopy performed at an outside facility revealed gastric varices and grade two esophageal varices, while a colonoscopy report indicated no abnormalities. The patient’s Child-Pugh score was classified as A5, with a serum bilirubin level of 1 mg/dL, a serum albumin level of 3.3 g/dL, and an international normalized ratio of 1.12. He exhibited no clinical signs of ascites or encephalopathy, and his liver enzyme levels and kidney function tests were within normal ranges.

The patient was restless, displayed a blood pressure of 100/50 mmHg, and exhibited tachycardia with a heart rate of 120 beats per minute. His serum hemoglobin level was measured at 7 g/dL. Emergent esophagogastroduodenoscopy was promptly conducted, revealing mild oozing from the esophageal varices and a stomach distended with blood. Band ligation was performed on the grade 2 esophageal varices, accompanied by suctioning and clearing of blood from the gastric lumen. At that time, the gastric varices were not actively bleeding. During the endoscopic procedure, sclerosant was not directly injected into the fundic or cardiac gastric varices due to concerns regarding non-target embolization. However, 4 hours after endoscopy, the patient experienced a massive bout of hematemesis, became hemodynamically unstable, and required emergency intubation.

The interventional radiology department was contacted to perform an emergency transjugular intrahepatic portosystemic shunt (TIPS) or balloon-occluded retrograde transvenous obliteration (BRTO) procedure. The decision was made to first obtain a triphasic computed tomography (CT) scan of the abdomen after stabilizing the patient hemodynamically with blood products, terlipressin, and noradrenaline support.

CT images (Fig. 1) revealed prominent gastric varices in the fundus/cardia, with hyperdense blood in the stomach and cirrhotic liver morphology. No gastrorenal shunt was observed. The efferent channel of the gastric varices was determined to be the narrow inferior phrenic vein, with a tributary measuring 6 mm in diameter draining at the junction of the left hepatic vein and the inferior vena cava (IVC) (Fig. 2). Given these findings, the decision was made to attempt BRTO via this channel rather than proceed with TIPS.

Figure 1. (A) Axial contrast-enhanced computed tomography image displaying prominent gastric varices in the fundus/cardia (black arrow), with hyperdense blood contents visible in the stomach. (B) Cirrhotic liver morphology with the efferent channel of the gastric varices (black arrow) identified as an inferior phrenic vein tributary, draining at the junction of the left hepatic vein and the inferior vena cava.

Figure 2. (A) Fluoroscopic image. (B) Digital subtraction angiographic image. A venogram taken after balloon inflation within the inferior phrenic vein demonstrates contrast material entering the pericardiophrenic vein (long black arrow) and the left lower intercostal veins (small black arrow).

The procedure was initiated by gaining access through the right femoral vein, using an 8-Fr, 11-cm sheath (Performer^TM; Cook Medical). The ostium of the tributary was cannulated at the junction of the left hepatic vein and the IVC with a 5-Fr diagnostic catheter (RC1; Cook Medical). Venography confirmed the filling of the left inferior phrenic vein. Subsequently, a 260-cm-long guide wire (Glidewire; Terumo Interventional Systems) was advanced through the tributary, and a flexible 7-Fr, 65-cm sheath (Super Arrow-Flex^®; Teleflex Inc.) was positioned at the ostium of the junction. A 6 mm × 40 mm balloon dilatation catheter (35LP Low-Profile; Cook Medical) was threaded through the long sheath into the tributary and inflated with contrast medium (Fig. 2). The resulting venogram of the shunt revealed opacification of the phrenic vein, pericardiophrenic vein, and lower left intercostal veins, with the gastric varices not yet visualized. To opacify the varices, the choice was made to embolize the collateral channels. A 2.7-Fr microcatheter (Progreat^TM; Terumo Interventional Systems) was coaxially inserted into the balloon catheter, and coil embolization of the lower intercostal and pericardiophrenic veins was performed using 14 mm × 6 mm pushable coils (Nester^®; Cook Medical) and a slurry of gelatin sponge (Gelfoam^®; Pfizer Inc.). Following adequate embolization, a repeat venogram demonstrated the filling of the gastric varices. The microcatheter was then redirected into the varices, and 30 mL of a sclerosant mixture composed of air, 3% sodium tetradecyl sulfate (Setrol^®; SAMARTH LIFE SCIENCES PVT. LTD.), and ethiodized oil (Lipiodol^®; Guerbet) in a 3:2:1 ratio, along with small Gelfoam pieces and contrast, was injected under fluoroscopic guidance until the varices were completely filled (Fig. 3).

Figure 3. (A) Digital subtraction angiography image displaying the coil obliteration of the intercostal and pericardiophrenic vessels. (B) Fluoroscopic image illustrating the presence of sclerosant within dilated and tortuous gastric varices (black arrows).

The balloon was maintained in an inflated state, and fluoroscopic examinations were conducted at 15-minute intervals for 1 hour to confirm stasis of the contrast agent within the varices. Subsequently, the patient was transferred to the intensive care unit with the balloon still inflated and was closely monitored for the following 12 hours. During this period, the patient’s hemodynamic status gradually improved. He was removed from noradrenaline support as his hemoglobin levels stabilized, and after 12 hours, the balloon was deflated. A CT scan of the abdomen, performed 24 hours after BRTO, revealed hyperdensity around the gastric varices (Fig. 4), indicating complete coverage and thrombosis. The patient was later extubated and was discharged 2 days after the procedure. A 3-month follow-up via telephone indicated no recurrence of bleeding. As this is a case report, IRB approval is not required.

Figure 4. Axial non-contrast computed tomography image displaying hyperdense lipiodol within gastric varices (black arrow).

Conventional BRTO is performed by accessing the gastrorenal shunt through the left renal vein via either the femoral or jugular route. During the procedure, a sclerosant or Gelfoam is injected into the varices following balloon inflation within the gastrorenal shunt to block the outflow, leading to the obliteration of the varices.⁵ Afferent vessels of fundal varices include the left gastric, short gastric, and posterior gastric veins. The gastrorenal shunt, which opens into the left renal vein, is the most common efferent channel, accounting for 80% to 85% of cases, and is the primary target of BRTO procedures.⁶ BRTO necessitates extended post-procedural monitoring and carries the risk of complications, such as balloon rupture leading to systemic dispersion of sclerosing agents. Consequently, modified BRTO techniques⁷ have been developed. These include vascular plug-assisted retrograde transvenous obliteration (PARTO) and coil-assisted retrograde transvenous obliteration, which reduce the duration of post-procedural monitoring and intensive care unit stays. Such modified techniques are increasingly favored for occluding the conventional gastrorenal shunt.

However, gastric varices lacking a gastrorenal shunt are not uncommon, accounting for 10% to 15% of cases.⁷ In these instances, the primary outflow may involve the inferior phrenic vein, cardiophrenic vein, and intercostal veins. The drainage of these outflow veins into the IVC or systemic veins often presents a challenge for cannulation via the femoral or jugular route. Alternative approaches in such cases include TIPS followed by variceal obliteration through the TIPS tract, or antegrade obliteration of the varices through the transhepatic or transplenic route.

In the present case, BRTO was selected due to the unavailability of an appropriately sized plug for the PARTO technique on an emergency basis. The procedure was performed through the inferior phrenic vein, which served as the efferent channel for the gastric varices, draining at the junction of the left hepatic vein and the IVC. Typically, these channels are smaller than the conventional gastrorenal shunt; the vessel in our case was successfully cannulated despite having only a 6-mm caliber. A literature search revealed only two publications documenting the use of this channel for BRTO: the case reports by Ibukuro et al⁸ and Khera et al⁹ reported a case of BRTO performed through the left inferior phrenic vein joining the IVC, which was visible only on selective angiography of the splenic artery and not on cross-sectional imaging. Additionally, a few case reports have described BRTO conducted through the intercostal vein and the pericardiophrenic vein.⁹

Increased volume of ascites or increased pressure within esophageal varices may develop following BRTO, occurring in 20% to 30% of cases.¹⁰ However, neither of these complications was observed in our case during 3 months of follow-up.

The present case underscores the importance of a detailed understanding of the anatomical efferent pathways of gastric varices lacking a gastrorenal shunt. This knowledge is essential for the successful planning of a BRTO procedure, as these channels are relatively small in caliber and may present technical challenges.

None.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

No potential conflict of interest relevant to this article was reported.