Fig. 1. A 67-year-old male with duodenal varices. (A) Endoscopy showed large varices in the duodenum. (B) Computed tomography during arterial portography showed tortuous and dilated varices in the third portion of the duodenum (arrows). The afferent vein was the inferior pancreaticoduodenal vein (asterisk) and the efferent vein drained into the left gonadal vein (arrowhead). (C) On retrograde venography under balloon occlusion of the left gonadal vein, a collateral vein (an anastomosis with retroperitoneal veins) (asterisk) was demonstrated, but the main efferent vein was not demonstrated. The arrow and arrowhead indicate an 8-F 50-cm-long sheath and a balloon, respectively. (D) Retrograde venography under balloon occlusion of the left gonadal vein performed after coil embolization of the collateral vein showed several small collateral veins connected with retroperitoneal veins. The collateral veins could be occluded by infusion of a small amount of 50% glucose solution (not shown). (E) Thereafter, infusions of ethanolamine oleate with iopamidol for 30 minutes were repeated three times through a microcatheter. The arrow indicates the inferior pancreaticoduodenal vein and the arrowhead indicates the microcatheter. (F) Contrast-enhanced computed tomography performed 4 days after balloon-occluded retrograde transvenous obliteration (BRTO) showed that the varices were completely thrombosed (arrows). The arrowhead indicates metallic coils in the anastomosis with retroperitoneal veins. (G) Endoscopy performed 4 months after BRTO showed the disappearance of the varices.
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