PMC9633575_01
(a) Contrast-enhanced 3D computed tomography (CT) showing gastric varices (red color), esophageal varices (orange), the left gastric vein (green), posterior gastric vein (yellow), an intraphrenic vein shunt (light blue), and the pericardiophrenic vein (purple). (b) Maximum intensity projection image of portal-phase contrast-enhanced CT demonstrating gastric varices in the fundus (arrow).
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The varices were mainly fed by the posterior gastric vein, and the dilated left gastric vein joined in the drainage route of the varices (Fig. 1).
Balloon-occluded retrograde transvenous venography from the pericardiophrenic vein (white arrowhead) did not show the varices, although it showed drainage via the gastrocaval shunt (black arrowhead) and intercostal veins (white arrow) (Hirota Grade 4).
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Balloon-occluded retrograde transvenous venography did not show the varices, although it showed drainage via the gastrocaval shunt and intercostal veins (Hirota Grade 4, Fig. 2).
Embolization method. (a) The schema of coil-assisted retrograde transvenous obliteration with the inverted catheter tip technique showing the catheter (orange color), microcatheter (red), coils (blue), and ethanolamine oleate iopamidol (EOI; yellow). i: The inverted tip of the microcatheter and the first coil in the inferior phrenic vein (IPV). ii: The second coil in the left gastric vein. iii: EOI injected from the released microcatheter tip. (b) Venography without balloon occlusion from the IPV did not show the afferent veins or varices. (c) The inverted microcatheter tip was placed in the IPV (white arrowhead). (d) Coil embolization was performed from the inverted catheter tip (black arrowhead) and the loop of the microcatheter was released (white arrowhead). (e) Venography after coil embolization showed the left gastric vein as the afferent vein (white arrow), although it did not show varices. (f) Following coil embolization of the left gastric vein (white arrow), 10 mL of 5% EOI was injected, which enabled visualization of the varices (black arrow).
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Terumo) was able to advance the catheter closer to the varices. Therefore, CARTO with the inverted catheter tip technique was performed, as described below (Fig. 3a). Venography from the IPV did not show the afferent veins or varices (Fig. 3b). First, the microwire was inverted using the arcuate edge of the IPV and followed by the microcatheter (Fig. 3c). Next, a fibered coil (Tornado18; Cook Medical, Bloomington, IN) was placed from the inverted microcatheter in the IPV (Figs. 3a-i). Then, the loop of the microcatheter was released (Fig. 3d). Venography showed that the left gastric vein was the afferent vein joining the drainage route of the varices, although it did not show varices (Fig. 3e). Then, the left gastric vein was embolized with a coil (Target XL; Stryker Neurovascular, Kalamazoo, MI; Fig. 3a-ii). And 5% ethanolamine oleate iopamidol was injected near the varices (Figs. 3a-iii and f).