PMC5478564_01
(a) Esophagogastroduodenoscopy (EGD) showed that the isolated gastric varices (IGVs) were white, large, and located in the cardia and fundus. (b, c) Dynamic computed tomography (CT) also showed that IGVs were in the cardia and fundus, suggesting that the left renal vein was the efferent vein.
1349-7235-56-1041-g001.jpg
PMC5478564_01_1349-7235-56-1041-g001.jpg
g001
Esophagogastroduodenoscopy (EGD) showed the IGVs to be white, large, and located in the cardia and fundus (Fig. 1a). Dynamic computed tomography (CT) also showed that the IGVs were in the cardia and fundus, with the left renal vein suspected to be their efferent vein (Fig. 1b and c).
The portal phase of superior mesenteric angiography showed that portal flow was hepatopetal, and the IGVs were not visualized (a). CT of splenic arterial portography showed that the efferent veins were the pericardiacophrenic vein (red arrow) (b), inferior phrenic vein (red triangle), para-esophageal vein (blue arrow) (c), and left renal vein (yellow arrow), which was the main drainage route afferent vein (d). CT also showed that the short gastric vein (green arrow) was the afferent vein (e).
1349-7235-56-1041-g002.jpg
PMC5478564_01_1349-7235-56-1041-g002.jpg
g002
Tokyo, Japan). The portal phase of superior mesenteric angiography showed that the portal flow was hepatopetal, and the IGVs were not visualized (Fig. 2a). We performed CT of splenic arterial portography to evaluate the precise hemodynamic of IGVs and found that the afferent vein was the short gastric vein and the efferent veins were the inferior phrenic vein, pericardiacophrenic vein, para-esophageal vein, and left renal vein, which was the main drainage route of the IGVs (Fig. 2b-e).
Balloon-occluded retrograde transvenous varicerography (BRTV) showed that the IGVs were not opacified because the inferior phrenic veins (red arrow) worked as collateral veins. (a) Frontal view, (b) lateral view.
1349-7235-56-1041-g003.jpg
PMC5478564_01_1349-7235-56-1041-g003.jpg
g003
BRTV showed that the IGVs were not opacified because the inferior phrenic vein was working as a collateral vein (Fig. 3).
We punctured the right internal jugular vein and introduced an 8-Fr balloon catheter with a 20-mm diameter. We advanced it to the left renal vein and occluded the end of the efferent vein (a). We then tried to cannulate the inferior phrenic vein from the inferior vena cava (IVC). We injected contrast medium via the balloon catheter and performed CT to determine where the end of the inferior phrenic vein was located (b, c). Although we used various types of catheter, such as Cobra, Multipurpose, and Michaelson types, we were unable to cannulate due to indentation.
1349-7235-56-1041-g004.jpg
PMC5478564_01_1349-7235-56-1041-g004.jpg
g004
We advanced it to the left renal vein and occluded the end of the efferent vein (Fig. 4a). Although we used various types of catheter, such as Cobra, Multipurpose, and Michaelson types, we were unable to cannulate due to indentation (Fig. 4b and c).
Shunt-occluded endoscopic injection sclerotherapy (SO-EIS) procedure. (a, b) First puncture. (c, d) Second puncture. (e) Just after the treatment.
1349-7235-56-1041-g005.jpg
PMC5478564_01_1349-7235-56-1041-g005.jpg
g005
Because an additional injection of EOI might have resulted in inflow to the systemic circulation, we stopped the injection of EOI and instead injected a mixture of 0.5 mL of cyanoacrylate and 0.3 mL of lipiodol to prevent bleeding from the puncture site (Fig. 5a and b). This time, the IGVs and left gastric vein were also successfully opacified, so we again injected the mixture of 0.5 mL of cyanoacrylate and 0.3 mL of lipiodol to prevent bleeding (Fig. 5c-e).
One week after shunt-occluded endoscopic injection sclerotherapy (SO-EIS), esophagogastroduodenoscopy (EGD) and enhanced computed tomography (CT) showed complete thrombosis of the isolated gastric varices (IGVs) and afferent vein (a-c). Three months after SO-EIS, EGD showed that the IGVs had shrunk (d).
1349-7235-56-1041-g006.jpg
PMC5478564_01_1349-7235-56-1041-g006.jpg
g006
One week after SO-EIS, EGD and enhanced CT showed complete thrombosis of the IGVs and afferent vein (Fig. 6a-c). Three months after SO-EIS, EGD showed that the IGVs had shrunk markedly (Fig. 6d). Enhanced CT showed that there were deposits of cyanoacrylate in the gastric wall, and we were unable to identify any recurrence of IGVs (Fig. 6e). The inferior phrenic vein, para-esophageal vein, and left renal shunt were also enhanced, indicating that they had been preserved as the collateral veins (Fig. 6f and g).