case_images: PMC3738354_01
case_images: (a) CT scan acquired 24 days before treatment. Note the giant rectal varices with tori (arrow) inside the rectal lumen. (b-d) Portal venography via the superior mesenteric vein. Flow from the hepatofugal dilated inferior mesenteric vein (IMV) (white large arrow) into rectal varices (black large arrow). The varices mainly drained into the left internal iliac vein (IIV) (black small arrow). White arrowheads and small arrows indicate the right and left superior rectal vein (SRV), respectively. (e) Schema of obliteration procedures. Step 1: 5.5 mL of a 1:10 mixture of N-butyl cyanoacrylate (NBCA)-lipiodol were injected from the left (Lt.) SRV via the microcatheter under inflation of the balloons in the IMV and left common iliac vein (CIV) and nine coils were placed in the left IIV. Step 2: 40 mL of 50% glucose and 12.5 mL of 5% ethanolamine oleate with iopamidol were injected into the right (Rt.) SRV and eight pushable microcoils were placed in the IMV under double balloon inflation. (f) Radiograph of portal venography obtained immediately after obliteration of the rectal varices. The presence of nine microcoils in the left IIV (small arrow) and of eight microcoils in the IMV (arrowhead) was confirmed. The rectal varices were filled with an NBCA-lipiodol mixture (large arrow)
case_images: 10.1258_arsr.2012.120024-fig1.jpg
case_images: PMC3738354_01_10.1258_arsr.2012.120024-fig1.jpg
case_images: ARSR-12-0024F1
case_images: Colonoscopy showed huge tortuous rectal varices. Contrast-enhanced computed tomography (CT) revealed giant varices with tori inside the rectal lumen (Fig. 1a). Portal venography via the superior mesenteric vein (SMV) confirmed that the rectal varices were supplied by the inferior mesenteric vein and mainly drained into the left internal iliac vein (Fig. 1b-d). Takeda Pharmaceutical, Osaka, Japan) with iopamidol (Iopamiron 300, Bayer HealthCare, Osaka, Japan) as a sclerotic agent through the microcatheter in the right superior rectal vein. Then eight pushable microcoils (diameter 8 mm) (Micronester) were placed in the internal mesenteric vein under double balloon inflation. As portal venography confirmed the complete obliteration of the rectal varices we removed the catheters (Fig. 1e, f). A plain radiograph obtained 30 min later confirmed that the coils remained in the left internal iliac vein. Throughout these procedures the patient's condition was stable and he was under continuous observation by anesthesiologists.
case_images: (a, b) CT scan acquired 5 days after treatment of the giant rectal varices. Complete obliteration of the rectal varices was obtained with the NBCA-lipiodol mixture (large arrow). A CT scout view shows that all microcoils placed in the left IIV had migrated into the right lung (small arrow). Microcoils placed in the IMV remained in place (arrowhead). (c) Chest X-ray study performed one month after treatment of the giant rectal varices. The coils remained in a lower trunk of the right pulmonary artery
case_images: 10.1258_arsr.2012.120024-fig2.jpg
case_images: PMC3738354_01_10.1258_arsr.2012.120024-fig2.jpg
case_images: ARSR-12-0024F2
case_images: A CT study performed on the fifth postoperative day confirmed complete obliteration of the rectal varices (Fig. 2a). However, all nine metallic coils placed in the left internal iliac vein had migrated into a lower branch of the right pulmonary artery (Fig. 2b and c).