case_images: PMC3909841_01
case_images: 35-year-old women with history of Crohn's disease, status post total abdominal colectomy, and portal vein and mesenteric vein thrombosis.. A, B. Coronal reformatted contrast-enhanced computed tomography (CT) scan 2 weeks after surgery shows large filling defect (arrow) in main portal vein with extension into both right and left portal veins and small isolated varices (arrow) in gastric fundus. C, D. Coronal reformatted contrast-enhanced CT scan at 2 week follow up shows interval decrease in size of portal vein thrombosis, new inferior mesenteric vein thrombosis (small arrow), and interval increase in size of gastric varices (arrow). E. Balloon occluded retrograde venogram shows filling of small gastric varices (arrow). Sclerosant was administered with filling of varices and occlusion balloon inflated. F. Spot image after embolization shows gastric varices with lipiodol uptake (arrow). G. Coronal reformatted contrast-enhanced CT scan 3 months after balloon occlusion retrograde transvenous obliteration procedure shows complete obliteration of gastric fundus with small residual lipiodol uptake (arrow).
case_images: kjr-15-108-g001.jpg
case_images: PMC3909841_01_kjr-15-108-g001.jpg
case_images: F1
case_images: An abdominal-pelvis computed tomography (CT) scan 10 days after surgery showed interval development of main portal vein thrombosis with extension into both the right and left portal veins (Fig. 1A) and small isolated varices in the gastric fundus (Fig. 1B). The 2 week follow-up abdominal-pelvis CT scan showed an interval decrease in the size of the portal vein thrombosis but a new inferior mesenteric vein thrombosis (Fig. 1C) and an interval increase in the size of the gastric varices (Fig. 1D). Arrow International Inc., Reading, PA, USA) was placed in the gastrorenal shunt, and balloon occluded retrograde venography was performed. A venogram showed filling of the small gastric varices (Fig. 1E). The spot image after embolization showed shrunken gastric varices with lipiodol uptake (Fig. 1F). Follow up CT scans at 3 and 5 months post BRTO procedure showed complete resolution of the portal vein thrombosis and complete obliteration of the gastric varices (Fig. 1G).
case_images: PMC3909841_02
case_images: 51-year-old women with necrotizing pancreatitis, portal vein thrombosis, and gastric varices.. A, B. Coronal reformatted (A) and axial (B) contrast-enhanced computed tomography (CT) scan 3 days prior to balloon occlusion retrograde transvenous obliteration (BRTO) procedure shows abrupt cut off of both right and left portal veins (arrow), representing portal vein thrombus, splenic vein thrombosis, and enhancing dilated veins (arrows) in region of gastric fundus representing gastric varices. C. Balloon occluded retrograde venogram shows filling of gastric varices (arrow) and multiple collateral veins including inferior phrenic vein (small arrows). Note previous coil embolized splenic and gastroduodenal arteries (arrowheads). Two collateral veins including inferior phrenic vein were embolized with multiple microcoils. Sclerosant was administered with occlusion balloon inflated and filling of varices. D. Spot image of gastric varices post embolization shows gastric varices with lipiodol uptake (arrows) and multiple coils (small arrows) at embolized inferior phrenic vein and small draining vein. E. Axial contrast-enhanced CT scan 6 months after BRTO procedure shows complete obliteration of gastric fundus with small residual lipiodol uptake (arrow).
case_images: kjr-15-108-g002.jpg
case_images: PMC3909841_02_kjr-15-108-g002.jpg
case_images: F2
case_images: The patient was a 51-year-old woman with necrotizing pancreatitis and extensive enterocutaneous fistulas also complicated by portal vein thrombosis with cavernous transformation and splenic vein thrombosis (Fig. 2A). She was referred for a BRTO procedure due to continual upper GI bleeding even after multiple variceal ligations, splenic and gastroduodenal artery embolization, and persistence of multiple gastric varices on both upper GI endoscopy and CT imaging (Fig. 2B). A balloon occluded retrograde venogram showed filling of the gastric varices and multiple collateral veins including the inferior phrenic vein (Fig. 2C). AngioDynamics) mixed with 3 mL lipiodol (Ethiodol; Savage Laboratories) and 9 mL of air. A spot image after embolization showed shrunken gastric varices with lipiodol uptake (Fig. 2D). Additionally, follow-up CT scans at 6 months post BRTO procedure showed complete obliteration of gastric varices (Fig. 2E).