Subscribe to RSS
DOI: 10.1055/s-0039-1681118
Endovascular Management of Ectopic Variceal Bleeding after Hepaticojejunostomy
Publication History
Received: 09 August 2018
Accepted after revision: 13 November 2018
Publication Date:
22 April 2019 (online)
A 62-year-old woman with a prior history of cholangiocarcinoma, left hepatectomy, hepaticojejunostomy, and portal vein reconstruction in September 2017 presented with recurring episodes of melena since March, 2018. Endoscopy revealed gastric varices, and the patient underwent multiple sessions of endoscopic management of the varices. However, the episodes of melena continued. Contrast-enhanced computed tomography (CT) of the abdomen revealed occlusion of the main portal vein with multiple venous collaterals at the hepaticojejunostomy ([Fig. 1A, B]). She was referred to the Interventional Radiology department for further management. On examination, she was clinically stable with pulse rate of 78 beats/min and blood pressure of 138/70 mm Hg. Her liver function tests, renal function tests, and coagulation parameters were normal. Hemoglobin was 12 gm/dL. Portal vein recanalization followed by embolization of the varices was planned.
Percutaneous transhepatic access of a peripheral portal vein radicle of the segment VI was achieved using a micropuncture set (AccuStick, Boston Scientific). Portal venography revealed occlusion of the main portal vein and filling of left gastric vein ([Fig. 1C]). The occluded segment of the main portal vein was crossed using a 0.035-in guidewire (Terumo). Balloon angioplasty of the occluded portal vein was performed using a 6- × 40-mm balloon. This was followed by placement of a 10-mm × 60-mm self-expanding metallic stent (Absolute Pro; Abbott) ([Fig. 2A, B]). The stent was dilated using a 10- × 40-mm balloon. Postprocedure venography revealed satisfactory antegrade flow across the stent. There was filling of multiple venous collaterals at the hepaticojejunostomy from the jejunal tributaries of the superior mesenteric vein ([Fig. 2A]). The left gastric vein was no longer visualized. These venous collaterals were superselectively catheterized, and embolization was performed using 33% n-butyl-cyanoacrylate–Lipiodol mixture ([Fig. 2B]). Postembolization venography revealed good antegrade flow across the stent with no filling of the varices at the hepaticojejunostomy ([Fig. 2C]). The portal vein access tract was embolized using n-butyl-cyanoacrylate. There were no procedural or immediate postprocedural complications. The patient was discharged in a stable condition without any further complaints of melena. Follow-up Doppler at 1 week of the procedure revealed a patent portal vein with good hepatopetal flow.
-
References
- 1 Lee DH, Kim YH, Lee YJ. et al. CT findings of afferent loop varices after bilioenteric anastomosis in patients with malignant disease. AJR Am J Roentgenol 2013; 200 (06) 1261-1268
- 2 Taniguchi H, Moriguchi M, Amaike H, Fuji N, Murayama Y, Kosuga T. Hemorrhage from varices in hepaticojejunostomy in the fifth and tenth year after surgery for hepatic hilar bile duct cancer: a case report. Cases J 2008; 1 (01) 59
- 3 Lee SD, Park SJ, Kim HB. et al. Jejunal varix bleeding with extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy: report of two cases. Korean J Hepatobiliary Pancreat Surg 2012; 16 (01) 37-42
- 4 Watson GA, Abu-Shanab A, O'Donohoe RL, Iqbal M. Enteroscopic management of ectopic varices in a patient with liver cirrhosis and portal hypertension. Case Reports Hepatol 2016; 2016: 2018642
- 5 Sasamoto A, Kamiya J, Nimura Y, Nagino M. Successful embolization therapy for bleeding from jejunal varices after choledochojejunostomy: report of a case. Surg Today 2010; 40 (08) 788-791