Plug assisted retrograde transvenous obliteration of gastric varices in failed endoscopic therapy as salvage option

A 35 year female patient presented to emergency department with abdominal distension, hematemesis and shock. She was known case of vitiligo vulgaris and chronic liver disease secondary to Autoimmune Hepatitis with features of Portal Hypertension. She had history of upper GI bleed in last 6 months and had undergone endoscopic glue and coil injection into gastric varices. On evaluation, her baseline investigations were hemoglobin 5.6 g/dl, serum creatinine of 1.1 mg/dl, serum bilirubin 2.3 mg/dl, INR 2.13 and serum albumin 1.92 g/dl. Endoscopy revealed small esophageal varices, severe portal hypertensive gastropathy and gastric varices with glue cast in situ, with no active bleed. Triple phase CT abdomen revealed shrunken/cirrhotic liver with splenomegaly and varices in region of fundus of stomach and esophagus (GOV2) with gastro-renal shunt measuring 14 mm (Fig. 1) which was draining to retro-aortic left renal vein (Fig.2). Previous coil and glue mass was also seen in gastric varices with contrast opacification of rest of the patent varices. Patient was simultaneously stabilized with vasopressors, blood transfusion and supportive care and also decision was made for retrograde transvenous obliteration of gastric varices. Both right jugular and right femoral access taken. GRS cannulated via femoral route and 7 Fr long sheath deployed (Fig. 3). C2 catheter was also negotiated into GRS. From femoral route 20 mm diameter AVP II plug deployed (~40% oversizing) and venogram done, which showed single efferent vein with insignificant collaterals (Fig 4). Varices and afferents were not opacified due to high flow. After significant stasis of contrast, sclerosant mixture of sodium tetradecyl sulphate, iodinated contrast and gel foam were injected in ratio 1:2:4 into efferent vein under fluoroscopic guidance. Sclerosant mixture was injected till complete opacification of gastric varices and minimal entry into afferent veins seen (Fig 5). C2 catheter removed and AVP II plug detached from introducer needle. Procedure was uneventful. On Postoperative day 1 NCCT abdomen was done to see the extent of sclerosant mixture deposition (Fig 6). Patient was discharged on postoperative day 2 in stable condition. At one month follow up patient was ambulatory and had persistent mild ascites. Lab investigations were hemoglobin of 9 g/dl, serum creatinine of 0.49 mg/dl, serum bilirubin-1.01 mg/dl, INR of 1.1 and serum albumin of 3.39 g/dl. Improvement in bilirubin levels, INR and albumin levels were noticed.