Successful plug-assisted retrograde transvenous obliteration via the right gonadal vein for duodenal variceal bleeding from a mesocaval shunt

Duodenal variceal bleeding is a rare but potentially life-threatening complication of portal hypertension, frequently associated with abnormal portosystemic collateral pathways. We present a case of successful plug-assisted retrograde transvenous obliteration (PARTO) performed for duodenal varices draining into the right gonadal vein via a mesocaval shunt in a patient with hepatocellular carcinoma and liver cirrhosis. Despite severe angulation and tortuosity of the shunt, a strategic approach involving dual vascular plugs and gelfoam injection successfully achieved complete shunt obliteration without recurrence over a two-year follow-up period. This case underscores the feasibility of PARTO even in anatomically complex ectopic varices and suggests its applicability beyond traditionally described shunt anatomies.