S4652 Successful Treatment of Isolated Gastric Varices With Coil-Assisted Retrograde Transvenous Obliteration (CARTO)

Introduction: Gastric varices (GV) typically develop in cirrhotic portal hypertension and carry high risks of bleeding and rebleeding. Unlike esophageal varices, GV are less amenable to endoscopic band ligation due to their location. We present a rare case of isolated gastric varices (IGV) successfully managed with coil-assisted retrograde transvenous obliteration (CARTO). Case Description/Methods: A 59-year-old woman with rheumatoid arthritis presented with hematemesis (bright red and black blood) and melena. She had a history of similar episodes requiring transfusions. On examination, she was mildly tachycardic, normotensive and had a soft, non-tender abdomen. Hemoglobin was 9.1 g/dL; fecal occult blood test was positive. Computed tomography abdomen with contrast revealed gastrosplenic varices consistent with IGV type 1. She was started on pantoprazole and octreotide drip. Esophagogastroduodenoscopy (EGD) showed a single large fundal varix with a cherry red spot and no esophageal varices, confirming IGV as the source. Interventional radiology performed CARTO via the right internal jugular vein. A 6 Fr sheath was advanced and angiography identified the left adrenal and gastric varix, which were embolized. Using a parallel catheter technique, the gastrorenal shunt was occluded proximally and coiled distally through the left renal vein. Post-procedure, no flow from the varix into the renal vein was observed. Discussion: GV are divided into gastroesophageal varices (GOV) or isolated gastric varices (IGV) per Sarin. IGV1 is limited to the fundus and receives inflow from short, left or posterior gastric veins and drains via gastrorenal shunt (GRS) in 80–85% of cases or gastrocaval shunt (GCS) in 10–15%. Treatment options include sclerotherapy, fibrin or cyanoacrylate injection, TIPS or balloon occluded retrograde transvenous obliteration (BRTO). BRTO, used for primary or secondary prophylaxis in patients with GRS or GCS, involves balloon occlusion of the outflow with retrograde injection of a sclerosant. While highly effective in preventing rebleeding, BRTO may cause adverse effects such as portal or renal thrombosis and pulmonary embolism, though it has lower rates of hepatic encephalopathy compared to TIPS. CARTO, a modification of BRTO, uses coils instead of balloons, reducing both procedure time and perforation risk. It is useful when shunt anatomy limits balloon access and offers comparable efficacy in bleeding control as seen in the study by Lee et al. CARTO is a safe, efficient alternative for managing GV.