Splenic artery proximal embolization after ectopic variceal bleeding: a case report on portal hypertension management

Introduction: Ectopic variceal bleeding is a rare but challenging event, often requiring multidisciplinary approach. Embolization of the splenic artery is an uncommon procedure for reducing portal hypertension, however, it is described as an alternative in clinical situations where there is a contraindication to transjugular intrahepatic portosystemic shunt (TIPS). Case Presentation: We report the clinical case of a 45-year-old male patient with a portal cavernoma secondary to alcohol-related chronic pancreatitis and dilated cardiomyopathy who presented to emergency department with melena. Upper endoscopy identified bulbar ectopic varices with bleeding stigmata. Cyanoacrylate injection treatment triggered high output hemorrhage, which was controlled after sclerosing agent injection. CT angiography revealed embolized glue in the hepatic hilum and periduodenal varices without active bleeding. The patient evolved favourably without rebleeding. Given high risk of recurrence, a multidisciplinary discussion with interventional radiology was undertaken. As the patient had contraindication to TIPS and portal revascularization, it was decided to perform proximal splenic embolization for portal hypertension control. The procedure had no complications and there were no further bleeding episodes at follow-up. Discussion/Conclusion: Although splenic artery embolization is a not so commonly used procedure for portal hypertension management, there is some growing evidence that it can be an useful and safe tool. This clinical case supports splenic artery proximal embolization in the particular setting of duodenal ectopic varices.