Long-term outcome of percutaneous transhepatic venous embolization for ectopic peristomal variceal bleeding

Rationale: Bleeding from ectopic varices secondary to portal hypertension represents a significant therapeutic challenge due to the absence of standardized management protocols. Patient concerns: This case report details the long-term management and follow-up of a rare and challenging case of recurrent hematuria caused by bleeding from ectopic peristomal varices secondary to portal hypertension in a patient with an ileal neobladder. Diagnoses: Hematuria secondary to ectopic peristomal varices of an ileal neobladder associated with portal hypertension. Interventions: The patient underwent 2 sessions of percutaneous transhepatic obliteration (PTO) (in April 2018 and February 2022) for active variceal bleeding. Outcomes: After the initial PTO, hematuria resolved immediately, and a follow-up computed tomography at 3 months confirmed complete occlusion of the variceal complex. Recurrent hematuria occurred at 16 and 20 months post-procedure; imaging demonstrated recanalization attributable to persistent portal hypertension rather than technical failure of the initial embolization. A second PTO in February 2022 again achieved complete control of bleeding. No further hematuria occurred after the second PTO, for a recurrence-free interval of approximately 3 years and 10 months (February 2022 to December 2025), approximately 7 years and 8 months after the initial procedure. The most recent computed tomography revealed only minimal, nonprogressive residual peristomal varices without active bleeding. Lessons: PTO may provide immediate hemostasis and durable symptom control in selected patients with ectopic peristomal variceal bleeding; however, because embolization does not treat the underlying portal hypertension, recurrence remains possible, necessitating structured long-term surveillance and readiness for repeat intervention or portal pressure–reducing therapy. This case, with 7-year follow-up, illustrates the feasibility and long-term outcomes of repeated PTO for ectopic variceal bleeding at a complex anatomical site.