Acute colonic variceal bleeding treated with coil-assisted retrograde transvenous obliteration following atezolizumab–bevacizumab therapy for advanced hepatocellular carcinoma

RATIONALE: Colonic variceal bleeding is a rare but potentially life-threatening manifestation of portal hypertension. Bevacizumab therapy is associated with an increased risk of variceal bleeding, but bleeding from ectopic varices is less well recognized. PATIENT CONCERNS: A 66-year-old man with alcohol-related cirrhosis and advanced hepatocellular carcinoma developed hematochezia on the day following the initiation of atezolizumab plus bevacizumab therapy. DIAGNOSES: Acute ascending colonic variceal bleeding in the setting of portal hypertension and portal vein thrombosis. INTERVENTIONS: Coil-assisted retrograde transvenous obliteration (CARTO) was performed via the right common femoral vein. The portocolonic shunt was embolized using detachable coils and gelfoam slurry. OUTCOMES: Hematochezia ceased immediately after the procedure, and the patient remained hemodynamically stable without further transfusion. Follow-up computed tomography confirmed successful embolization of the variceal complex without residual shunt. LESSONS: CARTO may be an effective treatment option for colonic variceal bleeding, particularly in patients with portal vein thrombosis or complex portosystemic shunts. Clinicians should remain aware of the potential for bleeding from ectopic varices in patients receiving bevacizumab-based therapy.