Case Report: Unilateral absence of pulmonary artery and cavernous transformation of the portal vein: a 13-year follow-up after balloon-occluded retrograde transvenous obliteration

Background The concurrent presentation of unilateral absence of the pulmonary artery (UAPA) and cavernous transformation of the portal vein (CTPV) is rare. Whether this coexistence reflects a shared developmental anomaly or is coincidental remains uncertain. Managing portal hypertension and life-threatening variceal bleeding in such patients is highly challenging. Methods We report a 13-year follow-up of a 44-year-old patient with this composite vascular anomaly who presented with severe, recurrent gastric variceal bleeding. To achieve hemostasis and block a massive gastrorenal shunt, the patient underwent balloon-occluded retrograde transvenous obliteration (BRTO) via a transfemoral approach using a 12 mm × 40 mm occlusion balloon and 25 mL of lauromacrogol foam (5 mL 1% lauromacrogol plus 20 mL air; Tessari 1:4) with a 3-hour balloon dwell. Results The patient demonstrated excellent physiological tolerance to the endovascular intervention. Endoscopic surveillance over the subsequent 13-year period revealed that the gastric varices remained morphologically persistent. Despite this structural persistence, the patient had no documented clinically significant rebleeding and experienced no exacerbation of portal hypertension-related complications. Conclusions In this patient, durable clinical control was observed after BRTO despite the absence of documented complete long-term anatomical obliteration and persistent variceal morphology on endoscopy. However, this uncontrolled observation cannot establish that BRTO itself prevented rebleeding, particularly because the varices remained morphologically persistent and portal pressure was not measured. BRTO may therefore be associated with durable clinical control in selected patients; causality and the proposed long-term mechanisms remain unproven.