A 79-year-old man was admitted to our hospital for treatment of intractable GV due to liver cirrhosis prior to surgery for hepatocellular carcinoma (HCC). Endoscopic sclerotherapy was performed 4 years previously, but GV were worsening. Based on endoscopic finding, the classification of GV was F3, Lg-CF, and white (Cw). The Child-Pugh score was 6 (class A). Laboratory data showed: platelets, 120,000/μl; prothrombin-international normalized ratio, 1.12; creatinine, 1.18 mg/dl. Angio-computed tomography (CT) was performed prior to treatment to evaluate the hemodynamics of GV and work up for HCC. CT during arterial portography (CTAP) was performed via the superior mesenteric artery, and the scanning was started 25 s after the infusion of 50 ml of iohexol (350mgI/ml) at a rate of 1.8 ml/sec was started. From CTAP, GV were revealed to drain mainly into the left inferior phrenic vein, and the gastrorenal shunt was absent. The main feeding vessels of GV were the posterior and short gastric vein. The left internal thoracic vein, pericardial phrenic vein, and left inferior pulmonary vein were observed to be collateral veins (Fig. 1). We initially planned BRTO from the left inferior phrenic vein. Single right femoral venous access was achieved and the guidewire (0.032 or 0.035 in., Radifocus, Terumo, Tokyo, Japan) was introduced into the inferior phrenic vein. However, mild stenosis between the inferior vena cava (IVC) and inferior phrenic vein, and the shunt angle, prevented introduction of the 6 Fr balloon catheter (Selecon MP Catheter II, Terumo, Tokyo, Japan). Therefore, CARTO was planned and attempted from the same single route.
A 7 Fr Flexor Ansel guiding sheath (Cook Medical, Bloomington, IN, USA) was placed in the IVC before the stenosis site, using 0.035 in. guidewire and 4 Fr non tapered angle catheter (Terumo, Tokyo, Japan). The left inferior phrenic vein was successfully accessed using 4 Fr catheter and 2.9 Fr steerable microcatheter (LEONIS Mova; Sumitomo Bakelite, Tokyo, Japan). The steerable microcatheter was passed through the shunt route without creating an angle. Digital subtraction venography (DSV) was performed to assess and confirm GV. We planned to place the coil behind the left inferior pulmonary vein. The steerable catheter was inverted from distal to the coil embolization site (Fig. 2a). Appropriately sized detachable coils (Target XL and XXL, Stryker:16, AZUL CX18, Terumo:1) were deployed using a 1.9 Fr micro catheter (Carnelian MARVEL; Tokai Medical Products, Aichi, Japan) through the inverted steerable catheter. Complete coil occlusion of the outflow shunt was confirmed, and the inferior phrenic vein was not visualized (Fig. 2b). Next, after moving the tip of microcatheter to the varices, 5% ethanolamine oleate with iopamidol (EOI, total 24 ml) was injected gradually through the microcatheter to embolize up to the coil in the outflow shunt, varices, and other minor collaterals (Fig. 2c). After waiting sufficiently after each embolization, we confirmed stagnation of the EOI and removed the system. One week after the procedure, contrast-enhanced CT was performed, which confirmed complete occlusion of GV (Fig. 2d). No complications were encountered.