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. 2023 Oct;16(5):668-672.
doi: 10.1007/s12328-023-01830-w. Epub 2023 Jul 15.

Combination of transjugular intrahepatic portosystemic shunt and antegrade through-the-TIPS coil embolization for bleeding mixed-type ectopic ileal varices

Andrea Michielan  1 , Filippo Vieceli  1 , Cecilia Pravadelli  1 , Luisa Moser  1 , Flora Agugiaro  1 , Giacomo Luppi  2 , Francesco Lorenzo Gatti  2 , Lorenzo Costa  2 , Umberto Maria Rozzanigo  3   4
Affiliations

Combination of transjugular intrahepatic portosystemic shunt and antegrade through-the-TIPS coil embolization for bleeding mixed-type ectopic ileal varices

Andrea Michielan et al. Clin J Gastroenterol. 2023 Oct.

Abstract

A 61-year-old man with alcoholic cirrhosis and a history of severe cholecystitis leading to secondary thrombosis of the recanalized paraumbilical vein was admitted to our hospital for recurrent gastrointestinal bleeding and severe anemia. Capsule endoscopy and CT angiography detected profuse bleeding in the proximal ileum from ectopic ileal varices. Hepatic venous-portal gradient (HVPG) measurement was consistent with severe portal hypertension. Persistent bleeding despite transjugular intrahepatic portosystemic shunt (TIPS) placement required a combined approach with antegrade through-the-TIPS coil embolization of the ileal varices.

Keywords: Ectopic varices; Embolization; Portal hypertension; TIPS; Venous interventions.

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Conflict of interest statement

The authors declare no conflicts of interest in association with this study.

Figures

Fig. 1
Fig. 1
Capsule endoscopy showing active bleeding in the ileum
Fig. 2
Fig. 2
A–B Venous phase CT scan at the level of the portal vein bifurcation A shows cirrhotic liver with the fibrotic remnant of the umbilical vein (black arrow) in the falciform ligament after thrombosis due to cholecystitis; splenomegaly due to portal hypertension is clearly visible. Venous phase CT scan of the paraumbilical region B depicts engorged branches of the superior mesenteric vein in connection with submucosal varices protruding into the lumen of the proximal ileum (white arrow); enlarged right epigastric veins (white arrowhead) are also demonstrated in the anterior abdominal wall
Fig. 3
Fig. 3
Portography performed with the tip of the guiding catheter (white arrow) positioned through-the-TIPS, after dilatation of the stent up to 6 mm
Fig. 4
Fig. 4
A–B Phlebography of the superior mesenteric vein (white arrow, indicating also the direction of flow) shows persistent reflux into the ileal varices (A), draining through the inferior epigastric veins (black arrowhead) into the right external iliac vein (white arrowhead). After embolization with multiples coils of the ileal varices (B), the injection of contrast medium into the superior mesenteric vein demonstrates absent opacification of the pathological portosystemic shunt through the right inferior epigastric veins
See this image and copyright information in PMC

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