Adrenal Hemorrhage as a Complication of Plug-assisted Retrograde Transvenous Obliteration of Gastrorenal Shunt Managed by Adrenal Artery Embolization: A Case Report

Abstract

We describe a patient who underwent plug-assisted retrograde transvenous obliteration for gastric varices. After the procedure, the patient developed hypotension and tachycardia. Contrast-enhanced computed tomography showed a left adrenal hematoma. The patient was managed with left inferior adrenal artery embolization. We herein describe an unexpected complication during plug-assisted retrograde transvenous obliteration and the endovascular management by adrenal artery embolization. We speculate that inadvertent cannulation of an adrenal vein tributary and iatrogenic trauma thereafter caused by sheath advancement was a probable cause for this complication. Further increase in intra-adrenal pressure due to blockage of the adrenal vein outflow postplug deployment possibly led to the rupture of adrenal vein tributary and adrenal gland hematoma in our case.

Keywords: adrenal artery embolization; adrenal hemorrhage; chronic liver disease (CLD); plug-assisted retrograde transvenous obliteration (PARTO); portal hypertension.

Figure 1.

Fluoroscopic spot images showing important steps of Plug Assisted Retrograde Transvenous Obliteration (PARTO) - (a): Using a Cobra catheter, the left renal vein was accessed through femoral vein access. Using the support of the microcatheter, the main Cobra catheter was further advanced. Note the microcatheter inadvertently mistakenly entering and abutting the adrenal vein (white arrow). The previous gastric banding clips also seen (white arrowhead). The illustrated image of this step is shown below in Fig 1. e. (b): The long sheath was advanced over a Stiff Amplatz guidewire. Venography taken after sheath advancement shows contrast extravasation, likely due to adrenal venous ooze secondary to stiff wire manipulation and advancement of sheath through the narrow adrenal vein. (c): The sheath was re-positioned into the gastro-renal shunt. Fluoroscopy spot film also shows a pericardio-phrenic collateral efferent draining channel from the gastric varices (which were embolized with coils); see image Fig 1. d. (d): Embolization of the gastric varices with Sodium Tetradecyl Sulfate (STS): Lipiodol: air foam mixture (white arrow) using a 2.7 Fr Progreat micro-catheter (thin white arrow) advanced through the sheath tracked from the side of the vascular plug (black arrowhead). Note the micro coils (white arrowhead) used to embolize the pericardio-phrenic efferent draining channel shown in the previous image Fig 1. c. The vascular plug is placed at the narrowest portion of the shunt caudal to the entry of the adrenal vein. The corresponding illustration is shown in Fig 1. f. (e): Illustration showing the steps of procedure causing the complication. Mistaken entry of guidewire-sheath into the adrenal vein with careless manipulation causing iatrogenic adrenal vein injury. (f): Illustration showing the mechanism of adrenal haemorrhage. Post PARTO showing vascular plug, Sodium Tetradecyl Sulfate (STS) and micro-coil. Note the position of the vascular plug at the narrowest portion of the gastro-renal shunt caudal to the entry of the adrenal vein. Prior inadvertent adrenal vein damage is responsible for further increased adrenal pressure to outflow obstruction causing adrenal gland damage and resultant adrenal haemorrhage.

Figure 2.

Post PARTO contrast enhanced Computed Tomography (CECT) - (a): Axial images in the early contrast-enhanced phase show a large adrenal hematoma in left suprarenal location with suspicious active contrast extravasation (white arrow). Note the vascular plug (white arrowhead) with streak artefact, which was deployed during PARTO. (b): Axial scan in the late venous phase shows increase in density of the contrast (white arrow) confirming active haemorrhage. (c): Coronal reformatted image better shows the left adrenal hematoma with suspicious extravasation (white arrow). Note the Lipiodol: Sclerosant in the gastric varices (white arrowhead). (d): Coronal reformatted images confirm the increased density of contrast in the delayed phase confirming active haemorrhage.

Figure 3.

(a): Fluoroscopy spot image shows previously deployed vascular plug (white arrow). A venography taken from a Cobra catheter placed in the gastro-renal shunt at the deployed plug showed no contrast extravasation from the uncovered landing zone of the shunt. Note the filling of the paravertebral venous plexus (black arrowhead). The micro-coils (white arrowhead) deployed during PARTO and the gastric ligation bands (thin white arrow) are also seen. (b): A selective angiogram done via the right femoral arterial access shows active contrast extravasation (thick white arrow) from the left inferior adrenal artery (thin white arrows) arising from the left renal artery. (c): Super selective angiogram after selective cannulation of the left inferior adrenal artery (thin white arrows) using a microcatheter confirms active contrast extravasation (thick white arrows). Superselective cannulation of the branch of the left inferior adrenal artery responsible for extravasation was done followed by glue [Glue:Lipiodol ratio 1:1] embolization. (d): Post embolization angiogram shows a short residual stump of the left inferior adrenal artery (thin white arrow) and no active contrast extravasation. Note the normal left renal artery and renal nephrogram.

Figure 4.

Graphical depiction of plausible etiology of adrenal hemorrhage post Plug Assisted Transvenous Obliteration in our case - (a): Normal anatomy showing the relation of the left adrenal vein (LAV), left inferior phrenic vein (LIPV) and gastrorenal shunt. The left IPV terminates inferiorly into the left renal vein (LRV) often together with the LAV. The LIPV may have two orifices; one enters the inferior vena cava (IVC) or the hepatic vein via the sub-diaphragmatic transverse part of the LIPV under the left diaphragm, while the other enters the LRV via the vertical part of the LAV. The latter course may be an origin site for a gastro-renal shunt from gastric varices in patients with portal hypertension due to close embryological development of both the organs. (b): In portal hypertension, due to increased portal pressures porto-systemic shunts develop at the site where the where LIPV enters LRV via the vertical portion of the LIPV i.e. the gastro-renal shunt with afferent usually from the left gastric vein and efferent into the LRV. (c): In our case, iatrogenic injury from damage to the adrenal vein was noted due to inadvertent mistaken and careless advancement of the sheath into the narrow adrenal vein. (d): Previous iatrogenic adrenal vein trauma and further increased backpressure changes due to vascular plug placement at the narrowest portion of the gastro-renal shunt caudal to the entry of the adrenal vein resulted in adrenal gland trauma, gland rupture and haemorrhage ultimately leading to adrenal arterial injury.