D0320 - Recurrent Gastric Variceal Hemorrhage From Eroding Endovascular Coil

Michelle Baliss, DO, Tim Brotherton, MD, David Westrich, MD, Samuel Burton, MD, Laith Numan, MD, Zarir Ahmed, DO, Soumojit Ghosh, MD, Justin Lendermon, MD, Ali Malik, MD, Kamran Qureshi, MD
Saint Louis University, St. Louis, MO

Introduction: Coil and Plug-assisted transvenous obliteration of gastric varices is a variation of balloon-occluded retrograde transvenous obliteration (BRTO) that alleviates the complications related to prolonged indwelling balloon time and the use of sclerosing agents. Few cases of coil migration have been reported in the literature, but the overall incidence remains unknown. We report a case of recurrent gastric variceal hemorrhage from erosion of an endovascular coil after coil and plug-assisted variceal obliteration.

Case Description/Methods: A 32-year-old female with alcoholic cirrhosis as well as portal and splenic vein thrombus presented with hematemesis, hemodynamic instability and Hgb of 5. She underwent EGD that showed small non-bleeding esophageal varices and large gastric varices with stigmata of recent bleeding. Given unfavorable anatomy for TIPS, she underwent transhepatic coil and plug assisted obliteration of multiple gastric varices and angioplasty of partially thrombosed portal and splenic veins. She remained asymptomatic on follow-up with improved liver function and recanalized portal and splenic veins on CTA. However, four months later, she was readmitted for hematemesis following a large meal. EGD showed a large amount of clotted blot in the stomach (Fig 1A) and cardiofundal varices with protruding coils and minimal active oozing from the varices above the coils (Fig 1B). She underwent plug assisted retrograde obliteration (PARTO) through gastrorenal shunt. She remained stable and was discharged with plans for possible TIPS in the future.

Discussion: Optimal management of gastric variceal hemorrhage often requires a multidisciplinary approach. BRTO is a well-accepted procedure for the treatment of isolated gastric varices associated with large gastrorenal shunts. BRTO involves the prolonged use of a balloon catheter and retrograde injection of sclerosing agents via the shunt outflow. BRTO has been associated with life-threatening complications such as pulmonary embolism, portal vein thrombosis, and anaphylaxis. As such, the use of vascular plugs or coils to achieve variceal occlusion has become popular owing to their safety, decreased procedure times and comparable efficacy. Attempts should be made to deploy coils proximally away from the mucosa, to avoid erosion through the thin walls of varices and overlying mucosa. This case highlights a rare but important complication of coil-assisted variceal obliteration.



Disclosures:


Michelle Baliss, DO, Tim Brotherton, MD, David Westrich, MD, Samuel Burton, MD, Laith Numan, MD, Zarir Ahmed, DO, Soumojit Ghosh, MD, Justin Lendermon, MD, Ali Malik, MD, Kamran Qureshi, MD. D0320 - Recurrent Gastric Variceal Hemorrhage From Eroding Endovascular Coil, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.