Off-label plug-assisted retrograde transvenous obliteration of a giant gastrorenal shunt: A report of two cases

Abstract

Plug-assisted retrograde transvenous obliteration has been recognized as a safe and effective treatment modality for patients with gastric variceal bleeding. The hallmark of this technique is to block the gastrorenal shunt (GRS) using an Amplatzer Vascular Plug, followed by infusion of gelatin sponge particles to completely occlude the varices. To ensure shunt occlusion and avoid device migration, the plug must be oversized by at least 20% compared to the shunt diameter. However, the maximal diameter of the commercially available plug is 22 mm, making the procedure technically infeasible for GRSs ≥ 18 mm. We report two challenging cases of recurrent gastric variceal bleeding due to liver cirrhosis and portal hypertension. Both patients had a giant and tortuous GRS with multiple dilated segments separated by waists. The transverse diameters of the GRSs were 24-30 mm and 23-32 mm, and the proximal waist diameters were 14 mm and 16 mm, respectively. Both GRSs were successfully embolized with 22-mm plugs. No bleeding recurrence was documented during 24 months.

Keywords

• embolization
• therapeutic; gastrointestinal hemorrhage; liver cirrhosis; portasystemic shunt
• surgical