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A case of high-risk giant esophagogastric varices was treated by blood supply route-targeted endoscopic injection sclerotherapy with multiple ligations (EISML). An endoscope was inserted in the left lower semi-lateral position under general anesthesia in the digital subtraction angiography room. The C-arm was rotated to obtain a frontal view for fluoroscopy. Before puncturing the esophageal varices, the balloon attached to the tip of the endoscope was inflated to block the variceal blood flow. At puncture, an intravascular injection was confirmed fluoroscopically, and a total of 18 m of 5% ethanolamine oleate with iopamidol was injected retrogradely at 5-minute intervals from the esophagogastric varices to the root of the left gastric vein, maintaining stagnation for 25 minutes. The variceal site of the injection was ligated immediately after the removal of the needle to prevent variceal bleeding. Multiple variceal ligations were added to stop the variceal blood flow. Contrast-enhanced CT 3 days after EISML showed the thrombus formation in esophagogastric varices and the left gastric vein. The blood supply route-targeted EISML can be a feasible procedure for giant esophagogastric varices.

We report a case of life-threatening bleeding from gastric varices in a patient with alcoholic cirrhosis, which was treated by emergency transileocolic vein obliteration (TIO). A 46-year-old male with a massive hematemesis was transported to our hospital by ambulance. Contrast-enhanced computed tomography demonstrated large gastric varices. Temporary hemostasis using balloon tamponade was attempted, however, bleeding could not be controlled, and his vital signs were unstable despite massive blood transfusions. First, endoscopic treatment was attempted, but the visual field could not be secured due to massive bleeding. Therefore, emergency TIO under general anesthesia was attempted. After laparotomy, 5 Fr. sheath was inserted into the ileocolic vein. Posterior and left gastric veins, which were the blood supply routes of gastric varices, were identified and embolized using microcoils and a 50% glucose solution. Hemostasis was achieved and vital signs recovered. Three days after TIO, transjugular retrograde obliteration was attempted successfully to embolize the residual gastric varices. After the procedures, his condition improved. We conclude that emergency TIO is a useful rescue option for life-threatening bleeding from gastric varices if endoscopic treatment or balloon tamponade is ineffective.

We report a case of life-threatening bleeding after endoscopic variceal ligation (EVL) in a patient with severe esophagogastric varices that was treated by percutaneous transhepatic obliteration (PTO). 3D-CT reconstruction image demonstrated giant esophagogastric varices and gastrorenal shunt. The spleen volume was 813 mL, and the liver volume was 716 mL; giving a spleen/liver volume ratio of 1.1. A strategy of stepwise partial splenic artery embolization (PSE) was employed to control portal venous pressure based on the concept of splanchnic caput Medusae. The S/L ratio improved to 0.3 by stepwise PSE. Subsequently, EVL was performed for esophageal varices, but bleeding occurred afterward, and hemostasis using a Sengstaken-Blakemore tube was attempted. Subsequently, PTO was performed the following day for embolization of the left gastric vein. Gastric varices and gastrorenal shunt were intentionally reserved to avoid portal venous pressure increase. After the procedure, his condition improved. We conclude, in patients with severe esophagogastric varices, prudent management of the splenomegaly and the collateral tracts is necessary.

Management of hepatic venous pressure gradient (HVPG) is important in the treatment of portal hypertension. We report a case that was treated by a hybrid procedure combining endoscopic injection sclerotherapy with ligation (EISL), left gastric artery embolization (LGE), and partial splenic artery embolization (PSE) based on a new concept ``splanchnic caput Medusae.'' The venous phase of left gastric arteriography just after EISL demonstrated thrombus formation in the gastric varices and the cardiac branch of the left gastric vein. The para-esophageal vein and lesser curvature branch of the left gastric vein were not affected. HVPG decreased from 14 to 11 mmHg immediately after LGE and PSE. 3D-CT reconstruction portal image revealed that the portal system reversed to almost normal form. This is the first case report in which thrombus formation in gastric varices and cardiac branch just after EISL could be demonstrated by the venous phase of left gastric arteriography.