Percutaneous transhepatic obliteration for life-threatening bleeding after endoscopic variceal ligation in a patient with severe esophagogastric varices

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.