Coil-Assisted Retrograde Transvenous Obliteration (CARTO) for the Treatment of Gastric Variceal Bleeding in a Patient with a Gastrorenal Shunt: A Case Report

Abstract

Background 
 Portal hypertension (pHTN) is primarily caused by liver cirrhosis, which can lead to varices at portosystemic anastomoses.1,2 Gastric variceal bleeding (GVB) is rare but can be life-threatening with a mortality up to 50% for each bleeding episode. When endoscopic banding is ineffective and TIPS placement is contra-indicated due to risk of post-TIPS encephalopathy, coil-assisted retrograde transvenous obliteration (CARTO), which has shown great success in some studies, can be an effective treatment.5,8,9,10 This case demonstrates successful use of CARTO to treat GVB in a patient with a gastrorenal shunt (GRS) who presented with pHTN. 
 
 Case Overview 
 A 62-year-old female with cirrhosis due to nonalcoholic steatohepatitis (NASH) presented with pHTN and GVB. The patient had a massive GRS, which permitted access through the systemic venous circulation to treat the bleeding varices. Furthermore, the patient had hepatic encephalopathy (HE), making TIPS placement a poor choice due to risk of HE exacerbation. CARTO was performed to treat the bleeding varices and had the added benefit of decreasing risk of HE. 
 
 Discussion/Results 
 This case highlights CARTO in a patient with a 22mm GRS using a dual catheter system. Eighteen detachable 035 coils were first deployed in the GRS, followed by complete occlusion with a Gelfoam slurry to obliterate the gastric varices. Studies have described CARTO, all of which have shown incredibly high technical (complete embolization by angiography and/or CT) and clinical (no variceal rebleeding) success rates. This patient returned for follow-up CT and endoscopic imaging, which confirmed technically and clinically successful CARTO. 
 
 Conclusion and Potential Impact 
 CARTO appears to be a safe alternative to TIPS when treating GVB caused by pHTN, especially in patients who have HE and a GRS. Thus, CARTO should be discussed as a treatment option for these patients. Although portal pressure increases post-CARTO, the improvement of HE can lead to an improved safety profile with future TIPS.