Ectopic varices: Hidden challenges in the vascular anatomy.

A 50 yo female with PSC and a bleeding duodenal varix (DV) was evaluated for possible enbucrilate therapy. Endoscopically (Figure 1), the DV was high risk for rebleeding but the relative in-flow and out-flow were uncertain. CT (Figure 2) showed portal vein thrombosis (PVT) and the vascular anatomy of the DV to consist of inflow from the superior mesenteric vein (SMV) with outflow through the DV and the right gonadal vein. Moreover, the more distal and narrower aspect of the varix was seen to constitute the constricted outflow of the varix rather than a small caliber inflow channel. Endoscopic enbucrilate was deemed to carry high risk of varix rupture or mesenteric venous occlusion and bowel ischemia. An angiographic approach was elected to open the portal outflow through a TIPs and once outflow was established to embolize the duodenal varix internally through balloon occluded antegrade transvenous obliteration (BATO).1 Angiography confirmed that splenic and mesenteric in flow was directed to the duodenal varix (Figure 3, arrow A) in a superior to inferior direction with ‘downward’ outflow through the gonadal vein (Figure 3, arrow B). Once the TIPS was established to provide a low resistance pathway, the outflow track to the The Official Journal of the Mexican Association of Hepatology, the Latin-American Association for Study of the Liver and the Canadian Association for the Study of the Liver