Typical laboratory workup and clinical resuscitation is performed, and abnormalities are corrected as necessary. If splenic vein or portal vein stenosis or occlusion is absent, then we evaluate the CT for the presence of a gastrorenal or gastrocaval shunt. In addition, imaging may demonstrate portal venous occlusion or stenosis as the etiology of portal hypertension, in which case, treatment would be directed toward potentially correcting the portal venous obstruction and, if necessary, following with embolization or obliteration of the gastric varices. If this is unsuccessful, splenic reduction through particle embolization would be performed, as splenectomy is not typically desired given the potential morbidity and challenges of surgically negotiating extensive perisplenic collaterals. If technically feasible, we attempt splenic vein recanalization from a transhepatic or transplenic approach. 8 In some circumstances, gastric varices develop secondary to chronic splenic vein occlusion. Upon initial consultation, if not already available, we perform contrast-enhanced CT for delineation of the portal venous and shunt anatomy. In this article, we discuss our preprocedural approach and workup, procedural technique, possible complications/adverse effects, and utilization of alternative outflow occlusion techniques including coil-assisted and plug-assisted transvenous obliteration. Transvenous gastric variceal obliteration is advantageous in patients with elevated MELD scores and encephalopathy, who would otherwise be poor candidates for TIPS. 3-6 Adjunctive and alternative endovascular techniques to decompress gastric varices include transjugular intrahepatic portosystemic shunts (TIPS) and splenic reduction through particle embolization. 1,2 Balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices is now an established endovascular technique to directly treat bleeding vessels with high technical success rates and good clinical outcomes. Unlike esophageal variceal bleeding, gastric variceal bleeding is more difficult to control endoscopically due to size and high flow and may bleed at lower portosystemic pressure gradients. Medical and endoscopic refractory bleeding or hepatic encephalopathy are complications that may occur from enlargement of these portosystemic collaterals. Gastric varices may develop from portal hypertension or splenic vein occlusion, so-called left-sided portal hypertension.
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