We report a case of refractory gastric varices treated by multi-endovascular and endoscopic techniques. A 41-year-old man was hospitalized with recurrent hematemesis. Enhanced CT and MRI revealed gastric varices with G-R shunt and B-RTO was offered. However, G-R shunt was too large to be occluded. After failed B-RTO, we performed TIPS (transjugular intrahepatic portosystemic shunt) and embolization of the gastric coronary vein via the TIPS. However, recurrent hematemesis has occurred and the short gastric veins were considered to be the feeding vein to gastric varices, Additional PSE and repeated B-RTO after EIS were required to obtain complete thrombosis of gastric varices. We think that subsequent embolization of the ruptured varix should be performed, even if successful decompression of portal trunk is obtained by TIPS. Moreover, when short gastric veins is considered to be an inflow to gastric varices, the balloon occlusion of the splenic artery or PSE should be an additional alternative, which enabled B-RTO or DBOE by reducing the blood flow to varices.
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