Percutaneous Transhepatic Venous Embolization and Portal Vein Stenting for Ectopic Variceal Bleeding at Choledochojejunostomy After Pancreaticoduodenectomy With Portal Vein Stenosis: A Case Report.

Ectopic varices can result from portal vein stenosis following pancreaticoduodenectomy with concomitant portal vein resection reconstruction, and they can cause gastrointestinal bleeding. Although they can sometimes be fatal, various treatments have been reported. This report describes a case in which a percutaneous transhepatic approach was used to simultaneously perform variceal embolization and portal vein stenting in which a favorable outcome was achieved. The patient was a 77-year-old woman who had undergone subtotal stomach-preserving pancreaticoduodenectomy and portal vein combined resection and reconstruction for stage IIA pancreatic cancer. Although postoperative portal vein stenosis was observed, the patient was followed up because the collateral blood flow was well developed, maintaining intrahepatic blood flow. About 18 months after surgery, the day before a routine outpatient visit, she noticed melena, and a blood test performed at the time of the outpatient visit revealed anemia. An emergency contrast-enhanced computed tomography and an emergency enteroscopy revealed ectopic varices around the elevated jejunum at the choledochojejunostomy, and bleeding from the same site was suspected. Since the patient was suspected to be suffering from portal hypertension, we planned to embolize the varices for bleeding and to place a portal stent to treat portal hypertension. Since the patient had undergone mesh placement for an incisional hernia approximately one year postoperatively, a percutaneous transhepatic route was selected, and the patient was approached via the right portal vein route. The varices were embolized with coils and histoacrylate, and a stent was placed in the stenotic portal vein. The portal vein pressure was measured before and after the procedure to confirm its reduction, and the procedure was completed without complications. The patient was discharged from the hospital seven days after the procedure with no problems and is currently under outpatient follow-up with no varice recurrence. Although the optimal treatment for ectopic varices has not been established, portal vein stenting and variceal embolization via a percutaneous transhepatic approach were effective.