This document describes a case where a 58-year-old female presented with massive hematemesis due to gastric variceal bleeding from malignant splenic venous thrombosis. Imaging showed pancreatic cancer with portal vein thrombosis and splenic vein occlusion, leaving no traditional gastrorenal access route. The challenging bleed was successfully managed with an uncommon trans-splenic approach, where the catheter was negotiated into the splenic vein and gastric varices were embolized with glue, achieving immediate hemostasis. This novel procedure demonstrated a safe, feasible alternative for palliative care in difficult portal hypertension cases.

1. SUCCESSFUL MANAGEMENT OF MASSIVE UGI BLEED BY TRANSSPLENIC VARICEAL
EMBOLISATION DUE TO MALIGNANT SPLENIC VENOUS THROMBOSIS
- A safe , feasible and effective alternate pathway for patients with challenging portal and
systemic venous route
Affiliation: NEIGRIHMS, Shillong , Meghalaya
Author – Dr. Shivangi Borah
Corresponding authors – Dr Akash Handique, Dr C.Daniala, Dr P.Phukan ,Dr D.Lynser Dr M.Sagar, Dr V.Joseph

2. Introduction
• Incidence of left sided /sinistral portal hypertension is extremely rare ( < 1
percent ).
• Novelty: To the best of our knowledge trans-splenic route for gastric variceal
embolisation in malignant splenic thrombosis has not been reported, hence we
are presenting this case of successful management of massive UGI bleed by the
above procedure in a known case of pancreatic malignancy.
• Challenge:
 Difficult access due to non-availability of traditional gastro-renal shunt access as
in the BRTO procedure
 Increased bleeding risks associated with trans-splenic procedures (track
embolization done)

3. CASE REPORT
• 58 yr/F presented with massive hematemesis
• Known case of pancreatic adenocarcinoma
with portal venous thrombosis and malignant
splenic vein occlusion
CASE SUMMARY
IMAGING
Figure 1: CECT abdomen showing pancreatic tail
hypoenhancing tail lesion, with a metastatic
anterior abdominal wall lesion

4. CECT ABDOMEN
Figure 2: CECT abdomen in a case of pancreatic tail
adenocarcinoma. A. showing encasement with
significant narrowing of the splenic vein ( ). B.
Perigastric collaterals along the greater curvature ( )
C. Gastric wall varices ( ). D. Splenomegaly with
gastro splenic collaterals.
A B
C D

5. Interventional procedural: Transsplenic embolization of gastric varices with
glue (3:1 lipiodol :NBCA )
Diagnostic Venography Glue embolization
Negotiation of catheter
into splenic vein by
direct splenic puncture
Splenic venogram showing
gastric collaterals and occlusion
of main splenic vein
Post embolization fluoroscopic
image with glue cast
Post procedure venography for
checking shows complete
embolization of gastric varices
• Immediate post procedure - mild hemoperitoneum
• Follow up for 5 months - No recurrent bleed.

6. SUMMARY
• Incidence of left sided portal hypertension rare
• No case has been reported about trans-splenic gastric variceal
embolization in malignant splenic thrombosis
• Although it is an uncommon procedure in a malignant pancreatic clinical
scenario, but through our case report and follow up we saw that it has
helped in providing palliative care thereby decreasing the morbidity .