The management of a 58-year-old man with post-hepatitis C advanced cirrhosis, mild ascites and massive haematemesis come to the emergency department of our hospital is referred. The patient presented in our emergency department with massive haematemesis, hypotension (blood pressure 90/60 mmHg), tachycardia (110 beats per minute) and anaemia (haemoglobin level 9 mg/dL). Haemodynamic instability of the patient was treated by blood transfusions and by Blakemore tube placement in the stomach. An emergency contrast-enhanced computed tomography (CT) showed large gastroesophageal varices and an occluded TIPS (Fig. 1a) placed 3 years ago at another hospital. A TIPS recanalisation with gastroesophageal varices embolisation was planned in emergency setting. The hemodynamically stabilised patient signed a specific institutional procedure-related consent form that covers retrospective observational studies. The procedure was performed by an experienced (> 20 years) interventional radiologist (M.V.) during patient conscious sedation.
After the placement of a 7-F introducer in the right jugular vein, the occluded TIPS was crossed using a 0.035-in. hydrophilic guidewire (Terumo, Tokyo, Japan) and a 4-F Headhunter catheter (Cordis, Miami Lakes, FL, USA). Portal pressure was 36 mmHg. The preliminary portography showed large gastroesophageal varices (Fig. 1b). First gastric varices (Fig. 1c), then oesophageal varices (Fig. 1d) were catheterised with a coaxial microcatheter (1.9 Carnelian, Tokai, Sarayashiki Taraga Kasugay City, Japan) and progressively embolised with detachable coils (18–20-mm diameter, 30–50-cm length; Interlock, Boston Scientific Corporation, Marlborough, MA, USA) and an (EVOH) copolymer agent (Squid-Peri 34, Emboflu, Gland, Switzerland). EVOH liquid embolic agent was shacked for 15–20 min and, before administration, the microcatheter dead space was filled with DMSO. Squid was then slowly injected to minimise DMSO-related pain due to its endothelial toxicity, progressively retracting the microcatheter to avoid its entrapment. No pain was recorded during Squid administration. After gastroesophageal varices embolisation, a self-expandable bare metal stent (12 mm diameter, 8 cm length; Wallstent, Boston Scientific Corporation, Marlborough, MA, USA) was overlapped to the previous stent and finally a balloon-angioplasty (10 mm diameter, 4 cm length, 18 atm insufflation pressure) of the whole TIPS was performed (Fig. 1e). Portal pressure at the end of the procedure was 24 mmHg. The final portography showed a quick opacification of the TIPS and the right atrium without gastroesophageal varices evidence, as good function of the portosystemic shunt (Fig. 1f). Contrast material administered during the procedure was about 60 mL of Iopromide (Ultravist 370, Bayer HealthCare, Berlin, Germany). After the procedure, clinical stabilisation of the patient was achieved, blood transfusions were suspended and Blakemore tube was removed. At discharge 6 days after the procedure, haemoglobin level was 11.4 mg/dL. No rebleeding episodes were recorded during 6 months of follow-up. Colour Doppler ultrasound at 24 h and at 1 and 6 months confirmed the TIPS patency.