Introduction: Balloon-occluded retrograde transvenous obliteration (BRTO) is used in the treatment of gastric varices because of its effectiveness as a curative procedure, and its role in both emergency and prophylactic settings. It is of utmost importance that the treating physicians are aware of potential procedure-related complications including fever, chest or epigastric pain, hemoglobinuria, and transient hypertension among others. We present an unusual post-procedure complication resulting in coil migration, which was promptly recognized and successfully treated.

Case Report:

A 59-year-old gentleman with a history of alcohol-related chronic liver disease (Child A6) was seen in our clinic for further management. The patient was found to have fundal varices (IGV-1) at screening endoscopy, and he denied any history of liver decompensation or GI bleeding. MRI abdomen was performed on the patient and showed changes of chronic liver disease in hepatic parenchyma and gastro-renal collaterals with gastric fundal varices. The main portal, splenic, and hepatic veins were attenuated but appear patent. After discussing with the patient, he was referred to interventional radiology (IR) for Balloon occluded and coil-assisted Retrograde Transvenous Obliteration (BRTO). CT angiogram was performed for the patient and showed Gastric varices with a prominent reno-gastric shunt measuring 15 mm in maximum diameter, having a tortuous course along with the lesser of the stomach and coursing down to join the splenic vein.The patient underwent IR guided BRTO procedure by injecting the mixture of sodium tetradecyl sulfate, Lipiodol, and air into the shunt and varix. After occlusion of the varix was confirmed by CT scan, Interlock coils were used to occlude the shunt.Six hours post-procedure, the patient started having left-sided pleuritic chest pain and tachycardia but no desaturation. XR chest showed migration of the coils seen overlying the heart shadow. Urgent CT chest showed a Migrated coil in the distal left main pulmonary artery, extending into the left lower lobe pulmonary artery. Successful retrieval of the coils was done using intraluminal biliary biopsy forceps (COOK medical), 7 F x 60 cm, to grasp the part of the coil WITHIN the sheath not reaching the pulmonary artery with the forceps. Post-retrieval Angiogram showed good opacification of the left inferior pulmonary artery with no filling defects. On day three, the patient was discharged from the hospital without further complications and had an uneventful follow-up. Conclusion:BRTO remains a useful option for both emergency and prophylactic treatment of gastric varices. Patients need post-procedure monitoring, and prompt recognition of potential complications can result in timely institution of treatment and favorable outcomes.