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Acute esophageal variceal bleeding is a complication with high morbidity and mortality, causing 70% of upper gastrointestinal bleeding in patients with liver disease [1]. The first-line treatment of bleeding combines the use of vasoactive drug therapy, endoscopic band ligation, and prophylactic antibiotic administration, following initial hemodynamic resuscitation efforts [2]. Around 10%–20% of cases are refractory to conventional therapy, necessitating alternative therapies for hemorrhagic control [1]. Among the rescue therapies for variceal hemorrhage are the traditional use of balloon tamponade and transjugular intrahepatic portosystemic shunt (TIPS). The current use of a self-expanding metal stent (SEMS) has also been utilized as a new option for refractory bleeding [3]. We describe the case of a 52-year-old man with cirrhosis secondary to primary biliary cholangitis, who was admitted because of an episode of upper gastrointestinal hemorrhage 5 days after an elective variceal ligation session (▶Video 1). On endoscopic evaluation, massive bleeding was diagnosed (▶Fig. 1 a) and a Sengstaken–Blakemore balloon was placed. At review 12 hours later, a further endoscopy was performed for balloon removal. During balloon removal, active bleeding was observed (▶Fig. 1 b) and a covered esophageal SEMS (SX-ELLA Danis, Czech Republic) was placed. After stent placement, successful hemostasis was achieved (▶Fig. 1 c). After 5 days of stent placement, the patient underwent TIPS (▶Fig. 2), and no new episodes of bleeding were observed (▶Fig. 3). With a substantial patient population who fail to respond to conventional medical therapy and band ligation, a variety of E-Videos

A novel technique in the management of refractory variceal bleeding