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hospital with tarry stool as his chief com− plaint. He had been suffering from liver cirrhosis (type C) and had a clinical his− tory of receiving treatment for hepatocel− lular carcinoma. Emergency upper endo− scopic examination revealed gastric fun− dal varices with an erosion, in which a red spot was observed (l" Fig. 1) [1]. There were no other lesions which would result in tarry stool, including the esoph− ageal varices. We therefore concluded that this red spot had caused gastric vari− ceal hemorrhage. We performed a com− bined balloon−occluded retrograde trans− venous obliteration (BRTO) procedure and percutaneous transhepatic oblitera− tion (PTO) [2]. Percutaneous transhepatic portographic images showed that the af− ferent vein of the gastric varices consisted mainly of the posterior gastric vein (l" Fig. 2 a) and short gastric vein (l" Fig. 2 b), and that the efferent vein was the gastrorenal shunt [3]. Some microcoils were placed in the short gas− tric vein [4]. An occlusive balloon cathe− ter was inserted through the gastrorenal shunt. The sclerosing agent used for BRTO was slowly infused through the posterior gastric vein in a antegrade man− ner [2]. In addition, some microcoils were also placed in the posterior gastric vein. Follow−up endoscopic examination after 10 days showed that the microcoil was exposed in the gastric erosion, and con− trast−enhanced abdominal computed to− mographic images revealed no enhance− ment of the gastric varices. We therefore concluded that the gastric varices were completely thrombosed (l" Fig. 3). Fol− low−up endoscopic examination after 2 months showed disappearance of the gastric varices (l" Fig. 4). Although endoscopic treatment options for gastric variceal hemorrhage, such as the injection of cyanoacrylate−based tis− sue adhesives, alcohol, sclerosants, and the use of band ligation, have been stud− ied, the efficacy or superiority of one ther− apy over another remains controversial [5]. However, combined BRTO and PTO therapy can obstruct both the feeding and the draining veins of gastric varices, and we suggest that this method can be more effective than the alternatives [2]. In addition, exposure of the microcoil in gastric varices is rare, but is one of the signs of thrombus formation in gastric varices.

Gastric fundal varices with an exposed microcoil after the combined BRTO and PTO therapy