Trans-splenic anterograde coil assisted transvenous occlusion (TACATO) of bleeding gastric varices associated with gastrorenal shunts in cirrhosis

Fundal gastric varices (GV) management in cirrhosis patients lacks consensus due to varied anatomy and hemodynamics. This study evaluates the safety and efficacy of trans-splenic anterograde coil-assisted transvenous occlusion (TACATO) for preventing recurrent bleeding in fundal GVs associated with gastro-renal shunt (GRS). In this four-year study, cirrhotic patients with GRS-associated GV bleeding were eligible for TACATO without prior esophageal variceal bleeding, ascites, or portal vein thrombosis. Trans-splenic access was achieved by puncturing a splenic venous branch using ultrasound/fluoroscopic guidance. A microcatheter was inserted into the varices for embolization with detachable microcoils and possibly N-butyl-cyanoacrylate-Lipiodol. Technical success was assessed by venography. All patients underwent follow-up endoscopy and decompensating events were recorded. A retrospective external control group of cirrhotic patients with similar GRS-associeted GVs treated by retrograde transvenous obliteration was enrolled as a comparative group. Twenty patients with cirrhosis underwent TACATO (17 GOV2, 6 IGV1 - median GRS size 23mm, range 15-32mm). Median occlusion of the shunt was 90% (complete in 14/20); complications included local abdominal pain and partial splanchnic thrombosis in 2 patients. Over a median follow-up of 23 months (range 10-31), no rebleeding or further decompensation occurred, liver function remained stable, and endoscopy showed reduced or resolved fundal GVs without worsening esophageal varices in all patients. The comparative group (18 patients – median GRS diameter 14mm, range 6-23mm) reported no rebleeding but had worsening varices in 2 and ascites progression in 2. TACATO is a viable secondary prophylaxis for bleeding from GVs associated with GRS, and may reduce hepatic decompensation risk. Further studies are needed to validate these results and determine TACATO's broader role in GV management. [Display omitted] •Management of fundal GV lacks consensus due to varied anatomy and hemodynamics.•TACATO matches efficacy of other radiological techniques.•Simplifies secondary prophylaxis for fundal GVs in cirrhosis.•Demonstrated to be safe and no worsening of portal hypertension was observed.•Suitable for diverse GVs anatomies and GRS sizes.•Transsplenic access granted an easy and safe access to the portal system and fundal GV.