Migration to the pulmonary artery of nine metallic coils placed in the internal iliac vein for treatment of giant rectal varices
A 64-year-old man with liver cirrhosis, advanced hepatocellular carcinoma (HCC) that invaded the main portal vein, and adrenal metastasis was admitted for the treatment of giant rectal varices due to portal hypertension. During the preceding 6 years he had undergone partial hepatectomy, six sessions of transcatheter arterial chemoembolization, and radiation therapy (39 Gy) for his HCC. He had no history of melena.\nOn admission, his functional reserve of the liver was Child-Pugh grade B. Colonoscopy showed huge tortuous rectal varices. Contrast-enhanced computed tomography (CT) revealed giant varices with tori inside the rectal lumen (Fig. a). Flow from the dilated inferior mesenteric vein was into the rectal varices that drained primarily into the left internal iliac vein. On inspiratory CT the diameter of the inferior mesenteric vein and left internal iliac vein was 10 mm.\nAfter obtaining informed consent from the patient and his family we attempted interventional therapy to prevent rupture of the varices. The plan was to fill the varices with a sclerotic agent via the IVM using balloon assistance. As tumor thrombosis into a main portal vein ruled out the percutaneous transhepatic approach we chose an ileocolic vein approach after laparotomy under general anesthesia. Portal venography via the superior mesenteric vein (SMV) confirmed that the rectal varices were supplied by the inferior mesenteric vein and mainly drained into the left internal iliac vein (Fig. b–d). Inflation of a 6-Fr balloon catheter (Selecon MP Catheter, Terumo Clinical Supply, Gifu, Japan) with a 2-cm diameter balloon in the inferior mesenteric vein failed to produce congestion in the varices. Consequently, we inflated a 6-Fr balloon catheter placed in the main trunk of the left internal iliac vein via the right common iliac vein (CIV) to block the in- and outflow of the rectal varices. However, we could not obtain congestion in the varices and contrast material in the varices drained into the collateral circulation of the left and right internal iliac vein. Thinking that flow in the rectal varices could be reduced by balloon occlusion of the left common iliac vein after coil embolization of the left internal iliac vein, we embolized the main trunk of the left internal iliac vein with nine microcoils. A 3-Fr microcatheter (Renegade, Boston Scientific, Natick, MA, USA) was advanced through the inflated 6-Fr balloon catheter placed into the orifice of the left internal iliac vein to prevent coil migration. First, one interlocking detachable microcoil (diameter 12 mm, length 30 mm) (InterlockTM, Boston Scientific, Cork, Ireland) was introduced as an anchor coil. Then we intertwined six pushable microcoils (diameter 8 mm, length 14 cm) (Micronester, Cook, Bloomington, IN, USA) with the anchor coil. Lastly two InterlockTM coils (diameter 10 mm and 12 mm, length 30 cm) was placed to hold the other seven coils and to obtain embolization.\nPostprocedure portal venography obtained under double balloon inflation in the inferior mesenteric vein and left common iliac vein revealed flow reduction in the rectal varices. However, as drainage via collateral vessels in the pelvis persisted 5 mL of absolute ethanol and 40 mL of a glucose solution were injected via the inflated balloon catheter in the IMV to embolize these drainers. This also failed to obtain complete congestion in the varices. As filling the rectal varices with a sclerotic agent was difficult under the existing conditions we attempted to embolize the varices with liquid glue. A 3-Fr microcatheter was advanced through the inflated balloon catheter in the internal mesenteric vein into the left superior rectal vein as close as possible to the rectal varices. Then 5.5 mL of a 1:10 mixture of N-butyl cyanoacrylate (NBCA) (Histoacryl, Aesculap, Tuttlingen, Germany) – lipiodol (André Guerbet, Aulnay-sous-Bois, France) was injected via the microcatheter under inflation of the balloons in the IMV and left CIV. As portal venography revealed that the right superior rectal vein flowed into residual rectal varices we injected 40 mL of 50% glucose and 12.5 mL of 5% ethanolamine oleate (Oldamin, Takeda Pharmaceutical, Osaka, Japan) with iopamidol (Iopamiron 300, Bayer HealthCare, Osaka, Japan) as a sclerotic agent through the microcatheter in the right superior rectal vein. Then eight pushable microcoils (diameter 8 mm) (Micronester) were placed in the internal mesenteric vein under double balloon inflation. As portal venography confirmed the complete obliteration of the rectal varices we removed the catheters (Fig. e, f). A plain radiograph obtained 30 min later confirmed that the coils remained in the left internal iliac vein. Throughout these procedures the patient's condition was stable and he was under continuous observation by anesthesiologists.\nDuring extubation the patient suffered a paroxysm of coughing and immediately after extubation he developed dyspnea and shivering. His partial pressure of arterial oxygen and percutaneous oxygen saturation slightly fell to 87 mmHg and 95% under oxygen inhalation of 5 L/min. Under continuous oxygen inhalation his symptoms abated somewhat and he was placed under observation with oxygen inhalation.\nOn the first postoperative day his dyspnea disappeared and the percutaneous oxygen saturation was 98% in room air. There were no respiratory symptoms. Although the liver function deteriorated transiently he developed no acute complications. A CT study performed on the fifth postoperative day confirmed complete obliteration of the rectal varices (Fig. a). However, all nine metallic coils placed in the left internal iliac vein had migrated into a lower branch of the right pulmonary artery (Fig. b and c). As this elicited no respiratory symptoms and as we considered the removal of the coils by interventional procedures inadvisable at that time, he was discharged 10 days after undergoing the procedures.\nHe subsequently received hepatic arterial infusion chemotherapy for HCC and endoscopic treatment for aggravated esophageal varices. Although colonoscopy showed shrinkage of the rectal varices, CT obtained 3 months later revealed progression of his intrahepatic HCC, enlargement of the adrenal metastasis, and newly developed lung metastasis. He died of HCC 5 months after the obliteration of the rectal varices.