Fig. 1. 68-year-old woman with nonalcoholic steatohepatitis cirrhosis and recurrent gastric variceal bleeding.

A. Balloon-occluded venogram of gastro-renal shunt shows contrast filling of gastric varices (arrows) along with draining inferior phrenic collateral vein (open arrow). B. Inferior phrenic vein was embolized with microcoils (open arrow). This was followed by injection of sodium tetradecyl sulfate (Sotradecol; AngioDynamics) mixed with Lipiodol into gastric varices (arrows). C. It was not possible to leave occlusion balloon and sheath due to common femoral artery injury while obtaining femoral venous access. Therefore, gastrorenal shunt was embolized with multiple coils (open arrow) to retain sclerosant (arrows) in gastric varices before balloon was deflated and sheath was removed. D. Patient presented with hematemesis two days following procedure. TIPS was performed due to presumed gastric variceal bleeding. Venogram after TIPS placement showed no gastric varix filling from afferent veins and dense Lipiodol uptake (arrows) in gastric varices. Portosystemic gradient decreased from 15 mm Hg to 5 mm Hg. TIPS = transjugular intrahepatic portosystemic shunts