Presentation
The patient presented with shortness of breath and desaturation immediately following gastric varix sclerotherapy.
Patient Data
Chest X-Ray shows multiple peri-hilar opacities following vascular structures and larger tubular opacities in the gastric region corresponding to the treated varices.
Axial and coronal non-contrast chest CT shows multiple hyperdense filling defects in the proximal and distal segments of the pulmonary arteries, in the right cardiac ventricle as well in the gastric region corresponding to the treated gastric varices.
There are also signs of chronic liver disease and portal hypertension.
Case Discussion
N-butyl-2-cyanoacrylate pulmonary embolism is a potentially life-threatening complication that can arise following endoscopic sclerotherapy for the treatment of variceal bleeding. It is usually due to the leakage into the portal venous system via the left gastric vein but there are also gastro-renal venous collaterals that enlarge due to the underlying portal hypertension allowing the spill of glue into the systemic venous circulation (thus entering the pulmonary artery branches via the right heart).
The size of the varicose vein, an important volume of injection, especially in the case of a large, high-flow varicose vein, and excess lipiodol (butyl-cyanoacrylate/lipiodol less than 5/8), have been described as risk factors for embolization 1.