Ectopic Variceal Hemorrhage in the Lower GI Tract: Endovascular Management and Imaging Review

Monday, March 31, 2025

5:20 PM – 5:25 PM CT

Location: Music City Center, 202 A

Abstract Presenter(s)

Kevin J. Curley, DO (he/him/his)

Interventional Radiology Resident
University of Arizona College of Medicine - Phoenix, United States

Author/Co-author(s)

LO

Liam M. O'Neill, MD

Interventional Radiology Resident
University of Arizona College of Medicine - Phoenix, United States
SC

Steve Chen, MD

Associate Clinical Professor - University of Arizona
Vascular & Interventional Partners, United States
NM

Nikhil Mehta, MD

Assistant Clinical Professor - University of Arizona
Vascular & Interventional Partners, United States
KH

Kevin Hirsch, MD

Clinical Professor of Radiology - University of Arizona
Vascular and Interventional Partners, United States
DL

Douglas Lewis, MD

Assistant Clinical Professor - University of Arizona
Vascular & Interventional Partners, United States
CG

Christopher Goettl, MD, MBA

Associate Clinical Professor
University of Arizona College of Medicine - Phoenix, United States
CM

Cole Mendenhall, MD

Assistant Clinical Professor - University of Arizona
Vascular & Interventional Partners, United States
MN

Moises I. Nevah Rubin, MD

Medical Director Hepatology and Liver Transplantation
Banner University Medical Center, United States
KL

Kevin Liu, MD

Assistant Clinical Professor - University of Arizona
Banner University Medical Center - Phoenix, United States
KZ

Kenneth Zurcher, MD

Resident
Mayo Clinic Arizona, United States

Learning Objectives:

Review pathophysiology, incidence, and anatomy of ectopic / lower gastrointestinal tract (LGT) varices seen in portal hypertension (pHTN)

Provide angiographic and CT imaging review of ectopic varices, specifically within small bowel, colon, rectum, and stomas

Discuss endovascular treatment strategies and efficacy in managing LGT ectopic varices, including TIPS, transhepatic, and direct stick interventions

Background: Ectopic varices are rare dilated portosystemic collaterals that can occur anywhere along the lower gastrointestinal tract, and are distinct from esophageal and gastric varices. Etiologies include cirrhotic pHTN, or pre-sinusoidal / extrahepatic pHTN related to venous stenosis or occlusion. While ectopic varices account for only 2-5% of all variceal hemorrhages, they are associated with high mortality rates, up to 40% {1}. Standardized endovascular or endoscopic treatment algorithms are limited due to the rarity and complexity of LGT varices, and are often dependent on available expertise. Endovascular treatment options include TIPS decompression, direct antegrade or retrograde embolization, transhepatic or splenic access, or direct puncture.

Clinical Findings/Procedure Details: Management of ectopic varices requires a multidisciplinary approach, in which IR plays a critical role in both diagnosis and treatment of varices. An understanding of portal anatomy and flow dynamics is vital in interpreting pre-procedural cross-sectional imaging and developing an individualized endovascular plan. In this presentation we provide a detailed imaging and anatomic review of LGT ectopic varices and associated portal anatomy and drainage patterns. Updated endovascular treatment strategies and corresponding efficacy will also be discussed. Specific cases and techniques presented include: stomal and rectal varices (TIPS with antegrade embolization vs. direct stick access), colonic varices, as well as jejunal varices due to extrahepatic portal stenosis (recanalization and stent placement).

Conclusion and/or Teaching Points:

Although less common than esophageal or gastric varices, ectopic / LGT varices represent a source of significant morbidity and mortality

An understanding of portal anatomy, pre-sinusoidal vs. cirrhotic pHTN, and portal venous drainage patterns is critical in diagnosing and managing ectopic variceal hemorrhage

Interventionalists should be aware of the various treatment strategies in LGT variceal embolization, which should be individualized to each clinical scenario