Inadvertent iatrogenic splenic vein occlusion resulting in sinistral portal hypertension and massive gastric variceal hemorrhage

A 27-year-old man with history of Budd–Chiari syndrome complicated by portal hypertension presented to an outside hospital with melena and hematemesis. He underwent direct intrahepatic portocaval shunt (DIPS) placement and variceal embolization. Eleven months later, the patient presented to the authors’ institution with recurrent upper gastrointestinal bleeding. DIPS venogram demonstrated a patent stent-graft; however, it also revealed plug occlusion of the splenic vein, inadvertently performed at the time of initial DIPS procedure. Interrupted splenic venous flow gave rise to sinistral portal hypertension, which, in turn, led to exacerbation of gastric varices and development of a massive gastrorenal shunt. Splenic artery embolization and a balloon-occluded retrograde transvenous obliteration were performed, resulting in resolution of gastrointestinal hemorrhage.