Percutaneous Transvenous Retrograde Embolization of Adhesion-Related Small Bowel Varices: A Case Report

Small bowel varices are a distinct subtype of ectopic varices that typically develop following prior abdominal surgery. Diagnostic delays are common because of their deep location within the gastrointestinal tract and the limited awareness among clinicians. Transvenous obliteration is the preferred treatment; however, obtaining a suitable and minimally invasive venous access route remains challenging. We report the case of a 54-year-old woman with advanced-stage primary biliary cholangitis (PBC) and celiac disease who presented with persistent melena requiring multiple transfusions. Endoscopic evaluations failed to identify the bleeding source. Contrast-enhanced computed tomography revealed adhesion-related jejunal varices arising from a mesenteric-iliac shunt. Percutaneous venous access was achieved via the efferent vein coursing within the anterior abdominal wall. Retrograde embolization of the varices was then performed using N-butyl-2-cyanoacrylate mixed with ethiodized oil. The procedure achieved immediate hemostasis, with no recurrence observed during nine years of follow-up. This case underscores three key points: (1) ectopic varices should be considered in any patient with portal hypertension presenting with unexplained gastrointestinal bleeding, particularly after abdominal surgery; (2) cross-sectional imaging is essential for diagnosis, delineation of shunt anatomy, and selection of the optimal treatment and venous access route; and (3) when anatomically feasible, superficial venous puncture should be the preferred approach for transvenous obliteration due to its minimally invasive nature.