Endoscopic Ultrasonography-guided Variceal Therapy as Salvage Treatment for Rebleeding From Duodenal Varices Following Balloon-occluded Retrograde Transvenous Obliteration

Duodenal varices, though rare, are potentially life-threatening complications of portal hypertension. Management is challenging when balloon-occluded retrograde transvenous obliteration (BRTO) fails to achieve complete obliteration. Endoscopic ultrasonography-guided variceal therapy (EUS-VT) is effective for gastric varices, but reports of duodenal varices remain limited. We present a case of a 71-year-old woman with alcoholic liver cirrhosis and duodenal variceal bleeding. Initial hemostasis was achieved with endoscopic variceal ligation, followed by BRTO. However, rebleeding occurred due to incomplete obliteration caused by dual afferent veins. EUS-VT comprising n-butyl cyanoacrylate was performed as salvage therapy because of ascites and vascular complexity. Despite technical challenges, EUS-VT successfully obliterated the varices. Post-procedural computed tomography showed lipiodol migration into the portal system. No rebleeding or liver dysfunction occurred. Ascites worsened—likely because of BRTO and/or EUS-VT—but was manageable with low-dose diuretics. This case highlights EUS-VT as a feasible option after failed BRTO for duodenal varices. A meticulous technique is essential to preventing glue migration.