Fig. 4

Clinical significance of afferent venous inflow (a–c) and outflow (d–g) of gastric varices during shunt embolization procedure. In type 1 gastric varices with ideal anatomy for occlusion, post sclerosant injection varices fully fill and are completely obliterated (a1, a2); in type 2 varices, with multiple afferents, the sclerosant tends to flow toward low-pressure gastric collateral increasing risk portal vein thrombosis [(b1, b2 (arrows)]; in type 3, the sclerosant tends to flow in the direction of large shunt [(c1, c2 (arrows)]; in type A (d1, d2), sclerosant completely fills the varices without run-off; in type B the sclerosant flows into the systemic veins (e1, arrows) and hence the associated high flow collateral vein needs additional gelfoam occlusion (e2, arrows) before sclerosant injection; in type C in presence of both gastrocaval (f1, arrow) and gastrorenal shunts the sclerosant tends to flow into a systemic vein through the second shunt. Hence the outflow shunt is occluded first with gelfoam (f2, arrow); in type D gastric varices (g), without draining veins, transjugular intrahepatic portosystemic shunt placement is ideal choice for complete variceal complex obliteration; h classical pre (h1, h2) and post (h3, h4) computed tomography demonstration of obliteration of gastric varices associated with a single large efferent shunt. Illustrations used in this figure is created by listed author (Sasidharan Rajesh)