Supplementary Material for: Management of Refractory Esophageal Variceal Bleeding When TIPSS Is Not Possible: Review of a challenging case

Esophageal variceal bleeding (EVB) is a common complication of portal hypertension. Guidelines recommend initiation of vasoactive agents in combination of antimicrobial therapy prior to endoscopic variceal ligation (EVL). In cases of refractory EVB, trans-jugular intrahepatic portosystemic shunt (TIPSS) is recommended, however, it is contraindicated in up to 35% of cases. We report a case of 61-year-old-male newly diagnosed with hepatocellular carcinoma and extensive portal vein thrombosis. The patient developed a refractory EVB failing medical and endoscopic therapies which was successfully treated with transcutaneous left gastric vein embolization. LGVE could be contemplated in instances where anatomical complexities or contraindications to TIPSS arise.