In this case report, NBC was used to embolize the right portal vein. Although this substance is used routinely for PVE in safe conditions[3
], it is friable and was reportedly responsible for a pulmonary embolism following gastric variceal obliteration in cirrhotic patients[4
]. There are two possible mechanisms for the migration of PVE material. The first relates to a spontaneous, intrahepatic portosystemic venous shunt that, although rare, has been already described a few times[5
]. The second possibility is the creation of an iatrogenic portosystemic venous shunt by high pressure injection of the NBC; however, this entity has not been yet described in the literature.
In the present case, our decision to use a percutaneous technique to retrieve the migrated material was prompted by two factors. Firstly, sternotomy and open heart surgery for foreign body extraction had a high risk of morbidity. Secondly, a cardiopulmonary bypass was ruled out because the required doses of anticoagulant and the multiple attempts to access the left portal branch for PVE would have been associated with a high risk of liver subcapsular hematoma.
Extraction of material from the right cardiac cavity using a basket catheter has already been described. This technique was used for extraction of thrombi in patients contraindicated for surgery, with the placement of an inferior vena cava filter above the thrombus[6
]. Lastly, given the high risk of fragmenting the PVE material during its extraction from the femoral vein, a femoral stent was used to trap the material against the vein wall and enlarge the vein. Anticoagulation was used to reduce the risk of venous thrombosis that could be potentialized by cancer (Figure ). Venous stenting has already been reported and has proven its efficacy[7
In conclusion, we have described a very rare case of a PVE material migration to the right atrial cavity. The embolism was successfully treated by withdrawal with a basket catheter and then femoral venous stenting. The mechanism of portosystemic venous shunting in this case was not clear but our report should prompt the physician to examine the patient’s portal anatomy even more carefully prior to injection of a PVE product. This previously unknown complication of PVE can be managed percutaneously in order to avoid open heart cardiac surgery.