Dear All,
Interesting the debate raised by your patient. Unfortunately we can not review the images of the CT-Scan. May I suggest to discuss the case through the ERN CPMS system? This will allor to uplaod the CT-scan and even (I think this part is not still working) the liver biopsy. It would be interesting to see the degree of stenosis of the splenic vein. I would suggest to do TIPSreview with an accurate measuremets of pressures of all the system pre and post splenic vein stenosis to assess the impact of the stenosis in the pressure gradient. If pressure in the portal vein and splenic vein before the stenois is OK (meaning that TIPS is adequately decompressing the system) and the pressure is increased proximally to the stenois, then stenting/angioplasty of the splenic stenosis would be my first choice. If despite that, still is feeding of the gastric varices I will suggest to embolize (through the splenic vein). Not BRTO.
All my best
JUan Carlos Garcia-Pagan