Direct venous‑to‑arterial communication as a novel mechanism for ectopic embolism following esophageal variceal embolization: A case report

Ectopic embolism is an infrequent but potentially life-threatening complication following esophageal variceal embolization. Although it has been hypothesized to result from right-to-left shunting via pulmonary arteriovenous malformations or patent foramen ovale, definitive anatomical routes often remain undetected. The present case study reports a 57-year-old male patient with decompensated cirrhosis who developed acute bilateral visual loss and lower limb weakness within 24 h after undergoing transjugular intrahepatic portosystemic shunt placement combined with endovascular embolization of esophageal varices. Brain imaging confirmed multiple acute cerebral infarctions; notably, angiographic review revealed an abnormal direct venous connection between the esophageal variceal plexus and the left heart/ascending aorta, bypassing the pulmonary circuit. No cardiac or pulmonary shunts were identified. This direct communication likely permitted embolic material to enter the systemic circulation, causing cerebral artery occlusion. In conclusion, to the best of our knowledge, the present case provides the first angiographic evidence of a direct vascular route from esophageal varices to the systemic arterial system. The present finding underscores the importance of comprehensive imaging before embolization and suggests that solid embolic agents such as coils may be preferable in select patients to prevent ectopic embolism.