Ischemic Stroke After Plug-Assisted Retrograde Transvenous Obliteration for Gastric Varices

Plug-Assisted Retrograde Transvenous Obliteration (PARTO) is increasingly used for bleeding gastric varices, particularly in patients at high risk of hepatic encephalopathy where Transjugular Intrahepatic Portosystemic Shunt may be unsuitable. Current American Gastroenterological Association guidelines state that PARTO and Balloon-Occluded Retrograde Transvenous Obliteration are more effective than Transjugular Intrahepatic Portosystemic Shunt in preventing rebleeding and have lower hepatic encephalopathy rates. We report a case of multifocal ischemic stroke after technically successful PARTO. The temporal relationship and a patent foramen ovale suggest paradoxical embolism. This first reported case highlights a previously unrecognized but critical risk of PARTO warranting consideration during patient selection and counseling.