Acute Refractory Variceal Bleeding (ARVB) is defined by a failure to control Esophageal Variceal (EV) bleeding by first line therapeutic strategies 1. Different strategies to control ARVB episodes have been developed such as balloon tamponade (BT), Self-expanding Esophageal metal Stent (ES) and Transjugular Intrahepatic Portosystemic Shunt placement. We would like to report here an exceptional case of ARVB, occurring during liver transplantation (LT). Orthotopic LT from deceased donor was performed for a 54-years old patient with alcoholic-related cirrhosis and Acute on Chronic Liver Failure grade 1. Upper Gastro Intestinal (GI) endoscopy achieved 13 days before OLT showed small and medium EV without signs of recent bleeding. No endo-scopic EV treatment was performed at this time because of a concomitant extra-digestive hemorrhage shock. At the time of LT, coagulation disorders were corrected according to a thromboelastometry-guided transfusion strategy. EV bleeding leading to hemodynamic failure occurred whilst performing a temporary portocaval anastomosis during the explantation phase.
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