Results of Portosystemic Shunt Embolization in Selected Patients with Cirrhosis and Recurrent Hepatic Encephalopathy

Abstract

Large portosystemic shunts (PSSs) may lead to recurrent encephalopathy in patients with cirrhosis and embolization of these shunts may improve encephalopathy. Five patients underwent balloon-occluded retrograde transvenous obliteration (BRTO) or plug-assisted retrograde transvenous obliteration (PARTO) of a large PSS at our center in last 2 years for recurrent hepatic encephalopathy (HE) at a tertiary care center at north India. Data are shown as number and mean±SD. None of these patients had Child's C cirrhosis or presence of large ascites/large varices. Five patients (all males), aged 61±7 years, underwent BRTO or PARTO for recurrent HE and presence of lienorenal (n=4) or mesocaval shunt (n=1). The etiology of cirrhosis was cryptogenic/non-alcoholic steatohepatitis in 3, and alcohol and hepatitis B in one each. All patients had Child's B cirrhosis; Child's score was 8.6±0.5, model for end-stage liver disease (MELD) score was 13.4±2.3. One patient had mild ascites; 3 patients had small esophageal varices before procedure. Sclerosants (combination of air, sodium tetradecyl sulphate, and lipiodol) were used in two patients, endovascular occlusion plugs were used in two patients, and both sclerosants and endovascular occlusion plug were used in one patient. Embolization of minor outflow veins to allow for stable deposition sclerosants in dominant shunt was done using embolization coils and glue in two patients. One patient needed 2 sessions. The pre-procedure ammonia was 127±35 which decreased to 31±17 after the shunt embolization. There was no recurrence of encephalopathy in any of these patients. One patient was lost to follow-up at 6 months; others are doing well at 6 months (n=2), 10 months (n=1) and 2 years (n=1). None of these patients developed further decompensation in the defined follow-up period. Good results can be obtained in selected patients after embolization of large PSS for recurrent HE.