Portosystemic Shunt Embolization Research Articles

A model for predicting poor survival in patients with cirrhosis undergoing portosystemic shunt embolization.

Portosystemic shunt embolization (PSSE) is a promising treatment for hepatic encephalopathy (HEP) and gastric varix (GV) in cirrhotic patients with a spontaneous portosystemic shunt. However, PSSE may worsen portal hypertension causing hepatorenal syndrome, liver failure, and mortality. This study aimed to develop and validate a prognostic model that helps identify patients with a risk of poor short-term survival after PSSE. We included 188 patients who underwent PSSE for recurrent HEP or GV at a tertiary center in Korea. To develop a prediction model for 6-month survival after PSSE, Cox proportional-hazard model was used. The developed model was validated in a separate cohort of 184 patients from two other tertiary centers. In multivariable analysis, the 1-year overall survival after PSSE was significantly associated with baseline levels of serum albumin, total bilirubin, and international normalized ratio (INR). We therefore developed the albumin-bilirubin-INR (ABI) score by assigning 1 point each for albumin <3.0g/dL, total bilirubin ≥1.5mg/dL, and INR≥1.5. Time-dependent areas under the curve of the ABI score for predicting 3-month and 6-month survival were 0.85 and 0.85 in the development cohort and 0.83 and 0.78 in the validation cohort, indicating good discrimination performance. The ABI score showed a better discrimination and calibration performance than the model for end-stage liver disease and the Child-Pugh scores, especially in high-risk patients. The ABI score is a simple prognostic model that helps decide whether to proceed with PSSE for the prevention of HEP or GV bleeding in patients with spontaneous portosystemic shunt.

Abstract No. 211 To Assess the Efficacy of Endovascular Embolization of Portosystemic Shunts in Management of Recurrent Hepatic Encephalopathy (HE)

Abstract No. 211 To Assess the Efficacy of Endovascular Embolization of Portosystemic Shunts in Management of Recurrent Hepatic Encephalopathy (HE)

Abstract No. 214 Combined Transjugular Intrahepatic Portosystemic Shunt Creation and Spontaneous Portosystemic Shunt Embolization for Hepatic Encephalopathy

Abstract No. 214 Combined Transjugular Intrahepatic Portosystemic Shunt Creation and Spontaneous Portosystemic Shunt Embolization for Hepatic Encephalopathy

FRI488 - A simple model for predicting survival in cirrhotic patients undergoing portosystemic shunt embolization

FRI488 - A simple model for predicting survival in cirrhotic patients undergoing portosystemic shunt embolization

FRI508 - Simultaneous large spontaneous portosystemic shunt embolization for the prevention of overt hepatic encephalopathy after TIPS: a randomized controlled trial

FRI508 - Simultaneous large spontaneous portosystemic shunt embolization for the prevention of overt hepatic encephalopathy after TIPS: a randomized controlled trial

Abstract No. 229 Does spontaneous portosystemic shunt embolization improve liver transplantation outcomes? A propensity-score matched analysis

Patients with large spontaneous portosystemic shunts (SPSS) are theoretically at risk for post liver transplant (LT) portal vein thrombosis (PVT) due to reduced hepatopetal flow. The purpose of this study was to evaluate changes in portal venous velocity from SPSS embolization with TIPS, and to compare post-LT outcomes in patients with vs without embolization ± TIPS for large SPSS. The hypothesis was SPSS embolization ± TIPS would improve portal venous velocity and reduce LT complications, specifically PVT and 30-day mortality.

Concurrent large spontaneous portosystemic shunt embolization for the prevention of overt hepatic encephalopathy after TIPS: A randomized controlled trial.

Large spontaneous portosystemic shunt (SPSS) is associated with increased risk of HE in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS). This study aimed to evaluate whether prophylactic embolization of large SPSS at the time of TIPS creation could reduce the incidence of post-TIPS HE in patients with cirrhosis and variceal bleeding. From June 2014 to August 2017, 56 patients with cirrhosis and large SPSS planning to undergo TIPS for the prevention of variceal bleeding were randomly assigned (1:1) to receive TIPS alone (TIPS group, n=29) or TIPS plus simultaneous SPSS embolization (TIPS+E group, n=27). The primary endpoint was overt HE. TIPS placement and SPSS embolization was successful in all patients. During a median follow-up of 24 months, the primary endpoint was met in 15 patients (51.7%) in the TIPS group and six patients (22.2%) in the TIPS+E group (p=0.045). The 2-year cumulative incidence of overt HE was significantly lower in the TIPS+E group compared with the TIPS group (21.2% vs. 48.3%; HR, 0.38; 95% CI, 0.15-0.97; p=0.043). The 2-year incidence of recurrent bleeding (TIPS+E vs. TIPS, 15.4% vs. 25.1%; p=0.522), shunt dysfunction (12.3% vs. 18.6%, p=0.593), death (15.0% vs. 6.9%, p=0.352), and other adverse events was not significantly different between the two groups. In patients with cirrhosis treated with TIPS for variceal bleeding, concurrent large SPSS embolization reduced the risk for overt HE without increasing other complications. Concurrent large SPSS embolization should therefore be considered for prophylaxis of post-TIPS HE.

Spontaneous portosystemic shunt embolization in liver transplant recipients with recurrent hepatic encephalopathy

Introduction and objectivesSpontaneous portosystemic shunts (SPSS) are a common cause of recurrent hepatic encephalopathy (HE). Shunt occlusion is an effective and safe procedure when performed in patients with cirrhosis and preserved liver function. We aimed to describe our experience with SPSS embolization after liver transplantation (LT). PatientsWe identified five patients who underwent SPSS embolization after LT. Clinical, biochemical and technical procedure data were collected. ResultsAt presentation, all patients had developed graft cirrhosis and HE after LT. Median Model for End-stage Liver Disease (MELD) at embolization was 9 (range 7-12), median Child-Pugh was 8 (range 7-9). Splenorenal and mesocaval shunt were the most frequent types of SPSS found. Three patients have been completely free of HE. Of the two patients who had HE recurrence after embolization, one patient had two episodes of HE which was controlled well with medications. The other patient required three embolizations because of recurrent HE. Median follow-up was 4.4 years (range 1.0-5.0) and MELD score at last follow up was 13 (range 10-18) and median Child-Pugh score B, 7 points (range 5-12). ConclusionsSPSS can be considered as a cause of HE after LT. SPSS embolization is feasible and safe in LT recipients.

A71 MESOCAVAL SHUNT EMBOLIZATION AS A TREATMENT FOR MEDICALLY REFRACTORY HEPATIC ENCEPHALOPATHY IN A PATIENT WITH NON-DECOMPENSATED CIRRHOSIS

Abstract Background Hepatic encephalopathy (HE) is a common complication of cirrhosis with a spectrum of neuropsychiatric manifestations. In patients with medically refractory HE (i.e. after a trial of Lactulose with or without Rifaximin), it is warranted to investigate and manage underlying spontaneous portosystemic shunts (SPS) as a cause of chronic or recurrent HE in the absence of precipitants. Aims Here we present a case report of a patient with non-decompensated cirrhosis who underwent mesocaval shunt embolization as a treatment for medically refractory HE (grade III) in the absence of underlying precipitants. Methods The patient’s chart was reviewed and radiological images pre- and post- shunt embolization were obtained. A literature review was performed on the treatment of SPS for HE in cirrhosis. Results Mr. H is a 56-year-old man with alcohol-related cirrhosis who was admitted to the hospital with a reduced level of consciousness. On examination he was arousable but nonverbal. Asterixis was observed with no focal neurologic findings. Laboratory, infectious and toxicology results were negative. His MELD-Na score was 11. Computed tomography (CT) of his head and ultrasound of his abdomen were normal. The patient did not improve with lactulose and rifaximin. A CT of his abdomen/pelvis revealed a large SPS arising from the superior mesenteric vein (SMV) to the infrarenal inferior vena cava (IVC). A decision was made to attempt partial occlusion of the shunt. A 22-mm Amplatzer™ Vascular Plug II and two 8mm x 59mm Atrium balloon expandable covered stents were deployed in the right gonadal vein. Partial occlusion was subsequently demonstrated with contrast injection. The patient had gradual improvement of his HE and became independent for his ADLs six months post-procedure. Conclusions Between 45–70% of patients with cirrhosis and medically refractory HE have SPS as a result of chronic liver injury and increased portal venous pressures. AASLD guidelines recommend screening for SPS in cirrhotic patients with medically refractory HE or in HE with compensated liver disease. Shunt embolization in patients with MELD &amp;lt; 11 has been shown to reverse chronic or recurrent HE as well as improve hepatic outcomes for at least a two-year follow-up, as shown by a recent multicentre survey done by Laleman et al. Further studies have shown that portosystemic shunt embolization can result in reversal of HE in over 75% of cases. The most frequently encountered shunt in these studies is the splenorenal shunt. Our case, however, offers insight into the less commonly experienced mesocaval shunt, which accounts for only 5% of large SPS. We have shown that mesocaval shunts, when discovered, have the potential for successful treatment with embolization that can lead to reversal and long-term clinical remission of HE. Funding Agencies None

2275 Anoxic Brain Injury From Hepatic Encephalopathy in Acute on Chronic Liver Failure: A Case Report

INTRODUCTION: Hepatic encephalopathy (HE) is a complication seen in both acute liver failure and acute on chronic liver failure (ACLF). There is a paucity of data regarding IV HE resulting in global anoxic brain injury in those with ACLF. We present a case of anoxic brain injury from severe HE in a patient with ACLF. CASE DESCRIPTION/METHODS: 74-year-old male with a past medical history of hypertension and CAD had recently been diagnosed with NASH cirrhosis when he presented to an outside hospital with ascites. Two months later he presented to our hospital with acute change in mental status. On presentation, the patient had normal vital signs. Physical examination revealed obtundation with response to noxious stimuli. There was no scleral icterus and labs were significant for WBC 5.1, platelet count 82, BUN/Cr 32/1.81, lactate 3.2, NH3 248, LFTs unremarkable, MELD Na 23. CT head and chest X-ray were negative for acute processes. On physical exam, patient was non-jaundiced with a mildly distended abdomen. He was started on lactulose every 6 hours. His mentation continuously deteriorated and he was intubated for airway protection and transferred to ICU 8 hours after admission, where he was started on rifaximin. Nephrology was consulted and CRRT was initiated after NH3 was noted to be &gt;500 in the ICU. Repeat CT head now showed increased intracranial pressure, and subsequent MRI one day later showed global hypoxic ischemic injury. EEG with global slowing pattern signifying anoxic brain injury. Ammonia levels normalized on CRRT (although patient required dialysis for anuria after completion of 6 days of CRRT) and SSEP was done which did show evoked potentials, however no improvement was noted on neurological exam. Family eventually made the decision to transition care to comfort measures and the patient expired soon after. DISCUSSION: Overt cerebral edema leading to coma in HE and ACLF is rare given the chronicity of high ammonia and brain adaptation. The pathophysiologic mechanism for HE in ACLF is thought to be a combination of elevated serum ammonia and systemic inflammatory changes. Our attempts with hemodialysis did not change the clinical course suggesting irreversible tissue damage. Advanced therapies including embolization of portosystemic shunts was not pursued as none were identified on contrast enhanced imaging. Preventing decompensation and early recognition may be the modifiable factor in this high mortality disease.

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

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.

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

Backround and Aim: Large portosystemic shunts may lead to recurrent encephalopathy in patients with cirrhosis and embolization of these shunts may improve encephalopathy. Methods: Five patients underwent balloon-occluded retrograde transvenous obliteration (BRTO) of a single large portosystemic shunt at our centre in last 2 years for recurrent hepatic encephalopathy. Data is shown as number and mean ± SD. None of these patients had Child's C cirrhosis or presence of large ascites/large esophageal varices. Results: Five patients (all males), aged 61 ± 7 years underwent BRTO for recurrent HE and presence of lienorenal (n = 4) or mesocaval shunt (n = 1). The etiology of cirrhosis was cryptogenic/NASH in 3, alcohol and hepatitis B in one each. All patients had Child's B cirrhosis; Child's score was 8.6 ± 0.5, MELD score was 13.4 ± 2.3. One patient had mild ascites; 3 patients had small esophageal varices before procedure. Sclerosant (combination of air, sodium tetradecyl sulfate 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. Embolisation of minor outflow veins to allow for stable deposition sclerosants in dominant shunt were done using embolisation coils and glue in two patients. One patient needed 2 sessions of BRTO. None of the patients had any procedure related complication. The pre-procedure ammonia was 127 ± 35 which decreased to 31 ± 17 after the shunt embolisation. 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. Conclusion: Good results can be obtained in selected patients after embolization of a single large portosystemic shunt for recurrent hepatic encephalopathy. The authors have none to declare.

Embolization of portosystemic shunts for treatment of medically refractory hepatic encephalopathy.

Treatment options for refractory hepatic encephalopathy (HE) are limited. Patients who fail medical management may harbor large portosystemic shunts (PSSs) which are possible therapeutic targets. This study aims to describe patient selection, effectiveness, and safety of percutaneous PSS embolization in those with medically refractory HE. A retrospective evaluation of consecutive adult patients with medically refractory HE referred for PSS embolization at a tertiary center was performed (2003-2015). Patient data collected included the type of HE, medications, Model for End-Stage Liver Disease (MELD) score, shunt type, embolization approach, and materials used. Outcomes of interest were immediate (7 days), intermediate (1-4 months), and longer-term (6-12 months) effectiveness and periprocedural safety. Effectiveness was determined based on changes in hospitalization frequency, HE medications, and symptoms. Twenty-five patients with large PSS were evaluated for shunt embolization. Five were excluded due to high MELD scores (n = 1), comorbid conditions (n = 1), or technical considerations (n = 3). Of 20 patients who underwent embolization, 13 had persistent and 7 had recurrent HE; 100% (20/20) achieved immediate improvement. Durable benefit was achieved in 100% (18/18) and 92% (11/12) at 1-4 and 6-12 months, respectively. The majority (67%; 8/12) were free from HE-related hospitalizations over 1 year; 10% developed procedural complications, and all resolved. Six developed new or worsening ascites. In conclusion, PSS embolization is a safe and effective treatment strategy that should be considered for select patients with medically refractory HE. Liver Transplantation 22 723-731 2016 AASLD.

PWE-099 Porto-systemic shunt embolization and recurrent ascites: a single centre case series

<h3>Introduction</h3> Porto-systemic shunt embolization (PSSe) is an emerging procedure for the treatment of refractory hepatic encephalopathy (HE).¹A criteria of MELD &lt;11 was proposed by Laleman <i>et al</i>as a cutodd to predict recurrent HE post embolization. No other significant liver-related complications were noted in this retrospective study. The aim of this retrospective study was to assess the efficacy and complication rate following PSSe at a single institution. <h3>Method</h3> All cirrhotic patients undergoing PSSe for refractory HE between March 2008 – September 2014 at Royal Free London were included in this study. Cirrhotic patients had refractory HE (West Haven score ≥2), an EEG pattern consistent with HE, and a demonstrable PSS on CT/MRI. All patients underwent embolization using Amplatz vascular plugs. Clinical and biochemical variables at the time of PSSe were recorded, and outcomes including HE grade, changes in MELD score and portal hypertension-related complications were noted. <h3>Results</h3> Ten patients underwent PSSe (M: 6; Age 60.9 ± 10.3 yr) and mean follow up was 37.3 ± 59.6 mo. A baseline MELD score &gt;11 was present in 5 patients. No significant change in mean MELD score was seen following PSSe (11.5 ± 2.8 vs 12.2 ± 6.9, pre vs post p = 0.57). No patients experienced variceal haemorrhage post PSSe. Five patients had diuretic controlled ascites prior to PSSe. Following PSSe two patients developed severe ascites requiring large volume paracentesis (Table 1). HE improved in 6 patients; recurrent HE developed in 4 patients – grade 3 in 2 patients, and grade 4 in 2 patients (Table 1). MELD &gt;11 did not predict occurence of ascites or HE post PSSe. <h3>Conclusion</h3> This small retrospective series demonstrates a 20% incidence of severe ascites post PSSe. With the caveat of the small size of this cohort, MELD score did not predict ascites or HE following PSSe. Further assessment of degree of portal hypertension, or of porto-systemic shunting, through hepatic haemodynamic and ICG studies may better predict the development of complications and the necessity for a concomitant TIPS at the time of PSSe. <h3>Disclosure of interest</h3> None Declared. <h3>Reference</h3> Laleman W, <i>et al</i>. Embolization of large spontaneous portosystemic shunts for refractory hepatic encephalopathy: a multicenter survey on safety and efficacy. Hepatology 2013;57:2448–2457

Canine intrahepatic vasculature: is a functional anatomic model relevant to the dog?

To clarify canine intrahepatic portal and hepatic venous system anatomy using corrosion casting and advanced imaging and to devise a novel functional anatomic model of the canine liver to investigate whether this could help guide the planning and surgical procedure of partial hepatic lobectomy and interventional radiological procedures. Prospective experimental study. Adult Greyhound cadavers (n = 8). Portal and hepatic vein corrosion casts of healthy livers were assessed using computed tomography (CT). The hepatic lobes have a consistent hilar hepatic and portal vein supply with some variation in the number of intrahepatic branches. For all specimens, 3 surgically resectable areas were identified in the left lateral lobe and 2 surgically resectable areas were identified in the right medial lobe as defined by a functional anatomic model. CT of detailed acrylic casts allowed complex intrahepatic vascular relationships to be investigated and compared with previous studies. Improving understanding of the intrahepatic vascular supply facilitates interpretation of advanced images in clinical patients, the planning and performance of surgical procedures, and may facilitate interventional vascular procedures, such as intravenous embolization of portosystemic shunts. Functional division of the canine liver similar to human models is possible. The left lateral and right medial lobes can be consistently divided into surgically resectable functional areas and partial lobectomies can be performed following a functional model; further study in clinically affected animals would be required to investigate the relevance of this functional model in the dog.

Embolization of Portosystemic Shunt for Treatment of Recurrent Hepatic Encephalopathy

Hepatic encephalopathy in the setting of advanced chronic liver disease, occurs following a precipitating factor and generally responds to correction of the precipitating factor and anticoma measures. We report the case of a lady with Child A cirrhosis who presented with frequent episodes of hepatic encephalopathy without any precipitating factors. She was found to be having a large portosystemic shunt. The shunt was obliterated by coil embolotherapy following which there was no further episodes of encephalopathy.

Abstract No. 328: Age factors and indications for congential portosystemic shunt embolization

Abstract No. 328: Age factors and indications for congential portosystemic shunt embolization

Percutaneous Transsplenic Access to the Portal Vein for Management of Vascular Complication in Patients with Chronic Liver Disease

To evaluate the safety and feasibility of percutaneous transsplenic access to the portal vein for management of vascular complication in patients with chronic liver diseases. Between Sept 2009 and April 2011, percutaneous transsplenic access to the portal vein was attempted in nine patients with chronic liver disease. Splenic vein puncture was performed under ultrasonographic guidance with a Chiba needle, followed by introduction of a 4 to 9F sheath. Four patients with hematemesis or hematochezia underwent variceal embolization. Another two patients underwent portosystemic shunt embolization in order to improve portal venous blood flow. Portal vein recanalization was attempted in three patients with a transplanted liver. The percutaneous transsplenic access site was closed using coils and glue. Percutaneous transsplenic splenic vein catheterization was performed successfully in all patients. Gastric or jejunal varix embolization with glue and lipiodol mixture was performed successfully in four patients. In two patients with a massive portosystemic shunt, embolization of the shunting vessel with a vascular plug, microcoils, glue, and lipiodol mixture was achieved successfully. Portal vein recanalization was attempted in three patients with a transplanted liver; however, only one patient was treated successfully. Complete closure of the percutaneous transsplenic tract was achieved using coils and glue without bleeding complication in all patients. Percutaneous transsplenic access to the portal vein can be an alternative route for portography and further endovascular management in patients for whom conventional approaches are difficult or impossible.

Treatment of chronic portosystemic encephalopathy in cirrhotic patients by embolization of portosystemic shunts

AIMS/BACKGROUNDS: Large spontaneous portal-systemic shunts can occasionally be the cause of chronic and disabling encephalopathy in cirrhotic patients. Shunt embolization has been proposed, however the clinical relevance of this technique remains uncertain. We report our results in seven patients treated by shunt embolization. Although the procedure was achieved and technically successful in all patients, the clinical results were poor as long-term improvement was obtained in only one patient. Three patients died within 3 months after the procedure from cirrhoses' end stage complications. We believe that optimal management of these patients with chronic spontaneous encephalopathy is liver transplantation.

Transvenous coil embolization of portosystemic shunt in dogs.

This paper describes transvenous coil embolization of portosystemic shunt in 10 dogs. Clinical signs resolved in 4 dogs with extrahepatic shunt, and in 3 dogs with intrahepatic shunt. Two dogs of less than 3 kg died because of migration of coils to the level of the main pulmonary artery. One dog was euthanized when acute portal hypertension developed following transvenous coil embolization. Transvenous coil embolization seems to be a less invasive alternative to surgical ligation in dogs with a single intrahepatic portosystemic shunt.