Shunt occlusion for portosystemic shunt syndrome related refractory hepatic encephalopathy—A single-center experience in 21 patients from Kerala

Abstract

Between October 2016 and July 2017, 21 patients (Child-Pugh score, CTP 6 to 13) with mean model of end-stage liver disease (MELD) and MELD-sodium scores 15.7 and 19.3 respectively with MRHE [3-cirrhotic Parkinsonism (CP)] were diagnosed to have single or multiple large SPSSs. A total of 29 shunts were occluded (1 surgical, 20 non-surgical). Recurrent and persistent HE and CP markedly improved in the short (n=20, 1 to 3 months), intermediate (n=12, 3 to 6 months), and long (n=7, 6 to 9 months) follow up. None had spontaneous or persistent HE at a median follow up 105 (30 to 329) days (p<0.05). Motor, speech, sleep abnormalities, daily activities of living, and liver disease severity scores improved significantly on follow up. Baseline arterial ammonia showed a statistically significant reduction in all time periods of follow up after shunt occlusion (p<0.05). CTP >11 predicted mortality post shunt occlusion (p=0.04). Embolization of large SPSS in liver disease patients with MRHE and modestly preserved liver function is safe and efficacious and associated with improved quality of life and can function as a bridge to liver transplantation in accurately selected patients.

Radiological Intervention for Shunt Related Encephalopathy

“…Interventional radiology treatments using a catheter have become a leading treatment for portal hypertension because of the extensive range of indications it provides using many kinds of procedures. 18 With Balloon-occluded Retrograde Transvenous Obliteration (BRTO), a balloon catheter is placed retrogradely in the gastrorenal shunt or in the inferior phrenic vein flowing into the inferior vena cava so that a sclerosant can be injected into the gastric varices for thrombus formation while the blood flow is cut off. The diameter of the gastrorenal shunt is measured at the base of the shunt at the communication point with the left renal vein, which where the occlusion balloon will be placed.…”

“…Regarding contraindications, BRTO should be avoided when the contrast agent flows easily from the shunt into the portal vein under balloon-occluded retrograde venography, because there is a risk of portal thrombosis due to sclerosing agent migrated into the portal vein. 18 Ethanolamine oleate has been used most commonly in Asia as a sclerosant. 21 However, reported complications include renal dysfunction, pulmonary edema, cardiogenic edema, and anaphylaxis.…”

“…Therefore, the pre-operative evaluation by CT scan and the occlusion of the collateral veins is necessary for the sclerosant to retain in the gastric varices. 18 Recently, newly developed techniques such as Plug Assisted Retrograde Transvenous Obliteration (PARTO) or Coil Assisted Retrograde Transvenous Obliteration (CARTO) have been developed in order to shorten the procedure time of conventional BRTO. In PARTO, a vascular plug is used as a substitute for the balloon and this has been found to be technically and clinically equivalent.…”

“…27 Different studies demonstrated that shunt-related HE due to the increased shunt blood flow can be dramatically improved by closing the shunts. 18,[28][29][30] In many cases, however, many other shunts exist, and mild HE may remain when only the gastrorenal shunt is closed. In these cases, it is necessary to consider closing the other shunts.…”

“…Philips et al demonstrated that in five of seven patients with hepatic Parkinsonism, the embolization of the shunt significantly improved neurological symptoms ( Figure 1). 18…”