Vascular Plug-Assisted Retrograde Transvenous Obliteration of Portosystemic Shunts for Refractory Hepatic Encephalopathy: A Case Report

Abstract

While balloon-assisted retrograde transvenous obliteration (BRTO) has been used for two decades in Asia for the management of gastric variceal bleeding, it is still an emerging therapy elsewhere. Given the shunt closure brought about by the procedure, BRTO has also been used for the management of portosystemic encephalopathy with promising results. Modified versions of BRTO have been developed, including plug-assisted retrograde transvenous obliteration (PARTO), where a vascular plug is deployed within a portosystemic shunt. To our knowledge, we present the first North American case of PARTO in the setting of a large splenorenal shunt for the management of portosystemic encephalopathy.

Evolution of Retrograde Transvenous Obliteration Techniques

“…For BRTO, PARTO, and CARTO, clinical success ranges from 91 to 100%, 90.6 to 100%, and 100%, respectively. 2,4,24,[27][28][29]31,38,39 Kim et al detected similar clinical success rates (defined as lack of variceal enhancement on postprocedural CT and cessation of bleeding on endoscopy) between BRTO with EO (93.9%) or STS (92%) and PARTO with Gelfoam (100%). 31 Acutely bleeding gastric varices carry a high mortality with limited treatment options.…”

“…For BRTO, PARTO, and CARTO, this ranges from 79 to 100%, 94.7 to 100%, and 100%, respectively. 2,4,5,[27][28][29]31,38,39 In a recent retrospective study comparing BRTO and PARTO, Kim et al reported similar technical success rates of BRTO with EO (93.9%) or STS (92%), and PARTO with Gelfoam (100%). 31 Notably, the success rate of BRTO increases from 84-98% to 98-100% when used in conjunction with balloon-occluded antegrade transvenous obliteration (BATO), although combination therapies are beyond the scope of this article.…”

“…Park et al reported a mean time of 20 minutes (range: 5-90 minutes) from plug deployment to detachment with PARTO, compared with a procedure time of 139.7 minutes (range: 40-360 minutes) for BRTO with EO and 114.8 minutes (range: 90-163 minutes) for BRTO with STS; p < 0.05. 38 Along with reduced procedural times, the presence of a plug rather than balloon reduces risk of nontarget embolization, a complication of BRTO reported in up to 5% of cases. 2 However, use of a plug typically blocks future vascular access, thus increasing the difficulty of repeat treatments.…”

Usefulness of intra-procedural cone-beam computed tomography in modified balloon-occluded retrograde transvenous obliteration of gastric varices

“…BRTO has a high efficacy in stopping acute gastric variceal bleeding and has shown to have a signifi cantly lower re-bleeding rate of gastric varices compared to tIPS or endoscopic treatment [9][10][11][12][13][14] . Recently, our group has shown the effectiveness of mBRtO using coils or vascular plugs in place of balloons [15][16][17] , which is comparable to conventional BRtO [8][9][10][11][12]18,19] . During the BRtO or mBRtO procedure, visualization of the gastric varices, feeding vessels, and its collaterals, is currently guided by 2D angiogram or digital subtraction angiogram.…”

The Amplatzer Vascular Plug: Review of Evolution and Current Applications

“…The plug is also very useful in the occlusion of large portosystemic shunts that may cause refractory hepatic encephalopathy or bleeding from ectopic varices. [58][59][60] They can also be used in the treatment of congenital portocaval shunts such as the type 2 Abernethy malformations. [61][62][63] In the treatment of these congenital shunts that may produce congestive heart failure, another advantage of the device is that it can be deployed temporally and the hemodynamic effects of the shunt closure is evaluated, to see if acute shunt closure is well tolerated before final deployment.…”