Embolization of portosystemic shunts for treatment of medically refractory hepatic encephalopathy

Abstract

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.

FIG. 1

Overview of patients excluded and/or lost to follow-up.

FIG. 2

Overall and durable response rates. Response is mild, moderate, or marked as outlined in text. Nonresponse is failure to improve symptoms between days 0 and 7. Lost response is when symptom severity or frequency return to baseline.

FIG. 3

(A) Coronal contrast-enhanced CT image demonstrating large left upper quadrant varices draining into the left renal vein. (B) Selective injection of the dilated left inferior phrenic vein prior to embolization. Same projection as Fig. 1A. (C) Injection into the left inferior phrenic vein after deployment of 2 Amplatzer plugs.

FIG. 4

(A) Coronal contrast-enhanced CT image demonstrated large left lower quadrant varices draining into the left gonadal vein. (B) Transhepatic splenic venogram demonstrating retrograde flow in the IMV with filling of large left lower quadrant varices. (C) Later image from the same splenic venogram shows the varices draining into the left gonadal and left renal veins. (D) Transhepatic splenic venogram after shunt embolization shows there is no longer filling of the IMV and that there is improved portal perfusion into the liver.