Antegrade embolization of spontaneous splenorenal shunt for post–transjugular intrahepatic portosystemic shunt refractory hepatic encephalopathy
Authors: Mehul Doshi, Keith Pereira, Andres Carrion, Paul Martin
Journal: Hepatology (2015)

Potential conflict of interest: Nothing to report. To the Editor: Recently, Wu et al.1 reported on a rare case of spontaneous port systemic shunt (SPSS) embolization for post–transjugular intrahepatic portosystemic shunt (TIPS) refractory hepatic encephalopathy (rHE). This retrograde approach has also been described by Shioyama et al.2 We report on a similar case, treated by a different approach. An 82‐year‐old male with decompensated cirrhosis had TIPS for treatment of esophageal variceal bleeding. He developed rHE. Model for End‐Stage Liver Disease (MELD) score was 11, and ammonia was 35 mcmol/L. TIPS reduction was performed. A 70% luminal reduction was achieved, but portosystemic gradient (PSG) barely increased from 3 to 6 mm Hg. Further shunt reduction was avoided to prevent complete shunt thrombosis. He returned 2 weeks later with a recurrent rHE. MELD was 14, and ammonia was 90 mcmol/L. Initial intent was shunt occlusion. Portal venogram revealed multiple gastric varices with hepafugal flow. We elected to prophylactically embolize the afferent veins to gastric varices, to prevent bleeding after shunt occlusion. The posterior and short gastric veins were embolized using coils. Left gastric venogram showed a large gastrorenal SPSS. Although Balloon‐occluded retrograde transvenous obliteration (BRTO) is the preferred method of SPSS embolization, it can cause catastrophic bleeding as a result of aggravation of esophageal varices.3 We embolized the left gastric vein antegradely. PSG increased from 6 to 14 mm Hg, and there was improved hepatopetal flow. Shunt occlusion was not performed. The patient's mental status dramatically improved within 20 minutes of the procedure. At 20‐week follow‐up, he had marked improvement in cognition and baseline level of mental acuity. MELD score improved to 10. High‐risk gastroesophageal varices have not redeveloped to date. In patients with a SPSS and coexisting TIPS, two shunts induce excessive portosystemic shunting and severe HE. Although antegrade embolization with coils can cause bleeding as a result of injury to friable variceal walls, this technique has been safely described in the past.4 Based on our experience and previous case reports,1 we think that (1) a thorough search for an SPSS is warranted in cases of post‐TIPS rHE and (2) antegrade embolization may have a dual role in the prevention of variceal bleeding in addition to treatment of rHE, the former being a significant concern when the more conventional retrograde approach is used.Figure 1: (A) TIPS reduction showing nearly 70% luminal narrowing (between red arrows). (B) Left gastric venogram after coiling sgv and pgv shows filling of GVs and a grs draining into the systemic veins through the lrv. (C) The lgv was embolized antegradely using two 7 × 5.5 mm VortX coils (Boston Scientific Inc., Marlborough, MA). Portal venogram shows no flow into the GV or grs shunt. Abbreviations: lgv, left gastric vein; pgv, posterior gastric vein; sgv, short gastric veins; GV, gastric varix; grs, gastrorenal shunt; lev, left gastric vein; IVC, inferior vena cava.