Embolization of spontaneous portosystemic shunt for treatment of refractory hepatic encephalopathy

Purpose Spontaneous portosystemic shunt (PSS) can cause significant hepatic encephalopathy (HE) in patients with liver disease. Medical treatment alone may have limited success and compliance. We investigated a subset of patients with HE that underwent shunt embolotherapy to determine the clinical effect and safety of embolization as a complement or cure to their current clinical management and encephalopathy. Materials and Methods The medical records of 33 patients with PSS who underwent shunt embolization from 2006 to 2012 at our institution were retrospectively reviewed. A total of 9 patients with non-GI bleeding recalcitrant HE who had undergone maximal medical therapy were identified. All patients underwent preprocedure MRI or CT in order to evaluate PSS. Embolization of the shunt was performed with coils, occlusion devices, and liquid agents via transhepatic, systemic, and recanalized paraumbilical venous routes. Results Follow-up data were available in 8 patients (6 women, 2 men; age range, 40 - 66 y; mean age, 55.5 y ± 10.1) who underwent 9 embolization procedures after medical treatment with one or more of lactulose, rifaximin, and neomycin. Etiology of liver cirrhosis was as follows: hepatitis-C, primary biliary cirrhosis, autoimmune hepatitis, nonalcoholic steatohepatitis, cryptogenic, and primary sclerosing cholangitis. Prior to embolization, 4 patients had liver transplants and none had ascites. The shunts were accessed successfully from the common femoral vein (n = 3), internal jugular vein (n = 1), and transhepatic approach (n = 3). In one patient, two embolizations were necessary and entrance was through a recanalized paraumbilical vein. Follow-up range was 3 - 28 months (mean duration, 15.5 m ± 9.9). Following the embolization, 7 patients were determined to be improved clinically (88%). Three patients were able to discontinue encephalopathy medications altogether and the remainder (n = 4) reduced the quantity of medications. There were no procedure-related complications or worsening portal hypertension. Conclusion Spontaneous PSS embolization is a feasible and safe procedure that serves as a complementary or curative treatment method for HE patients who are refractory to medical management.