Antegrade Embolization of Spontaneous Splenorenal Shunt for Post–Transjugular Intrahepatic Portosystemic Shunt Refractory Hepatic Encephalopathy 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,(1,2) 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.

FIG. 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 3 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. 


HEPATOLOGY, Vol. 64, No. 1, 2016

Mehul Doshi, M.D.1 Keith Pereira, M.D.1 Andres Carrion, M.D.2 Paul Martin, M.D.2 1 Department of Interventional Radiology 2 Department of Hepatology Jackson Memorial Hospital University of Miami Miami, FL

REFERENCES 1) Wu W, He C, Han G. Embolization of spontaneous splenorenal shunt for after-TIPS hepatic encephalopathy in a patient with cirrhosis and variceal bleeding. HEPATOLOGY 2015;61: 1761-1762.


2) Shioyama Y, Matsueda K, Horihata K, Kimura M, Nishida N, Kishi K, et al. Post-TIPS hepatic encephalopathy treated by occlusion balloon-assisted retrograde embolization of a coexisting spontaneous splenorenal shunt. Cardiovasc Intervent Radiol 1996;19: 53-55. 3) Saad WE, Kitanosono T, Koizumi J, Hirota S. The conventional balloon-occluded retrograde transvenous obliteration procedure: indications, contraindications, and technical applications. Tech Vasc Interv Radiol 2013;16:101-151. 4) Qi X, Liu L, Bai M, Chen H, Wang J, Yang Z, et al. Transjugular intrahepatic portosystemic shunt in combination with or without variceal embolization for the prevention of variceal rebleeding: a meta-analysis. J Gastroenterol Hepatol 2014;29: 688-696. C 2015 by the American Association for the Study of Liver Diseases. Copyright V

View this article online at wileyonlinelibrary.com. DOI 10.1002/hep.28343 Potential conflict of interest: Nothing to report.

Which Approach Is Appropriate for Spontaneous Portosystemic Shunt Embolization in Patients With Post-Transjugular Intrahepatic Portosystemic Shunt Refractory Hepatic Encephalopathy: Antegrade or Retrograde? TO THE EDITOR: Based on our recently published case in a patient with cirrhosis with variceal bleeding,(1) we are pleased to read the letter of Doshi et al., which was regarding large spontaneous portosystemic shunt (SPSS) embolization for post-transjugular intrahepatic portosystemic shunt (TIPS) hepatic encephalopathy (HE). We are in agreement with Doshi et al. Recently, SPSS has attracted increasing attention. Because the coils may not completely occlude the shunt of large diameter, an Amplatzer plugging device is often used for large SPSS embolization. In our center, the Amplatzer plugging device is preferred in TIPS patients, so as to embolize the large SPSS through an antegrade transjugular approach. Moreover, the retrograde approach by femoral vein will be the next choice only when the transjugular approach is complicated. Similarly, by employing the antegrade transjugular approach, varices of small diameter or SPSS are almost embolized with coils, as with Doshi et al. (Fig. 1). The study of Laleman et al., concerning the efficacy and safety of large portosystemic shunts embolization for

refractory HE management, reported on the same procedure approach, in which the SPSS was embolized using coils in an antegrade way and the Amplatzer plugging device in a retrograde way.(2) In order to embolize the large SPSS in patients without TIPS implantation, the retrograde femoral vein approach is preferred on account of the feasibility and efficacy, as well as balloon-occluded retrograde transvenous obliteration.(3) Provided that the retrograde way is not accessible, the antegrade transjugular approach will be established without stent insertion. Nevertheless, both antegrade and retrograde approaches may increase portal vein pressure. Furthermore, no final conclusion has yet been reached on the possibility of the retrograde approach increasing the risk of variceal bleeding when compared to the antegrade approach. During the procedure, hepatic venous pressure gradient (HVPG) is always measured. In our center, the majority of patients maintained HVPG

Antegrade embolization of spontaneous splenorenal shunt for post-transjugular intrahepatic portosystemic shunt refractory hepatic encephalopathy.

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