Chronic portosystemic encephalopathy: embolization of portosystemic shunts.

Abstract

Operative ligation of portosystemic shunts is effective in controlling chronic portosystemic encephalopathy (CPSE) but is associated with significant mortality. Review of the records of five patients with CPSE treated with radiologic occlusion procedures showed that these are suitable alternatives to surgery. Three patients had alcoholic cirrhosis, one had hepatic fibrosis from schistosomiasis, and one had post-necrotic cirrhosis. All had CPSE with progressive, severe cerebral impairment refractory to clinical treatment. Four patients had a spontaneous splenorenal shunt, and one had a surgically created mesocaval shunt (MCS). Partial splenic embolization was performed in two patients, direct shunt embolization was performed via percutaneous transhepatic portography in two other patients, and an MCS embolization was performed in one patient through the inferior vena cava. In four patients embolization controlled the CPSE. In the remaining patient it could not be evaluated because of his premature death from intraabdominal bleeding, a late complication of the procedure. Interventional radiologic procedures are effective in the control of CPSE in selected patients.

Stent graft closure of a high flow splenorenal shunt in a patient after liver transplantation

“…Surgical ligation is a complex procedure associated with high morbidity and mortality (3,4), although it may be indicated in a few carefully selected patients (5). Percutaneous approaches are less invasive, and they have been shown to increase portal pressure, improve portal flow to the liver, and decrease encephalopathy (5).…”

“…Embolization, however, has hardly been used for surgical shunts. Most of the reports involved spontaneous splenorenal shunts in which the distal splenic vein was usually connected to the left renal vein, and the shunt was long and tortuous (4,6). In such cases, there is enough room for balloon-occluded retrograde transvenous obliteration with ethanolamine oleate (7), embolization with coils or detachable balloons (4), or transhepatic splenic vein embolization, which preserves the splenorenal shunt and prevents retrograde flow to the shunt from the SMV (8)(9)(10).…”

Reply

“…Transmission electron microscopy (TEM) has contributed considerably to liver research [1][2][3][4][5][6][7][8][9][10] after the introduction of perfusion fixation, with glutaraldehyde fixative through the portal vein. A clear distinction of sinusoidal endothelial, Kupffer, pit, and stellate cells became apparent, including details such as the endothelial fenestrae.…”

“…This latter partially explains the heterogeneous results obtained in previously reported small single-center case reports or series. [2][3][4][5][6] In our series, 1 we wanted to overcome this particular problem by putting together the datasets of different European liver units leading to inclusion of 37 patients, resulting in the largest experience ever reported in this matter. As an additional advantage, this approach also omitted potential selection bias for this kind of procedure of an individual center…”

Actualización en el tratamiento de la encefalopatía hepática

“…La oclusión de las mismas podría ser una buena opción terapéutica en pacientes adecuadamente seleccionados (51). Los mejores candidatos son pacientes con EH recurrente, con función hepáti-ca relativamente preservada y bajo riesgo de hemorragia por hipertensión portal (52 cientes con cirrosis es por radiología intervencionista, por ser más segura y presentar menos complicaciones que la cirugía.…”