Embolization of large spontaneous portosystemic shunts for refractory hepatic encephalopathy: A multicenter survey on safety and efficacy

Abstract

Refractory hepatic encephalopathy (HE) remains a major cause of morbidity in cirrhosis patients. Large spontaneous portosystemic shunts (SPSSs) have been previously suggested to sustain HE in these patients. We aimed to retrospectively assess the efficacy and safety of patients treated with embolization of large SPSSs for the treatment of chronic therapy-refractory HE in a European multicentric working group and to identify patients who may benefit from this procedure. Between July 1998 and January 2012, 37 patients (Child A6-C13, MELD [Model of Endstage Liver Disease] 5-28) with refractory HE were diagnosed with single large SPSSs that were considered eligible for embolization. On a short-term basis (i.e., within 100 days after embolization), 22 out of 37 patients (59.4%) were free of HE (P < 0.001 versus before embolization) of which 18 (48.6% of patients overall) remained HE-free over a mean follow-up period of 697 6 157 days (P < 0.001 versus before embolization). Overall, we noted improved autonomy, decreased number of hospitalizations, and severity of the worst HE episode after embolization in three-quarters of the patients. Logistic regression identified the MELD score as strongest positive predictive factor of HE recurrence with a cutoff of 11 for patient selection. As to safety, we noted one major nonlethal procedure-related complication. There was no significant increase in de novo development or aggravation of preexisting varices, portal hypertensive gastropathy, or ascites. Conclusion: This multicenter European cohort study demonstrated a role for large SPSSs in chronic protracted or recurrent HE and substantiated the effectiveness and safety of embolization of these shunts, provided there is sufficient functional liver reserve. (HEPATOLOGY 2013;57:2448-2457 H epatic encephalopathy (HE) is a major complication of cirrhosis and refers to potentially reversible alterations in autonomy, consciousness, behavior, and psychomotor functions related to an accumulation of toxins due to hepatocellular dysfunction and portosystemic shunting.1-5 While in some patients HE is initiated abruptly by a precipitating event such as infection or gastrointestinal bleeding (the so-called episodic HE), other patients have persistent HE characterized by continuous high levels of ammonia, chronic electrophysiological abnormalities, and recurrent or persistent incapacitating alterations in mental status, often without evident precipitating events. 1,3,4 In this latter group, medical treatment is Abbreviations: EASL-CLIF, European Association for the Study of the Liver -Consortium on Chronic Liver Insufficiency; HE, hepatic encephalopathy; MELD, Model of Endstage Liver Disease; mRS, modified Rankin Scale; SPSS, spontaneous portosystemic shunt; SRS, splenorenal shunt; TIPS, transjugular intrahepatic portosystemic shunt.From the

Embolization of Portosystemic Shunt for Treatment of Recurrent Hepatic Encephalopathy

“…However, in a large multicentre European cohort study, Laleman et al found that there was no significant increase in de novo development or aggravation of preexisting varices, portal hypertensive gastropathy, or ascites. 6 This study showed overall improvement in autonomy, decreased number of hospitalizations and, and severity of the worst HE episode in threequarters of the patients. Partial splenic embolisation has been suggested as additional treatment by some authors.…”

Jet-fixation: A novel method to improve microscopy of human liver needle biopsies

“…Critical point drying or HMDS (hexamethyldisilazane) drying can be applied after dehydration for scanning electron microscopy (SEM). 1 Jet-fixation leads to well-fixed tissue with open sinusoids, free of blood cells (Fig. 2B,C).…”

“…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.…”

Efficacy and Safety of Transcatheter Embolization for Hepatic Encephalopathy Caused by Spontaneous Portosystemic Shunts

“…Several authors have reported the safety and efficacy of transcatheter embolization of portosystemic shunts in patients with refractory HE [13,[32][33][34][35][36][37][38]. In addition, in the previous 10 years, many case reports on HE due to portosystemic shunts that were successfully treated by transcatheter embolization have been published [17][18][19][20][21][22][23][39][40][41][42].…”