Portosplenic Blood Flow Separation in a Patient with Portosystemic Encephalopathy and a Spontaneous Splenorenal Shunt

Zamora, Carlos; Sugimoto, Koji; Tsurusaki, Masakatsu; Yamaguchi, Masato; Izaki, Kenta; Taniguchi, Takanori; Iwama, Yuki; Mimura, Fumitoshi; Sugimura, Kazuro

doi:10.1097/01.rvi.0000136984.47892.4c

Cited by 17 publications

(12 citation statements)

References 10 publications

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“…SRSS was previously treated by left renal vein ligation which rapidly decreased the blood ammonia levels and improved the encephalopathy 73–76. However, there was a noted increase in the risk of bleeding varices and ascites by increasing the portal blood flow.…”

Section: Spontaneous Splenorenal Shuntmentioning

confidence: 99%

“…However, there was a noted increase in the risk of bleeding varices and ascites by increasing the portal blood flow. Due to the significant postoperative morbidity and mortality risk with conventional surgical ligation, newer treatment modalities are now utilized and these include endovascular embolization with a metal coil or plug, balloon-occluded retrograde transvenous obliteration, and shunt-preserving disconnection of the systemic and portal circulation 73–76. A comparative study of the long-term outcomes and efficacy of these different therapeutic options is needed.…”

Section: Spontaneous Splenorenal Shuntmentioning

confidence: 99%

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Vascular Diseases of the Spleen: A Review

Francisco

Trivedi

et al. 2017

Journal of Clinical and Translational Hepatology

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Vascular diseases of the spleen are relatively uncommon in the clinical practice. However, the reported incidence has been progressively increasing, probably due to advances in the imaging modalities used to detect them. This disease condition often presents with non-specific clinical manifestations, but can be associated with significant morbidity and mortality. This review article aims to provide updated clinical information on the different vascular diseases of the splenic vasculature—splenic vein thrombosis, splenic vein aneurysm, splenic artery aneurysm, splenic arteriovenous fistula, and spontaneous splenorenal shunt—in order to aid clinicians in early diagnosis and management.

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Section: Spontaneous Splenorenal Shuntmentioning

confidence: 99%

Section: Spontaneous Splenorenal Shuntmentioning

confidence: 99%

Vascular Diseases of the Spleen: A Review

Francisco

Trivedi

et al. 2017

Journal of Clinical and Translational Hepatology

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“…17 Some authors recommended separation therapy instead of complete occlusion of the shunt to avoid abrupt increases in portal venous pressure. 12,14 In the present case, we could not directly measure the portal venous pressure because we did not choose the percutaneous portal vein approach owing to the narrow intrahepatic portal vein. Therefore, we could not anticipate the change in portal venous pressure before and after occlusion of the shunt.…”

Section: Discussionmentioning

confidence: 91%

“…Nowadays, less invasive endovascular procedures have been advocated as alternatives to surgical ligation. [5][6][7][8][9][12][13][14][15][16] In Japan, BRTO is widely accepted for obliterating gastric varices with the transvenous approach. 4,17 This method is also used for obliterating portal-systemic shunts.…”

Section: Discussionmentioning

confidence: 99%

Successful portal-systemic shunt occlusion of a direct shunt between the inferior mesenteric vein and inferior vena cava with balloon-occluded retrograde transvenous obliteration following recanalization after placing a covered stent in the portal and superior mesenteric veins

et al. 2009

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Extrahepatic portal-systemic shunts cause portal-systemic encephalopathy. Direct communication between the inferior mesenteric vein (IMV) and the inferior vena cava (IVC) is a relatively rare pathway among the variety of portal-systemic shunts. This report describes a case of successful occlusion of an IMV-IVC shunt. Based on laboratory data and computed tomography findings, a 69-year-old woman with liver cirrhosis was diagnosed with portal-systemic encephalopathy due to a shunt between the IMV and the IVC. Her hepatic coma had not been adequately controlled by oral or intravenous pharmacotherapy. First, we placed a covered stent in the main trunk of the portal vein and the superior mesenteric vein (SMV) to block the SMV hepatofugal flow and splenic vein hepatopetal flow, but this therapy showed only a transient therapeutic effect due to recanalization. Next, we performed balloon-occluded retrograde transvenous obliteration (BRTO) of the portal-systemic shunt. After the BRTO, she has had no episodes of portal-systemic encephalopathy for 2 years.

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“…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).…”

Section: Discussionmentioning

confidence: 99%

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

Litvin

Atar²,

Knizhnik³

et al. 2009

Diagn Interv Radiol

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312P ortal hypertension can be effectively reduced by the surgical creation of a portosystemic shunt. However, in patients after liver transplantation, a preexisting portosystemic shunt may steal the portal blood flow, predisposing the patient to liver dysfunction and even to portal vein thrombosis (1). Moreover, alternate outflow due to a large, active portosystemic shunt has been linked to hepatic encephalopathy (2). Thus, surgical portosystemic shunts must be occluded during the transplantation procedure or soon thereafter. We describe the use of a stent graft to occlude a symptomatic surgical portosystemic shunt in a patient after orthotopic liver transplantation. Case reportA 27-year-old woman was referred to our angiography unit 10 days after orthotopic liver transplantation for treatment of a high flow splenorenal shunt that caused mild disturbances in liver function. The shunt had been identified by findings of a markedly enlarged left renal vein and suprarenal inferior vena cava (IVC) on computed tomography (CT) with contrast medium (Fig. 1), performed as part of the routine pre-transplantation evaluation. The patient reported that the shunt had been surgically created during her childhood in another country. It had been unaccessable for closure during the transplant surgery because of the presence of extensive adhesions.Informed consent was obtained from the patient before the procedure. Owing to the absence of anatomical surgical details, in order to gain access to the shunt, we opted for a retrograde approach from the right femoral vein through the left renal vein into the splenic vein. A 4 F C1 catheter (Terumo, Japan) and a 0.035 inch glidewire (Terumo, Japan) were used. A dilated left renal vein with rapid flow to the IVC was noted, but flow into the portal vein was not demonstrated with several injections of contrast medium (Fig. 2). Vigorous attempts to reach the portal vein from the splenic vein using different catheters were unsuccessful. To reduce the risk of contrastmedium-induced nephropathy, we decided to cannulate the portal vein transhepatically in another session. Under fluoroscopic guidance, and after administration of IV sedation, we accessed the right portal vein via the right liver lobe using a 21 G needle (Cook, Bloomington, Indiana, USA) and a Neff set (Cook, Bloomington, Indiana, USA), as in percutaneous transhepatic cholangiography. A 4 F Bernstein catheter (AngioDynamics, New York, USA) over a 0.035 inch glidewire (Terumo, Japan) was used to negotiate into the main portal vein. Direct portography revealed hepatofugal flow toward a splenorenal shunt and into the left renal vein (Fig. 3).Considering the wide and short communication between the splenic and renal veins, and in order to prevent migration of the embolizing material (Amplatzer vascular plug), we decided to use an IVC filter as a barrier. An ALN IVC filter (ALN Implants Chirurgicaux, France) was introduced ABSTRACTWe describe a patient after liver transplantation with a preexisting surgical splenorenal shunt close to ...

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Portosplenic Blood Flow Separation in a Patient with Portosystemic Encephalopathy and a Spontaneous Splenorenal Shunt

Cited by 17 publications

References 10 publications

Vascular Diseases of the Spleen: A Review

Vascular Diseases of the Spleen: A Review

Successful portal-systemic shunt occlusion of a direct shunt between the inferior mesenteric vein and inferior vena cava with balloon-occluded retrograde transvenous obliteration following recanalization after placing a covered stent in the portal and superior mesenteric veins

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

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