Significant improvement in portal‐systemic liver failure symptoms and successful management of portal‐splenic venous hemodynamics by the combination of interventional radiology and pharmacotherapy

Abstract

This study describes a case of hepatitis C virus-related decompensated cirrhosis with portal-systemic liver failure and refractory encephalopathy. It was successfully managed with a combination of interventional radiology and pharmacotherapy, to improve hepatic function, including hyperammonemia and to control portal-splenic venous hemodynamics with hepatic venous pressure gradient (HVPG) monitoring. A man in his late 50s presented with a Child-Pugh score of 13, Model for End-Stage Liver Disease-sodium (MELD-Na) score of 19 and blood ammonia level of 185 μg/dL. He underwent balloon-occluded retrograde transvenous obliteration (BRTO) followed by partial splenic embolization (PSE) and non-selective beta-blocker (NSBB) administration. BRTO induced drastic changes in the portal-splenic venous hemodynamics, resulting in dramatically improved hepatic function and reduced hyperammonemia. However, the procedure resulted in increased HVPG from 13.6 mmHg at baseline to 23.5 mmHg at 1-month post-BRTO, accompanied by ascites retention and development of portal hypertensive gastropathy. Thereafter, PSE was performed, followed by NSBB administration, to control the elevated portal venous pressure following BRTO. Postoperatively, the patient's ascites and portal hypertensive gastrophy improved after splenic artery embolization, which eventually disappeared after the additional administration of NSBBs 1 month later. The HVPG finally decreased to 16.9 mmHg; the Child-Pugh score, MELD-Na score and blood ammonia level improved to 7, 11 and 22 μg/dL, respectively, after all therapies. BRTO significantly improved the symptoms of portal-systemic liver failure with refractory encephalopathy. PSE and NSBB administration could contribute to additional amelioration of hepatic function and successful management of complications induced by portal hemodynamic changes following BRTO.

Prevalence and characteristics of portopulmonary hypertension in cirrhotic patients who underwent both hepatic vein and pulmonary artery catheterization

“…A case-control study from the USA revealed that the prevalence of PoPH was significantly higher among females and patients with AIH and was numerically higher among patients with PBC. 34 Splenectomy and splenic arterial embolization 35 are well known as one of the treatments for portal hypertension, and they are often performed for complications associated with portal hypertension. Segraves et al reported a high risk of subsequent PoPH in patients with AIH and in those with a history of splenectomy.…”

Partial Splenic Artery Embolization to Treat Portal Hypertension

“…55 56 57 Moreover, PSE can reverse portal hypertension and hepatic dysfunction induced by balloon-occluded retrograde transvenous obliteration for hepatic encephalopathy. 58 The improvement in portal-systemic encephalopathy is likely attributed to obliteration of portal-systemic shunts followed by PSE. 59 For patients undergoing liver transplant which may be complicated by graft dysfunction or hepatitis C, 60 these therapeutic benefits of PSE persist.…”

Management of Thrombocytopenia with Partial Splenic Embolization in Liver Cirrhosis

“…Tajiri reported that cholinesterase activity and serum albumin increased ammonia levels after all therapy was carried out. 11,20,27 Long-term monitoring is carried out for up to 1 year after the procedure to assess responses such as recurrent variceal bleeding, bleeding at other sites such as gingiva or epistaxis, and the ability to respond to the planned intervention. Laboratory examination after the PSE procedure is in the form of a complete blood picture to assess the number of erythrocytes, leukocytes, and platelets, which are assessed every 2 weeks, 1 month, 6 months, and 1 year after the PSE procedure.…”