Hepatic encephalopathy due to intrahepatic portosystemic venous shunt successfully treated by balloon occluded retrograde transvenous embolization with GDCs
A 65-year-old man was referred with a history of repeated episodes of unconsciousness. The patient had no history of trauma, liver biopsy, or liver disease. Gastrectomy had been performed for gastric cancer 3 years previously, and at the time of admission the patient was free from tumor. A review of the entire family tree revealed no inherited disorder. Laboratory studies showed no liver dysfunction with the exception of a mild increase in the serum ammonia level (147 μg/dl; normal range, <79 μg/dl). Contrast-enhanced multidetector-row CT revealed a large abnormal vessel in communication with a peripheral right portal branch and the right hepatic vein, which suggested the existence of an IPSVS. The shunt was 15 mm in diameter. These findings confirmed that a hepatic encephalopathy caused by an IPSVS was responsible for the repeated episodes of unconsciousness. Therefore, we attempted embolization of the IPSVS.\nAfter the patient provided written informed consent, the following procedures were performed with the patient under local anesthesia. First, a 5-F cobra-shaped catheter (Terumo Clinical Supply, Gifu, Japan) was inserted from the right femoral artery. Then, superior mesenteric arterial portography was performed, which confirmed the presence of an IPSVS forming a communication between the right portal vein and the right hepatic vein. Next, a 6-F sheath introducer (Medikit, Tokyo, Japan) was inserted from the right femoral vein after which a 6-F hook-shaped guiding catheter (Terumo Clinical Supply) was advanced to the right hepatic vein. Subsequently, a 3.3-F micro-balloon catheter (Fuji Systems, Fukushima, Japan) with a balloon 10 mm in diameter was advanced through the guiding catheter into the right hepatic vein. Third, a 5-F sheath introducer (Medikit) was inserted from the right femoral vein to accommodate a 5-F hook-shaped catheter (Terumo Clinical Supply). The 5-F hook-shaped catheter was inserted into the right hepatic vein, followed by coaxial passage by a 0.018-inch micro-catheter (Renegade; Boston Scientific, Watertown, MA, USA) through the IPSVS into the portal vein (Fig. a). Fourth, the balloon of the micro-balloon catheter was inflated to decrease hepatofugal blood flow in the intrahepatic portosystemic venous shunt and to avoid migration of the coils to the systemic venous site. Injection of the contrast medium via the micro-catheter advanced into the portal vein showed stasis of hepatofugal blood flow in the IPSVS. Fifth, the micro-catheter was re-positioned in the IPSVS, and 11 GDCs (GDC-18, 360°; diameter, 10–16 mm; length, 30 cm; and GDC-18 fibered-Vortx, diameter 4–6 mm) were placed in the IPSVS from the micro-catheter. Superior mesenteric arterial portography obtained after the balloon was deflated showed sufficient embolization of the IPSVS (Fig. b). Finally, all catheters were withdrawn. There were no procedural complications, and liver function was consistently normal after embolization. The serum ammonia level had normalized to 66 μg/dl the day following the procedure. Enhanced multidetector row CT obtained 1 week after the procedure revealed sufficient embolization of the IPSVS.\nCurrently, 14 months after this interventional procedure, the patient has no symptoms of hepatic encephalopathy and his clinical condition is good.