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Intractable hepatic encephalopathy in cirrhotic patients: mid-term efficacy of balloon-occluded retrograde portosystemic shunt obliteration

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Abstract

Purpose

To evaluate the efficacy and intermediate-term outcome of balloon-occluded retrograde transvenous obliteration (BRTO) for the treatment of hepatic encephalopathy (HE) secondary to portosystemic shunt (PSS) in cirrhotic patients.

Materials and methods

Institutional review board (IRB) approval was obtained for this study and hospital records of patients who underwent BRTO, from August 2011 to August 2015, were analyzed. Based on the inclusion and exclusion criteria, 39 patients (age, 54.07 ± 9.1 years (37–67 years); 33 males and 6 females) with cirrhosis and spontaneous PSS were included. Clinical and laboratory parameters and HE grade were evaluated in all patients before and after the procedure.

Results

Forty sessions of BRTO were attempted in 39 patients. Follow-up imaging revealed complete obliteration of the treated PSS in all patients with clinical success in 37 patients (94.9%). The 1-, 2-, 3-, 4-, 5-, 6-, and 7-year HE-free survival rates among responders were 91.7%, 91.7%, 88.8%, 85.5%, 80.8%, 80.8%, and 80.8% respectively and overall survival rates were 89.7%, 82.1%, 76.9%, 74.4%, 74.4%, 64.8%, and 64.8% respectively. Logistic regression highlighted Child-Turcotte-Pugh (CTP) score at 6 months as a positive predictive factor of HE recurrence with a cutoff of ≥ 9. Five patients (12.8%) had fever and leukocytosis and 1 (2.6%) patient developed spontaneous bacterial peritonitis after the procedure.

Conclusion

BRTO is an effective treatment for refractory HE in cirrhotics secondary to large PSS with a few possible complications.

Key Points

• BRTO is an effective and safe treatment for refractory HE, arising from PSS in cirrhotic patients.

• Patients with preserved liver function show better outcome and CTP score is the most important predictor of relapse during follow-up.

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Abbreviations

AKI:

Acute kidney injury

BRTO:

Balloon-occluded retrograde transvenous obliteration

CARTO:

Coil-assisted retrograde transvenous obliteration

CIN:

Contrast-induced nephropathy

CTP:

Child-Turcotte-Pugh

EOI:

Ethanolamine oleate with iopamidol

HBV:

Hepatitis B virus

HE:

Hepatic encephalopathy

INR:

International normalized ratio

IVC:

Inferior vena cava

KFT:

Kidney function test

LFT:

Liver function test

MELD:

Model for end-stage liver disease

PARTO:

Plug assisted retrograde transvenous obliteration

PSS:

Portosystemic shunt

PVT:

Portal vein thrombosis

ROC:

Receiver operating characteristic

SBP:

Spontaneous bacterial peritonitis

STS:

Sodium tetradecyl sulfate

TIPS:

Transjugular intrahepatic portosystemic shunt

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Acknowledgments

The statistical support extended by Dr. Guresh Kumar.

Funding

The authors state that this work has not received any funding.

Author information

Correspondence to Amar Mukund.

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Guarantor

The scientific guarantor of this publication is Dr. Amar Mukund.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

Dr. Guresh Kumar kindly provided statistical advice for this manuscript.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.

Methodology

• Retrospective

• Observational

• Performed at one institution

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Mukund, A., Chalamarla, L.K., Singla, N. et al. Intractable hepatic encephalopathy in cirrhotic patients: mid-term efficacy of balloon-occluded retrograde portosystemic shunt obliteration. Eur Radiol (2020). https://doi.org/10.1007/s00330-019-06644-4

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Keywords

  • Hepatic encephalopathy
  • Portosystemic shunt
  • Cirrhosis