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.
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.
BRTO is an effective treatment for refractory HE in cirrhotics secondary to large PSS with a few possible complications.
• 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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Acute kidney injury
Balloon-occluded retrograde transvenous obliteration
Coil-assisted retrograde transvenous obliteration
Ethanolamine oleate with iopamidol
Hepatitis B virus
International normalized ratio
Inferior vena cava
Kidney function test
Liver function test
Model for end-stage liver disease
Plug assisted retrograde transvenous obliteration
Portal vein thrombosis
Receiver operating characteristic
Spontaneous bacterial peritonitis
Sodium tetradecyl sulfate
Transjugular intrahepatic portosystemic shunt
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The statistical support extended by Dr. Guresh Kumar.
The authors state that this work has not received any funding.
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.
Written informed consent was waived by the Institutional Review Board.
Institutional Review Board approval was obtained.
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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
- Hepatic encephalopathy
- Portosystemic shunt