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

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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.

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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Acute kidney injury


Balloon-occluded retrograde transvenous obliteration


Coil-assisted retrograde transvenous obliteration


Contrast-induced nephropathy




Ethanolamine oleate with iopamidol


Hepatitis B virus


Hepatic encephalopathy


International normalized ratio


Inferior vena cava


Kidney function test


Liver function test


Model for end-stage liver disease


Plug assisted retrograde transvenous obliteration


Portosystemic shunt


Portal vein thrombosis


Receiver operating characteristic


Spontaneous bacterial peritonitis


Sodium tetradecyl sulfate


Transjugular intrahepatic portosystemic shunt


  1. 1.

    Córdoba J (2011) New assessment of hepatic encephalopathy. J Hepatol 54:1030–1040

  2. 2.

    Laleman W, Landeghem L, Wilmer A, Fevery J, Nevens F (2005) Portal hypertension: from pathophysiology to clinical practice. Liver Int 25:1079–1090

  3. 3.

    Shawcross DL, Olde Damink SW, Butterworth RF, Jalan R (2005) Ammonia and hepaticencephalopathy: the more things change, the more they remain the same. Metab Brain Dis 20:169–179

  4. 4.

    Stepanova M, Mishra A, Venkatesan C, Younossi ZM (2012) In-hospital mortality and economic burden associated with hepatic encephalopathy in the United States from 2005 to 2009. Clin Gastroenterol Hepatol 10:1034–1041

  5. 5.

    Riggio O, Efrati C, Catalano C et al (2005) High prevalence of spontaneous portal-systemic shunts in persistent hepatic encephalopathy: a case-control study. Hepatology 42:1158–1165

  6. 6.

    Lam KC, Juttner HU, Reynolds TB (1981) Spontaneous portosystemic shunt: relationship to spontaneous encephalopathy and gastrointestinal hemorrhage. Dig Dis Sci 26:346–352

  7. 7.

    Ohnishi K, Sato S, Saito M et al (1986) Clinical and portal hemodynamic features in cirrhotic patients having a large spontaneous splenorenal and/or gastrorenal shunt. Am J Gastroenterol 81:450–455

  8. 8.

    Laleman W, Simon-Talero M, Maleux G et al (2013) EASL-CLIF-Consortium. Embolization of large spontaneousportosystemic shunts for refractory hepatic encephalopathy: a multicenter survey on safety and efficacy. Hepatology 57:2448–2457

  9. 9.

    Kato K, Kondo S, Hirano S et al (2001) Surgical closure of the gastrorenal shunt with distal splenorenal shunt operation for portosystemic encephalopathy. Hepatogastroenterology 48:840–841

  10. 10.

    Henderson JM (1989) Treatment of post-shunt portal systemic encephalopathy by embolization of the shunt. Hepatology 9:164–165

  11. 11.

    Zidi SH, Zanditenas D, Gelu-Siméon M et al (2007) Treatment of chronic portosystemic encephalopathy in cirrhotic patients by embolization of portosystemic shunts. Liver Int 27:1389–1393

  12. 12.

    Uflacker R, Silva Ade O, d'Albuquerque LA, Piske RL, Mourão GS (1987) Chronicportosystemic encephalopathy: embolization of portosystemic shunts. Radiology 165:721–725

  13. 13.

    Boixadera H, Tomasello A, Quiroga S, Cordoba J, Perez M, Segarra A (2010) Successful embolization of a spontaneous mesocaval shunt using the Amplatzer Vascular Plug II. Cardiovasc Intervent Radiol 33:1044–1048

  14. 14.

    Fukuda T, Hirota S, Sugimura K (2001) Long-term results of balloon-occluded retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy. J Vasc Interv Radiol 12:327–336

  15. 15.

    Mukund A, Rajesh S, Arora A, Patidar Y, Jain D, Sarin SK (2012) Efficacy of balloon-occluded retrograde transvenous obliteration of large spontaneous lienorenal shunt in patients with severe recurrent hepatic encephalopathy with foam sclerotherapy: initial experience. J Vasc Interv Radiol 23:1200–1206

  16. 16.

    Takashi M, Igarashi M, Hino S et al (1985) Portal hemodynamics in chronic portal-systemic encephalopathy. Angiographic study in seven cases. J Hepatol 1:467–476

  17. 17.

    Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K (1996) Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol 11:51–58

  18. 18.

    Sabri SS, Swee W, Turba UC et al (2011) Bleeding gastric varices obliteration with balloon-occluded retrograde transvenous obliteration using sodium tetradecyl sulfate foam. J Vasc Interv Radiol 22:309–316

  19. 19.

    Park SJ, Chung JW, Kim HC, Jae HJ, Park JH (2010) The prevalence, risk factors, and clinical outcome of balloon rupture in balloon-occluded retrograde transvenous obliteration of gastric varices. J Vasc Interv Radiol 21:503–507

  20. 20.

    Caturelli E, Pompili M, Squillante MM et al (1994) Cruveilhier-Baumgarten syndrome: an efficient spontaneous portosystemic collateral preventing oesophageal varices bleeding. J Gastroenterol Hepatol 9:236–241

  21. 21.

    Hsieh JS, Wang JY, Huang CJ, Chen FM, Huang TJ (2004) Effect of spontaneous portosystemic shunts on hemorrhage from esophagogastric varices. World J Surg 28:23–28

  22. 22.

    Khalilzadeh O, Baerlocher MO, Shyn PB et al (2017) Proposal of a new adverse event classification by the Society of Interventional Radiology Standards of Practice Committee. J Vasc Interv Radiol 28:1432–1437

  23. 23.

    Akahane T, Iwasaki T, Kobayashi N et al (1997) Changes in liver function parameters after occlusion of lienorenal shunts with balloon-occluded retrograde transvenous obliteration. Am J Gastroenterol 92:1026–1030

  24. 24.

    Cardoso JE, Gautreau C, Jeyaraj PR et al (1994) Augmentation of portal blood flow improves function of human cirrhotic liver. Hepatology 19:375–380

  25. 25.

    Park JK, Saab S, Kee ST et al (2014) Balloon-occluded retrograde transvenous obliteration (BRTO) for treatment of gastric varices: review and metaanalysis. Dig Dis Sci 60:1543–1553

  26. 26.

    Lee EW, Saab S, Kaldas F et al (2018) Coil-assisted retrograde transvenous obliteration (CARTO): an alternative treatment option for refractory hepatic encephalopathy. Am J Gastroenterol 113:1187–1196

  27. 27.

    Inoue H, Emori K, Toyonaga A et al (2014) Long term results of balloon-occluded retrograde transvenous obliteration for portosystemic shunt encephalopathy in patients with liver cirrhosis and portal hypertension. Kurume Med J 61:1–8

  28. 28.

    An J, Kim KW, Han S, Lee J, Lim YS (2014) Improvement in survival associated with embolization of spontaneous portosystemic shunt in patients with recurrent hepatic encephalopathy. Aliment Pharmacol Ther 39:1418–1426

  29. 29.

    Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J (2017) Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology 65:310–335

  30. 30.

    Runyon BA (2013) Introduction to the revised American Association for the Study of Liver Diseases practice guideline management of adult patients with ascites due to cirrhosis 2012. Hepatology 57:1651–1653

  31. 31.

    Sakurabayashi S, Sezai S, Yamamoto Y, Hirano M, Oka H (1997) Embolization of portal-systemic shunts in cirrhotic patients with chronic recurrent hepatic encephalopathy. Cardiovasc Intervent Radiol 20:120–124

  32. 32.

    Chikamori F, Kuniyoshi N, Shibuya S, Takase Y (2000) Transjugular retrograde obliteration for chronic portosystemic encephalopathy. Abdom Imaging 25:567–571

  33. 33.

    Kato T, Uematsu T, Nishigaki Y, Sugihara J, Tomita E, Moriwaki H (2001) Therapeutic effect of balloon-occluded retrograde transvenous obliteration on portal-systemic encephalopathy in patients with liver cirrhosis. Intern Med 40:688–691

  34. 34.

    Naeshiro N, Kakizawa H, Aikata H et al (2014) Percutaneous transvenous embolization for portosystemic shunts associated with encephalopathy: long-term outcomes in 14 patients. Hepatol Res 44:740–749

  35. 35.

    Lynn AM, Singh S, Congly SE et al (2016) Embolization of portosystemic shunts for treatment of medically refractory hepatic encephalopathy. Liver Transpl 22:723–731

  36. 36.

    Philips CA, Kumar L, Augustine P (2017) Shunt occlusion for portosystemic shunt syndrome related refractory hepatic encephalopathy-a single-center experience in 21 patients from Kerala. Indian J Gastroenterol 36:411–419

  37. 37.

    Choudhary NS, Baijal SS, Saigal S et al (2017) Results of portosystemic shunt embolization in selected patients with cirrhosis and recurrent hepatic encephalopathy. J Clin Exp Hepatol 7:300–304

  38. 38.

    Zhu Y, Wang X, Luo X, Yang L (2018) Balloon-occluded retrograde transvenous obliteration (BRTO) or coil-assisted retrograde transvenous obliteration (CARTO): which one do we choose? Am J Gastroenterol 113:1901–1902

  39. 39.

    Kim DJ, Darcy MD, Mani NB et al (2018) Modified balloon-occluded retrograde transvenous obliteration (BRTO) techniques for the treatment of gastric varices: vascular plug-assisted retrograde transvenous obliteration (PARTO)/coil-assisted retrograde transvenous obliteration (CARTO)/balloon-occluded antegrade transvenous obliteration (BATO). Cardiovasc Intervent Radiol 41(6):835–847

  40. 40.

    Ishikawa AY, Matsuda T, Iwamoto T, Takami T, Sakaida I (2017) Plasma glucose level is predictive of serum ammonia level after retrograde occlusion of portosystemic shunts. AJR Am J Roentgenol 209:W169–W176

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The statistical support extended by Dr. Guresh Kumar.


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

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Correspondence to Amar Mukund.

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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.


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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).

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  • Hepatic encephalopathy
  • Portosystemic shunt
  • Cirrhosis