Vascular Plug-Assisted Retrograde Transvenous Obliteration of Portosystemic Shunts for Refractory Hepatic Encephalopathy: A Case Report

While balloon-assisted retrograde transvenous obliteration (BRTO) has been used for two decades in Asia for the management of gastric variceal bleeding, it is still an emerging therapy elsewhere. Given the shunt closure brought about by the procedure, BRTO has also been used for the management of portosystemic encephalopathy with promising results. Modified versions of BRTO have been developed, including plug-assisted retrograde transvenous obliteration (PARTO), where a vascular plug is deployed within a portosystemic shunt. To our knowledge, we present the first North American case of PARTO in the setting of a large splenorenal shunt for the management of portosystemic encephalopathy. 1. Introduction Portosystemic shunts may result in chronic portosystemic encephalopathy, a debilitating condition that may be refractory to medical management [1, 2]. Balloon-occluded retrograde transvenous obliteration (BRTO) is an interventional therapy for the treatment of gastric fundal varices developing in the course of a portosystemic shunt vessel [3, 4]. Due to shunt closure by the procedure, BRTO has also been applied to treat portosystemic encephalopathy [4]. In terms of portosystemic shunt closure, a balloon catheter may have a limited role because balloon inflation per se provides temporary blockage of the shunt flow until forming the thrombotic shunt occlusion by the sclerosant. Instead, use of a vascular plug might provide more stable and permanent shunt occlusion. Vascular plug-assisted retrograde transvenous obliteration (PARTO) has recently been utilized to treat gastric varices and hepatic encephalopathy in Korea [5]. While a recent series has been published reporting the use of portosystemic shunt embolization for hepatic encephalopathy [6], PARTO employs a distinct advantage in utilizing additional small particle embolization in addition to shunt closure. We present to our knowledge the first North American case of PARTO utilized in the setting of large splenorenal and splenocaval shunts secondary to chronic cirrhosis as a successful primary therapy for portosystemic encephalopathy, along with a technical description. 2. Case Report and Technique A 55-year-old male patient with a history of hepatitis C cirrhosis diagnosed 15 years prior was referred to our clinic by hepatology for consultation on possible BRTO. Symptoms included ascites, a history of esophageal bleeding, and multiple episodes of hepatic hydrothorax, as well as stage II hepatic encephalopathy. The patient had a Model for End-Stage Liver Disease (MELD) score of 14 and Child-Pugh score C