(Left to right) Early image from the IMV showing the shunt and the renal vein.; Later image from the IMV showing the shunt and renal vein.; Coiled shunt and the thrombosed IMV which shut down as soon as the shunt was closed.; Unsubtracted image showing the contrast in the retroperitoneal hematoma and the thrombosed IMV.


Additional commentary: Portosystemic shunt embolization is typically indicated in the nonacute primary and secondary prevention setting of variceal hemorrhage and shunt-type portosystemic encephalopathy.1


Occlusion of the


pathological upstream shunts using balloon-occluded retrograde transvenous obliteration (BRTO) and, more recently, plug- or coil-assisted retrograde transvenous obliteration (PARTO or CARTO, respectively), are safe and clinically effective interventions.1–4


Transvenous obliteration via the internal jugular or femoral veins can be performed with technical success in the treatment of gastroesophageal and ectopic varices in addition to simple shunts. 1–4


A transhepatic


approach with direct injection and targeted embolization of the shunt’s tributaries may be useful when anatomy is not delineated clearly or with more complex shunts having difficult, tortuous access like this case.4 Pre-procedure imaging with CT, MRA or MRV is essential to evaluate the portal vein, extent of the shunt and its inflow, and the presence of collateral veins.1


Potential complications of


transhepatic approach are well described and similar to that of other percutaneous transhepatic procedures, such as portal vein embolization, transient hemobilia, bleeding (subcapsular hematoma) and infection.5


Choice of access


size, embolic agent and stability of the embolic agent in vein are also overall important periprocedural considerations.4


For example, the


advantages of Amplatzer Vascular Plug or coil approach with a Gelfoam


slurry include a lack of balloon or sclerosant requirement, which is a one-time procedure for the patient and entails a lesser need for collateral vein embolization.1,2


In choosing a particular approach as an interventional radiologist, the focus is on collaboration, risks and deciding which patients would most benefit from embolization.6,7


For portal hypertension


in the setting of liver disease, patients referred to multidisciplinary teams including gastroenterology, diagnostic and interventional radiology, general surgery, and pathology have been shown in a prospective study to have positive outcomes and a significantly lower risk for gastroesophageal variceal rebleed.6


Additionally, a large,


retrospective multicenter survey on safety and efficacy of embolization of large portosystemic shunts for refractory hepatic encephalopathy demonstrated that the MELD score was a positive predictor value for hepatic encephalopathy recurrence and that the effect of embolization appeared to be irrespective of the type of shunt.7


These


collaborations and tools are invaluable in improving periprocedural outcomes for our patients as IRs.


As pointed out in this discussion, a complicated patient such as the one presented here reminds us that IR operates best in a joint, collaborative fashion with our clinical peers and IR colleagues. Even experienced IRs rely on pre-procedural review of a case with their colleagues to help ensure they have considered all the potential approaches to treat their patients safely and successfully.


References


1. Kandarpa K, Hendricks N.J, Haskal Z.J. Balloon- occluded retrograde transvenous obliteration. Handbook of Interventional Radiologic Procedures. Lippincott Williams & Wilkins. 2016;407–412.


2. Gwon D.I, Gi-Young K, Hyun-Ki Y, Kyu-Bo S, Jin Hyoung K, Ji Hoon S, Heung Kyu K, Ho-Young S. Gastric varices and hepatic encephalopathy: Treatment with vascular plug and gelatin sponge–assisted retrograde transvenous obliteration—A primary report. Radiology. 2013;268(1): 281–87.


3. Lee E.W, Saab S, Gomes A.S, Busuttil R, McWilliams J, Durazo F, Han S, et al. Coil-assisted retrograde transvenous obliteration (CARTO) for the treatment of portal hypertensive variceal bleeding: Preliminary results. Clin Transl Gastroenterol. 2014;5(10):e61.


4. Lynn AM, Singh S, Congly SE, Khemani D, Johnson DH, Wiesner RH, Kamath PS, Andrews JC, and Leise MD. Embolization of portosystemic shunts for treatment of medically refractory hepatic encephalopathy. Liver Transplant. 2016;22(6):723–31.


5. Madoff DC, Hicks ME, Vauthey J, Charnsangavej C, Morello FA, Ahrar M, Wallace MJ, Gupta S. Transhepatic portal vein embolization: Anatomy, indications, and technical considerations. RadioGraphics. 2002;22(5): 1063–76.


6. Tseng Y, Ma L, Lv M, Luo T, Liu C, Wei Y, Liu C, et al. The role of a multidisciplinary team in the management of portal hypertension. BMC Gastroenterology. 2020;20(1);83.


7. Laleman W, Simon-Talero M, Maleux G, Perez M, Ameloot K, Soriano G, Villalba J, et al. Embolization of large spontaneous portosystemic shunts for refractory hepatic encephalopathy: A multicenter survey on safety and efficacy. Hepatology. 2013;57(6): 2448–57.


Disclaimer: This column represents the work and opinions of the contributing authors and do not necessarily reflect the views or policies of SIR. SIR assumes no liability, legal, financial or otherwise, for the accuracy of information in this article or the manner in which it is used. The statements made in the column are not intended to set a standard of care and should not be treated as medical advice nor as a substitute for independent, professional judgment.


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