Effective balloon-occluded retrograde transvenous obliteration of the superior mesenteric vein-inferior vena cava shunt in a patient with hepatic encephalopathy after living donor liver transplantation

Hepatic-associated vascular morphological assessment to predict overt hepatic encephalopathy before TIPS: a multicenter study

BACKGROUND

To provide patients the chance of accepting curative transjugular intrahepatic portosystemic shunt (TIPS) rather than palliative treatments for portal hypertension-related variceal bleeding and ascites, we aimed to assess hepatic-associated vascular morphological change to improve the predictive accuracy of overt hepatic encephalopathy (HE) risks.

METHODS

In this multicenter study, 621 patients undergoing TIPS were subdivided into training (413 cases from 3 hospitals) and external validation datasets (208 cases from another 3 hospitals). In addition to traditional clinical factors, we assessed hepatic-associated vascular morphological changes using maximum diameter (including absolute and ratio values). Three predictive models (clinical, hepatic-associated vascular, and combined) were constructed using logistic regression. Their discrimination and calibration were compared to test the necessity of hepatic-associated vascular assessment and identify the optimal model. Furthermore, to verify the improved performance of ModelC-V, we compared it with four previous models, both in discrimination and calibration.

RESULTS

The combined model outperformed the clinical and hepatic-associated vascular models (training: 0.814, 0.754, 0.727; validation: 0.781, 0.679, 0.776; p < 0.050) and had the best calibration. Compared to previous models, ModelC-V showed superior performance in discrimination. The high-, middle-, and low-risk populations displayed significantly different overt HE incidence (p < 0.001). Despite the limited ability of pre-TIPS ammonia to predict overt HE risks, the combined model displayed a satisfactory ability to predict overt HE risks, both in the low- and high-ammonia subgroups.

CONCLUSION

Hepatic-associated vascular assessment improved the predictive accuracy of overt HE, ensuring curative chances by TIPS for suitable patients and providing insights for cirrhosis-related studies.

Interventional Radiology Management of Hepatic Encephalopathy

Hepatic encephalopathy (HE) is a clinically severe and devastating complication of decompensated liver disease affecting mortality, quality of life for patients and families, hospital admission rates, and overall health-care costs globally. Depending on the cause of HE, several medical treatment options have been developed and become available. In some refractory HE, such as spontaneous portosystemic shunt-related HE (SPSS-HE) or posttransjugular intrahepatic portosystemic shunt HE (post-TIPS HE), advanced interventional radiology (IR) procedures have been used, and shown to be effective in these conditions. This review presents 2 effective IR procedures for managing SPSS-HE and post-TIPS HE.

Spontaneous portosystemic shunt embolization in liver transplant recipients with recurrent hepatic encephalopathy

INTRODUCTION AND OBJECTIVES

Spontaneous portosystemic shunts (SPSS) are a common cause of recurrent hepatic encephalopathy (HE). Shunt occlusion is an effective and safe procedure when performed in patients with cirrhosis and preserved liver function. We aimed to describe our experience with SPSS embolization after liver transplantation (LT).

PATIENTS

We identified five patients who underwent SPSS embolization after LT. Clinical, biochemical and technical procedure data were collected.

RESULTS

At presentation, all patients had developed graft cirrhosis and HE after LT. Median Model for End-stage Liver Disease (MELD) at embolization was 9 (range 7-12), median Child-Pugh was 8 (range 7-9). Splenorenal and mesocaval shunt were the most frequent types of SPSS found. Three patients have been completely free of HE. Of the two patients who had HE recurrence after embolization, one patient had two episodes of HE which was controlled well with medications. The other patient required three embolizations because of recurrent HE. Median follow-up was 4.4 years (range 1.0-5.0) and MELD score at last follow up was 13 (range 10-18) and median Child-Pugh score B, 7 points (range 5-12).

CONCLUSIONS

SPSS can be considered as a cause of HE after LT. SPSS embolization is feasible and safe in LT recipients.

Prediction of overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt treatment: a cohort study

Background/purpose

Overt hepatic encephalopathy (HE) risk should be preoperatively predicted to identify patients suitable for curative transjugular intrahepatic portosystemic shunt (TIPS) instead of palliative treatments.

Methods

A total of 185 patients who underwent TIPS procedure were randomised (130 in the training dataset and 55 in the validation dataset). Clinical factors and imaging characteristics were assessed. Three different models were established by logistic regression analyses based on clinical factors (ModelC), imaging characteristics (ModelI), and a combination of both (ModelCI). Their discrimination, calibration, and decision curves were compared, to identify the best model. Subgroup analysis was performed for the best model.

Results

ModelCI, which contained two clinical factors and two imaging characteristics, was identified as the best model. The areas under the curve of ModelC, ModelI, and ModelCI were 0.870, 0.963, and 0.978 for the training dataset and 0.831, 0.971, and 0.969 for the validation dataset. The combined model outperformed the clinical and imaging models in terms of calibration and decision curves. The performance of ModelCI was not influenced by total bilirubin, Child–Pugh stages, model of end-stage liver disease score, or ammonia. The subgroup with a risk score ≥ 0.88 exhibited a higher proportion of overt HE (training dataset: 13.3% vs. 97.4%, p  < 0.001; validation dataset: 0.0% vs. 87.5%, p  < 0.001).

Conclusion

Our combination model can successfully predict the risk of overt HE post-TIPS. For the low-risk subgroup, TIPS can be performed safely; however, for the high-risk subgroup, it should be considered more carefully.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s12072-021-10188-5.

Endovascular management of portal steal syndrome due to portosystemic shunts after living donor liver transplantation

Background and Aim

After liver transplant, pre‐existent porto‐systemic shunts (PSS) may persist, causing “portal steal,” leading to graft dysfunction, hepatic encephalopathy (HE), and eventual rejection. In recipients of small‐for‐size transplant liver grafts, shunts may be created intraoperatively, facilitating diversion of portal flow to systemic circulation to avoid ill‐effects of portal overperfusion. These iatrogenic shunts may also subsequently lead to portal steal. We aim to evaluate safety and efficacy of endovascular techniques in management of portal steal due to PSSs in living donor liver transplantation (LDLT) recipients.

Methods

Between 2013 and 2020, we encountered five LDLT recipients with large PSS, who presented with graft dysfunction and/or HE. One patient had a surgically created shunt and four had spontaneous shunts, not surgically ligated during transplant. Endovascular techniques including plug‐assisted or balloon‐occluded retrograde transvenous obliteration (PARTO/BRTO) or covered inferior vena cava (IVC) stent grafts were to occlude these PSS and counter the portal steal in all patients. Technical success and clinical outcomes at 1‐year‐follow‐up were assessed.

Results

Imaging showed large PSS causing portal steal syndrome in all five patients. IVC stent graft was used to isolate the shunt in two patients and PARTO/BARTO was performed in three patients. One patient had guarded prognosis due to multiple organ dysfunction and died 5 days after endovascular procedure. At 1‐year follow up, graft functions normalized in four patients with no recurrence of HE. No procedure‐related complications were seen.

Conclusion

Endovascular techniques can be safely and effectively used to counter portal steal syndrome in LDLT recipients, thus avoiding surgical re‐exploration in these patients.

Retrograde Transvenous Obliteration (RTO): A New Treatment Option for Hepatic Encephalopathy

Hepatic Encephalopathy (HE) is a complication of liver disease, consisting of brain dysfunction often due to portosystemic shunting of blood flow in the liver. HE can range from minimal HE, presenting with normal neurological function, to overt HE, with neurological and neuropsychiatric abnormalities. Various clinical grading systems are used to differentiate HE to provide the appropriate treatments. Traditional treatment of HE aims to identify and resolve precipitating factors through targeting hyperammonemia and administering antibiotics or probiotics. While retrograde transvenous obliteration (RTO), including balloon-occluded retrograde transvenous obliteration, coil-assisted retrograde transvenous obliteration or plug-assisted retrograde tranvenous obliteration, is an established procedure to manage gastric varices, little is known about its potential to treat HE. RTO is a procedure to occlude a spontaneous portosystemic shunt, minimizing shunting of portal blood to systemic circulation. Though there is not a large study with HE patients who have undergone RTO; the results appear promising in reducing HE. Side effects, however, should be considered in the treatment of HE such as the transient worsening of portal hypertension and the formation of additional shunts. While additional studies are needed to assess the long-term success, RTO appears to be an effective alternative method to alleviate clinical symptoms of HE when pharmacological therapies and other conservative medical managements have failed.

Post-transplant inflow modulation for early allograft dysfunction after living donor liver transplantation

Background

To treat small-for-size syndrome (SFSS) after living donor liver transplantation (LDLT), many procedures were described for portal flow modulation before, during, or after transplantation. The selection of the procedure as well as the best timing remains controversial.

Case presentation

A 43-year-old female with end-stage liver disease underwent LDLT with extended left with caudate lobe graft from her donor who was her 41-year-old brother (graft volume/standard liver volume (GV/SLV), 35.7%; graft to recipient weight ratio (GRWR), 0.67%). During the surgery, splenectomy could not be performed owing to severe peri-splenic adhesions to avoid the ruined bleedings. The splenic artery ligation was not also completely done because it was dorsal to the pancreas and difficult to be approached. Finally, adequate portal vein (PV) inflow was confirmed after portal venous thrombectomy. As having post-transplant optional procedures that are accessible for PV flow modulation, any other procedures for PV modulation during LDLT were not done until the postoperative assessment of the graft function and PV flow for possible postoperative modulation of the portal flow accordingly. Postoperative PV flow kept as high as 30 cm/s. By the end of the 1st week, there was a progressive deterioration of the total bilirubin profile (peak as 19.4 mg/dL) and ascitic fluid amount exceeded 1000 mL/day. Therefore, splenic artery embolization was done effectively and safely on the 10th postoperative day (POD) to reverse early allograft dysfunction as PV flow significantly decreased to keep within 20 cm/s and serum total bilirubin levels gradually declined with decreased amounts of ascites below 500 mL on POD 11 and thereafter. The patient was discharged on POD 28 with good condition.

Conclusions

SFSS can be prevented or reversed by the portal inflow modulation, even by post-transplant procedure. This case emphasizes that keeping accessible angiographic treatment options for PV modulation, such as splenic artery embolization, after LDLT is quite feasible.