K.E.M. Radiology
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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Contributed by : Harshitha Shetty
Embolization of a spontaneous mesocaval shunt in a patient of liver cirrhosis and portal hypertension with recurrent episodes of hepatic encephalopathy
Introduction:
Liver cirrhosis causes increased intrahepatic vascular resistance to the portal flow leading to increased portal venous pressure and portal hypertension. Once portal hypertension develops, there is portosystemic collateral formation which can either be due to opening up of the pre-existing vessels or neo angiogenesis due to growth factors like VEGF (1, 2). These portosystemic collaterals divert a fraction of the portal blood into systemic circulation. With the progression of portal hypertension, these collaterals enlarge and form large vascular channels known as spontaneous portosystemic shunts (SPSS) (3). Though previously thought to be beneficial in decompressing the portal pressure, recent studies have shown an increased incidence of the development of hepatic encephalopathy, hepatorenal syndrome, gastroesophageal varices, ascites and spontaneous bacterial peritonitis (4). Large SPSS defined as those >8 mm diameter can be treated by embolization especially in the early stages (5).
Here, we describe a case of mesocaval shunt embolization in a patient presenting with recurrent episodes of hepatic encephalopathy.
Case presentation:
A 53 year old man, chronic alcoholic since the past 30 years, came with the complaints of altered sleep for one week in the form of excessive daytime sleepiness and tremors involving both upper limbs. The patient has had similar episodes occurring about every 20 days since the past six months for which he took some medications from a local practitioner, details of which were not available. There was no history of hematemesis/ malena/ jaundice/ altered sensorium. On examination, flaps were present in both upper limbs.(Video 1) An ultrasound of the abdomen showed altered echotexture of the liver suggestive of liver parenchymal disease with splenomegaly. LFTs showed Total bilirubin- 3 gm %, D. Bilirubin- 1.2 gm%, SGOT-73, SGPT-46, ALP-321. A contrast enhanced CT scan (Fig. 1) of the abdomen showed liver cirrhosis with portal hypertension (splenomegaly, portosystemic collaterals and minimal ascites). A serpiginous collateral was noted between the superior mesenteric vein and the IVC suggestive of a mesocaval shunt. Upper GI endoscopy showed small esophageal varices. A portosystemic shunt gram was performed which confirmed the presence of a mesocaval shunt at the level of L2 vertebral body from a tributary of SMV draining into IVC (Figure 1A and 1B). The patient was planned for mesocaval shunt embolization.
Video 1 : Flaps seen in the patient due to hepatic encephalopathy.
Fig 1 : Axial (Figure 1A) and coronal (Figure 1B) contrast enhanced CT images show a bunch of serpiginous tortuous collaterals connecting the tributary of the superior mesenteric vein with IVC suggestive of a mesocaval shunt.
An 8 Fr vascular access was taken through the right IJV. A 6 Fr Rabbe sheath was positioned at the opening of the mesocaval shunt in the IVC across the ostium. A 5 Fr SIM 1 catheter was placed deep in the collateral venous system. Shunt gram obtained by placing the catheter in the shunt with thelong sheath obstructing the shunt ostium shows retrograde filling of contrast into the collaterals which is seen draining into the portal vein confirming that it is a portosystemic shunt communicating the IVC with tributaries of SMV. Further selective canulation was performed using Terumo Progreat Microcatheter (Figure 2 and Video 2)
Figure 2: Portosystemic shunt gram shows the mesocaval shunt at the level of L2 vertebral body from a tributary of SMV draining into IVC.Teru
Video 2: Shunt gram taken by placing the catheter in the shunt and long sheath obstructing the shunt ostium shows retrograde filling of contrast into the collaterals which is seen draining into the portal vein confirming that it is a portosystemic shunt communicating the IVC with tributaries of SMV.
Multiple detachable coils both 0.035in and 0.018in system and COOK 0.035in pushable coils were used for the embolization of the mesocaval shunt. Check gram showed reflux of the contrast into IVC with non-filling of mesocaval shunt. (Figure 3A, 3B and Video 3)
Figure 3: Post-embolization shunt gram shows non-opacification of the mesocaval shunt with reflux of contrast into the IVC in the anteroposterior (Figure 3A) and lateral views (Figure 3B).
Video 3: Post-embolization check gram shows the reflux of the contrast into IVC with non-filling of mesocaval shunt.
Fig. 4 : Post-embolization axial (Figure 4A) and coronal (Figure 4B) contrast enhanced CT images show metallic artifacts of the embolization coils and non-opacification of the tortuous mesocaval shunt.