Percutaneous transretroperitoneal direct approach to occlude a major shunt in a patient with extrahepatic...

A 73-year-old woman had sudden dystrophy and amnesia in our hospital. Her serum ammonia level was high. Marked collateral vessels from the splenic vein to the left renal vein around the spleen were seen on a computed tomography (CT) scan with contrast enhancement. An abdominal angiogram showed that the direction of the splenic vein was hepatofugal on superior mesenteric arterial portography, with a marked splenorenal shunt on splenic arterial portography. Hepatic encephalopathy due to a marked extrahepatic portal-systemic shunt was diagnosed. Transjugular retrograde obliteration (TJO) was attempted, but the catheter and guide wire could not selectively approach the splenorenal shunt because of many outflow routes. We punctured the vessels from the left side of the back under ultrasonographic guidance. We injected microcoils and ethanolamine oleate to completely obliterate the shunt. Marked collateral vessels showed no venous flow on a CT scan after treatment. The serum ammonia level was in the normal range. There has been no recanalization of the shunt vessels for 4 years after treatment. Hepatic encephalopathy has not recurred, and no other collateral vessels have developed. To our knowledge, this is the first report to document the use of a percutaneous transretroperitoneal direct approach to occlude a major shunt in a patient with extrahepatic portal-systemic encephalopathy.