Introduction: Spontaneous Porto-Systemic Shunts (SPSS) are common in patients with cirrhosis, and can contribute to hepatic encephalopathy. Occlusion of SPSS can improve cognition, reduce episodes of overt hepatic encephalopathy, and may even improve liver function. This is usually achieved by transvenous access occluding the shunt using sclerosant, coils, or vascular plug. Endoscopic ultrasound (EUS) has lately been used extensively in management of fundal varices, which often have coexisting SPSS. EUS guided embolization can lead to complete occlusion of SPSS in patients with variceal bleeding. We here describe a series of seven cases of occlusion of portosystemic shunts with EUS-guided Transgastric Shunt Occlusion (ETSO).
Case Description/Methods: Patients with cirrhosis of liver, who had recurrent or refractory hepatic encephalopathy & SPSS on cross-sectional imaging were screened. Patients who were not candidates for retrograde transvenous access due to prior transvenous obliteration or financial limitations were offered ETSO. The shunt was identified and punctured with a 19G EUS needle and occluded using undiluted n-butyl 2-cyanoacrylate glue with or without coils. Nine patients were evaluated for shunt occlusion for recurrent/refractory hepatic encephalopathy, and seven patients underwent ETSO. Two patients required a second session. Complete cessation of doppler flow during the procedure was seen in 6 of the 7 cases, and one showed flow reduction. Clinical response was seen in 6 of the 7 cases. The three cases which did not achieve complete occlusion of the shunt were not subjected to a repeat procedure as they had satisfactory clinical improvement. Four patients were assessed with serial electroencephalograms, who showed improvement in cerebral electrical activity.
Discussion: The advantages of using EUS for occlusion of SPSS are reduced cost, shorter procedure time, no need for fluoroscopy, on-table confirmation of flow cessation, and the ability to target multiple feeders. Additionally, the ability to achieve partial/multistep occlusion is invaluable. Potential drawbacks include risk of systemic embolization and bleeding from puncture, which were not seen in our cases. EUS-guided Transgastric Shunt Occlusion is an effective, quick, and resource efficient alternative to radiological procedures for occluding large portosystemic shunts.
