Daniel M. Keller, PhD

April 30, 2013

AMSTERDAM, the Netherlands -- Embolization of large spontaneous portosystemic shunts can relieve refractory hepatic encephalopathy and can keep many patients free of it for the long term as long as they have sufficient functional liver reserve, a new study has shown.

In the 100 days after embolization, 60% of patients were free of hepatic encephalopathy. During the overall follow-up of more than 2 years, that was reduced to still a very impressive 49%. Compared with the 2-year period before embolization, both reductions were significant (P < .001), reports Wim Laleman, MD, PhD, from the Department of Liver and Biliopancreatic Disorders at University Hospitals Leuven and the Catholic University of Leuven in Belgium.

Dr. Laleman presented the study results here at the International Liver Congress 2013.

The retrospective study involved men and women from a European multicenter cohort with cirrhosis, refractory encephalopathy, and large spontaneous portosystemic shunts that were amenable to angiographic embolization. Patients were excluded if they had a surgical shunt or transjugular intrahepatic portosystemic shunt graft, portal vein thrombosis, or hepatocellular carcinoma.

Most of the cirrhosis was caused by alcohol abuse or hepatitis C. Child–Pugh score before embolization was 7.9, and model for end-stage liver disease (MELD) score was 13.2 (range, 5 - 28).

In 37 of 38 patients, embolization was achieved with a percutaneous, transhepatic, or femoral vein approach using coils, Amplatzer plugs, or matrix. The most common spontaneous shunt was splenorenal (n = 20); the rest were mesentericocaval, periumbilical, or mesentericorenal.

In addition to the reduction in hepatic encephalopathy, embolization was associated with a reduction in the number of hospitalizations, from 3.8 in the preprocedure period to 1.3 in the follow-up period (< .001). Hospital days were reduced from 41.0 to 17.8 (P < .001).

Quality of Life

Dr. Laleman explained that quality of life is very important in the context of hepatic encephalopathy. Before embolization, almost 73% of patients had limited quality of life and were in need of help with daily activities. After embolization, only 25% of patients had limited quality of life. Autonomy increased from 21.6% of patients to 64.9%, but there was no change in complete disability (about 10% before and after embolization), he reported.

Near-term safety was excellent. There was no mortality and 8 procedure-related complications, only 1 of which was serious (hypovolemic shock after a transhepatic approach that resolved after surgical hemostasis).

Dr. Laleman put to rest concerns about possible long-term complications of worsening liver function, thrombosis, and portal hypertensive complications. "There was no increase in the presence of gastroesophageal varices and no increase in gastropathy (2 patients developed de novo varices, but this was not considered statistically significant). With regard to ascites, we saw a similar evolution, so there was no apparent increase in portal hypertensive complications," he said.

There was no change in liver function (MELD score) from before to after the procedure (13.2 vs 15.2; P = .26). Although 4 patients had thrombotic problems, this was not statistically significant.

Patient Selection

On multivariate analysis, adjusted for time between diagnosis of hepatic encephalopathy and embolization, serum albumin, International Normalized Ratio, the presence of ascites, and preprocedure Child score, the only independent predictors of recurrence of hepatic encephalopathy were sex (odds ratio [OR], 0.06; 95% confidence interval [CI], .005 - 0.971; P = .048) and pre-embolization MELD score (OR, 1.52; 95% CI, 1.073 - 2.180; = .019).

"Embolization of these shunts is feasible, effective, and safe, provided that sufficient functional liver reserve is guaranteed," Dr. Laleman concluded. According to the investigators, patients should have a MELD score of 11 or lower to be considered for the procedure.

This is important work because it is a large study, session chair Isabelle Colle, MD, PhD, professor of hepatology and gastroenterology and head of the gastroenterology clinic at Gent University in Belgium, told Medscape Medical News.

She explained that embolization of large spontaneous portosystemic shunts is "a good treatment for patients who have really important hepatic encephalopathy and have large shunts, because they are often Child A patients.... It's clinically important that we can offer treatment to those patients without offering transplantation."

Dr. Laleman and Dr. Colle have disclosed no relevant financial relationships.

International Liver Congress 2013: 48th Annual Meeting of the European Association for the Study of the Liver (EASL). Abstract 77. Presented April 26, 2013.