50 year old female patient s/p liver transplant presents with persistent encephalopathy. A massively dilated splenorenal shunt was identified but an attempted BRTO procedure failed. The patient presents for transhepatic embolization.
Comment: This patient had gradually progressing and increasingly severe and prolonged episodes of encephalopathy after liver transplantation. As it turns out, there was a significant splenorenal shunt that was likely responsible for this. An attempt was made at an outside hospital to perform retrograde embolization via the left renal vein but the large size of the varices made that ineffective. As a result, we attempted to access the splenorenal shunt using a transhepatic approach. Once the portal vein was catheterized, a venogram demonstrated hepatofugal flow with preferential flow into the splenorenal shunt. We were then able to catheterize the shunt and embolize the major branches. Following embolization, hepatopetal flow was restored.