Reversal of hepatic encephalopathy following a trans-scrotal approach to mesogonadal shunt embolization: a case report.

backgroundSpontaneous portosystemic shunts are defined as venous conduits that occur in response to elevated portal venous pressure, resulting in alternative outflows from the portal circulation. We present a case of atypical portosystemic shunt formation between the inferior mesenteric vein branches and the left testicular vein resulting in hepatic encephalopathy in a patient with a history of cirrhosis, describing the access technique we used for successful portosystemic shunt embolization via a combined right common femoral vein and trans-scrotal approach. CASE PRESENTATION: A 57-year-old male with a history of cirrhosis presented with a 1-month history of progressive cognitive decline despite adherence to a medical regimen of lactulose, rifaximin, and a low-sodium diet. Abdominal computerized tomography and scrotal ultrasound revealed shunt formation from the mesenteric venous system to the systemic circulation, with intermediate connections through the scrotal venous plexus and left gonadal vein. Following an outpatient consultation with interventional radiology for worsening hepatic encephalopathy, the inflow and outflow tracts of the shunt were visualized using digital-subtraction venography. Embolization with Penumbra Ruby XL coil packs and Sotradecol infusion was achieved using an ultrasound-guided trans-scrotal approach for the inflow tract and a femoral approach for the outflow tract. The patient's hepatic encephalopathy resolved shortly after the procedure.

conclusionsMesogonadal shunts can be a sequela to portal hypertension and leave patients susceptible to hepatic encephalopathy due to direct entry of metabolic toxins such as ammonia into the systemic circulation. Although systemic access is the standard approach for existing coil embolization and balloon-occluded retrograde transvenous obliteration (BRTO) procedures used for the treatment of mesogonadal shunts, further consideration should be given for unconventional vascular access in difficult portosystemic shunt presentations to better address shunt inflow and prevent recurrence. Future avenues for research can include comparing shunt recurrences in patients with layered sclerosant and coil embolization to patients with BRTO or coil embolization alone.