![]() The patient had a slightly worse CP score of 7 (CP classification of B) on admission ( Table). Laboratory testing on admission revealed the following: alanine aminotransferase, 83 IU/L (normal range, 6-35 IU/L) platelet count, 9.4×10 4 g/dL (normal range, 15-35×10 4 g/dL) total bilirubin, 1.80 mg/dL (normal range, 0.3-1.2) ammonia, 159 μg/dL (normal range, 20-80) indocyanine green retention rate at 15 minutes of 39.2% (normal range, <10) HCV genotype, 1b and HCV viral load, 6.3 log IU/L (high titer). A physical examination on admission revealed the following: height, 156 cm body weight, 54 kg body temperature, 36.8☌ pulse, 78 bpm blood pressure, 102/54 mmHg chest, no abnormal sounds on auscultation abdomen, soft and flat liver, not palpable palmar erythema, present and flapping tremor, positive. BCAA and lactitol hydrate treatment was discontinued in order to initiate DAA therapy, but the patient was admitted to the hospital two months later because of disturbance of consciousness. She had been treated with ursodeoxycholic acid, a branched-chain amino acid (BCAA)-enriched elemental diet, and lactitol hydrate. She had a CP score of 6 and a CP classification of A. The patient was a 70-year-old woman with liver cirrhosis associated with hepatitis C virus (HCV) (genotype 1b) infection. These results suggest that B-RTO using a combination of CANDIS™ Ⓡ and Target Ⓡ XL 360 is effective in complicated shunt cases that are difficult to treat using conventional B-RTO. After treatment, the patient was completely free from hepatic encephalopathy, with a serum ammonia level within the normal range. ![]() The combined use of CANDIS™ Ⓡ and Target Ⓡ XL 360 led to successful shunt occlusion. The Target Ⓡ XL 360 coils are equipped with a shape-memory function and are more physically stable than conventional metallic coils because they form 3D loops. Therefore, we attempted re-treatment using Target Ⓡ XL 360 shape-memory coils (Stryker Japan, Tokyo, Japan). However, the shunt was too large in diameter to be occluded completely with a balloon and treated with sclerosing agents. Therefore, B-RTO was attempted using a coaxial and double interruption system (CANDIS™ Ⓡ Medikit, Tokyo, Japan). ![]() The insertion of catheters has been shown to be difficult in several cases with thick, long, and winding shunts on three-dimensional computed tomography (3D-CT). We herein report a case of hepatic encephalopathy due to spleno-renal shunt (SRS) that could not be controlled with medical treatment. However, in some cases, complete occlusion is difficult to achieve by conventional B-RTO because the shunt is large in diameter, long, or markedly winding. Balloon-occluded retrograde transvenous obliteration (B-RTO) is established as the standard treatment for gastric varices (GV) and hepatic encephalopathy associated with porto-systemic shunt. ![]()
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