Antecubital vein approach of retrograde transvenous obliteration using a steerable triaxial system for portosystemic encephalopathy

We report a case of portosystemic encephalopathy treated by retrograde transvenous obliteration (RTO) with an antecubital vein approach using a steerable triaxial system. A 77-year-old female was referred to our department complaining of dizziness and tremor. Laboratory data showed hyperammonemia. Contrast-enhanced CT and 3D-CT reconstruction images demonstrated an inferior mesenteric vein (IMV)-left common iliac vein shunt and a splenorenal shunt. The former was treated as a responsible shunt. The spleen volume was 212 mL, and the liver volume was 757 mL; giving a spleen/liver volume ratio of 0.3. Partial splenic artery embolization (PSE) was employed to control portal venous pressure. The hepatic venous pressure gradient (HVPG) changed from 13.2 to 9.6 mm Hg and the spleen/liver volume ratio improved from 0.3 to 0.2 by PSE. Two months after PSE, RTO with an antecubital vein approach using a steerable triaxial system was performed. HVPG changed to 12.5 mm Hg after RTO. Contrast-enhanced CT and 3D-CT reconstruction images 3 days after the procedure demonstrated the thrombus in the IMV-left common iliac vein shunt. We conclude that the antecubital vein approach using a steerable triaxial system is a feasible and minimally invasive technique in RTO for portosystemic shunts.