CARTO effective for refractory hepatic encephalopathy

Last Updated: 2018-07-03

By Will Boggs MD

NEW YORK (Reuters Health) - Coil-assisted retrograde transvenous obliteration (CARTO) is an effective option for patients with medically refractory hepatic encephalopathy (HE), a retrospective study suggests.

"As many physicians are aware, HE is extremely challenging and causes a huge burden to the patients and their families," Dr. Edward Wolfgang Lee from UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California told Reuters Health by email. "It also causes a massive healthcare cost to our society."

"I think is it important to know that we have another treatment option for these patients, CARTO," he said. "It is relatively safe with a high clinical efficacy. Hopefully, CARTO can be remembered when physicians see patients with HE and spontaneous portosystemic shunt (SPSS)."

Despite aggressive medical treatment with lactulose, rifaximin, and the like, many patients develop refractory encephalopathy due to SPSS. Occlusion of SPSS can correct the encephalopathy by redirecting blood to the liver for more complete metabolic degradation of digested protein and other potential toxins.

Dr. Lee's team evaluated the efficacy and safety of CARTO, which has been shown effective for treating gastric variceal bleeding resulting from portal hypertension, in 43 patients with refractory overt HE.

The overall technical success rate was 100%, with 37 patients achieving complete occlusion of the shunt and 6 patients achieving partial occlusion, the authors reported online June 14th in The American Journal of Gastroenterology.

All but 4 patients (90.7%) achieved clinical success, defined as an improvement in HE as evidenced by a West Haven (WH) score improvement from 2, 3, or 4 (overt HE) to 0 or 1 (covert or minimal HE).

Clinical response rates were significantly higher with complete occlusion (35/37) than with partial occlusion (4/6).

Overt HE recurred in 3 patients, all of whom had a partial occlusion during the initial CARTO. None of the 35 responders in the complete occlusion group had recurrent overt HE.

Overall, 13 patients who underwent CARTO have received orthotopic liver transplant, 11 patients are still wait-listed for transplant, 4 are not listed or were denied by the transplant committee, 5 were already post-transplant at the time of CARTO, and 10 patients (23.3%) died during the follow-up period.

The overall mean survival was 1,465 days, and the overall mean ascites-free survival was 1,571 days. Overall mean esophageal varices-free survival was 1,469 days.

"More than 50% of patients either received liver transplant or are still on waitlist for liver transplant," Dr. Lee said. "I think that is an exciting finding where these patients probably didn't do well with their encephalopathy symptoms and were probably denied from being listed. In that sense, our procedure made a huge difference in patient care."

"Overall, these patients lived an average of over 4 years since the CARTO procedure, which may not have happened without the procedure," he said. "I think (this) is also an exciting finding, as an average survival of these patients with hepatic encephalopathy is very poor as severe HE (like our patient cohorts) is associated with a high mortality rate."

"I would strongly recommend CARTO to be highly considered for those patients with HE and SPSS," Dr. Lee concluded. "However, the decision should be made in a multidisciplinary manner with hepatologists, gastroenterologists, internists, transplant surgeons, and interventional radiologists. Also, although the procedure is relatively safe, a properly trained interventional radiologist should be performing it."

Dr. Cyriac Abby Philips from PVS Memorial Hospital, Kochi, India, who recently reported successful shunt occlusion for SPSS-related refractory HE, told Reuters Health by email, "An important aspect to be noted is that with the use of only coils, larger complex shunts may not be completely occluded, and a partial occlusion (seen in the current study) may lead to recurrence of hepatic encephalopathy leading to repetition of the procedure."

"Larger studies need to look into comparing other modalities for shunt occlusion, such as BRTO (balloon-assisted) and PARTO (plug-assisted) and a combination of these with CARTO, which may provide a 100% occlusion rate to patients," he said. "The choice of single versus multimodal treatment depends upon the shunt anatomy."

Dr. Philips added, "The most important aspect of this study is that treating physicians must be aware of the fact that in the presence of recurrent hepatic encephalopathy not associated with any identifiable precipitating factors, evaluation must include cross-sectional imaging of the abdomen in the portal venous phase to look for large portosystemic shunts. This might help the patient have a transplant-free survival in case an expert shunt occlusion can be performed for improving quality of life; ameliorating portal hypertension complications; and preventing progressive liver failure in the long term by reducing further shunt syndrome burden that eventually compromises portal flow, leading to portal vein thrombosis and further worsening of hepatic function."

SOURCE: https://go.nature.com/2MN4Z43

Am J Gastroenterol 2018.