Balloon-Occluded Retrograde Transvenous Obliteration for Recurrent Hepatic Encephalopathy by the Trans-Paraumbilical Venous Approach

Hepatic encephalopathy is a serious complication of liver cirrhosis often associated with portosystemic shunts (PSSs), which may be refractory to medical management. We present the case of a 58-year-old man with liver cirrhosis who developed recurrent hepatic encephalopathy associated with mesorenal and paraumbilical PSSs. Despite medical therapy, his symptoms recurred, necessitating interventional treatment. The first session consisted of partial splenic embolization and balloon-occluded retrograde transvenous obliteration (BRTO) of the mesorenal shunt via the transjugular route, resulting in transient improvement. Due to recurrence of encephalopathy, a second BRTO was performed via percutaneous trans-paraumbilical venous access under ultrasound guidance, allowing for stable catheterization and successful embolization with detachable coils, and partial splenic embolization was also performed during the second session to further control portal pressure. Following the procedures, the patient achieved sustained clinical and biochemical improvement, with no recurrence of encephalopathy during seven months of follow-up. This case highlights the safety and utility of the trans-paraumbilical venous approach as an alternative access route for BRTO in patients with complex PSSs.