Ectopic testicular vein portosystemic shunt causing recurrent hepatic encephalopathy

Abstract Background Refractory hepatic encephalopathy (HE) in decompensated chronic liver disease may result from large spontaneous portosystemic shunts, including ectopic pathways that are often overlooked on routine imaging. Case A 51-year-old man with alcohol-related decompensated chronic liver disease presented with recurrent low-grade HE despite optimal medical therapy. Imaging demonstrated a large spontaneous ectopic portosystemic shunt arising from an epiploic tributary of the splenic vein, forming a retroperitoneal variceal complex draining via the left testicular vein into the left renal vein. Retrograde transvenous embolization was performed through the left gonadal vein using an Amplatzer Vascular Plug II at the shunt–testicular vein junction, followed by n-butyl-cyanoacrylate embolization of distal varices. Serum ammonia decreased from 118 to 49 µmol/L with rapid clinical improvement and no immediate complications. Conclusion Selective embolization of ectopic portosystemic shunts is a safe and effective treatment for refractory HE in appropriately selected patients.