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CARTO technique safe, effective for overt hepatic encephalopathy

Coil-assisted retrograde transvenous obliteration was safe and effective in treating patients with refractory overt hepatic encephalopathy caused by spontaneous portosystemic shunts, according to recently published data.

The CARTO procedure is a modified form of balloon-occluded retrograde transvenous obliteration (BRTO) that involves the use of coils and Gelfoam (Pfizer) instead of indwelling balloons and sclerosing agents.

“Without the indwelling balloon, CARTO can be performed as an outpatient procedure in many cases or as an inpatient procedure with a shorter length of stay or lower level of care,” Edward Wolfgang Lee, MD, PhD, from the University of California Los Angeles Medical Center, and colleagues wrote. “The indwelling balloon has been shown to increase the length of stay because the patient needs to be continuously monitored, while the balloon is in place.”

Lee and colleagues reviewed the records of 43 patients who received CARTO for refractory overt hepatic encephalopathy with spontaneous portosystemic shunts (SPSSs).

The technical success rate was 100% with complete shunt occlusion in 37 patients and partial occlusion in six patients. The researchers noted that partial occlusion was due to multiple large shunts.

The clinical success rate was 90.7% with a significant improvement in West Haven scores among 33 patients and mild improvement in six patients. Patients with complete occlusion had significantly better response rates than those who achieved partial occlusion (P = .0031).

Three patients experienced recurrent over hepatic encephalopathy. Two of these patients underwent a second CARTO procedure and showed improvement in West Haven score.

Of the four patients who did not respond to treatment, three had prior document neurological issues including ischemic stroke and dementia.

Median ammonia levels decreased from 138 µg/dL to 71 µg/dL at day 3 posttreatment (P < .001), down to 69 µg/dL at 3 months (P < .001).

Ten patients died during a mean follow-up period of 893 days. However, no patients died within the first 30 days following CARTO. Overall mean survival was 1,465.47 days (95% CI, 1,242.99-1,687.95).

“CARTO could be an excellent addition to currently available treatment options for these patients,” the researchers wrote. “In addition, CARTO may have comparable effectiveness with a better safety profile compared with traditional and modified BRTO techniques.” – by Talitha Bennett

Disclosure: The authors report no relevant financial disclosures.