For refractory HE attributed to a large SPSS (≥8 mm) in a patient with MELD 12–16 and prior variceal bleeding, what is your standard peri-procedural and post-embolization plan (portal HTN prophylaxis and surveillance) to minimize worsening ascites or rebleeding while maximizing cognitive benefit?

Closing a clinically significant portosystemic shunt may worsen portal HTN, so it’s reasonable to update an EGD in 1-2 months post intervention to ensure there are no high-risk esophageal varices that would require banding.

A non-selective beta blocker can also be considered to mitigate this risk of...

Ideally, consider liver transplant - even at low MELD via the living donor pathway or improved options with a pump. Alternatives include small-caliber TIPS with embolization of SPSS and embolization of varices; however, unclear if there is continued HE risk. Would not necessarily consider BRTO speci...