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 worsening portal HTN after closure of a shunt, as such a patient probably would qualify for one, but data are lacking on the efficacy of such a maneuver, so I would still do the EGD.

In severe refractory cases with excellent hepatic reserve where there are numerous SPSS (too many to embolize), and you have a skilled IR doctor who has delineated the patient’s vasculature and has skill in management of post-TIPS complications, a TIPS could be cons...

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 specifically for HE given increased risk for varices/ascites.