Paradoxical Cerebral Embolization during Transjugular Intrahepatic Portosystemic Shunt Creation and Variceal Sclerotherapy

Transjugular intrahepatic portosystemic shunts (TIPS) are widely performed and have replaced more invasive surgical shunt alternatives in the treatment of medically and endoscopically refractory portal hypertensive variceal bleeds and ascites.[ 1 ] [ 2 ] In the setting of refractory gastroesophageal variceal hemorrhage, creation of a TIPS to decompress the portal system is often combined with variceal embolization to directly treat the source of hemorrhage and decrease rebleed rates.[ 3 ] While coil or plug embolization is performed to interrupt flow into the variceal circuit, the addition of sclerotherapy to permeate through and eliminate the variceal circuit has been suggested as a more efficacious therapy with lower rebleed rates.[ 4 ] [ 5 ] [ 6 ] Controlling the distribution of sclerosants in a high-flow system that may have large capacitance and multiple inflow vessels, however, may result in incomplete treatment and the potential for non-target embolization. Herein, a case of TIPS creation and variceal sclerotherapy complicated by paradoxical cerebral embolization is reported followed by a review of the pertinent literature. Disclosures No relevant financial disclosures. N.K.: Research Grant and Proctor, Sirtex Medical. B.S.M.: Scientific Advisory Board, Balt Medical.