Refractory hepatic encephalopathy due to concomitant transjugular intrahepatic portosystemic shunt and spontaneous mesocaval shunt controlled by embolization of the competitive portosystemic shunt.

Spontaneous mesocaval shunt (SMCS) is an uncommon cause of refractory encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS) creation. We report a patient who presented with refractory hepatic encephalopathy (HE) post-TIPS creation for variceal bleeding in whom a SMCS was found. Percutaneous transhepatic occlusion of the SMCS reduced the portal vein flow diverted from the liver and provided sufficient liver perfusion to reverse the HE while maintaining satisfactory decompression of esophageal varices.