Reversal of Hepatic Encephalopathy Following a Trans-scrotal Approach to Mesogonadal Shunt Embolization: A Case Report

Reversal of Hepatic Encephalopathy Following a Trans-scrotal Approach to Mesogonadal Shunt Embolization: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Reversal of Hepatic Encephalopathy Following a Trans-scrotal Approach to Mesogonadal Shunt Embolization: A Case Report Adil Basha, Ifeadikanwa Emejulu, Swar Shah This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8734542/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 5 You are reading this latest preprint version Abstract Background Spontaneous portosystemic shunts are defined as venous conduits that occur in response to elevated portal venous pressure, resulting in alternative outflows from the portal circulation. We present a case of atypical portosystemic shunt formation between the inferior mesenteric vein branches and the left testicular vein resulting in hepatic encephalopathy in a patient with a history of cirrhosis, describing the unique access technique we used for successful portosystemic shunt embolization via a combined right common femoral vein and trans-scrotal approach. Case Presentation A 57-year-old male with a history of cirrhosis presented with a one-month history of progressive cognitive decline despite adherence to a medical regimen of lactulose, rifaximin, and a low-sodium diet. Abdominal computerized tomography and scrotal ultrasound revealed shunt formation from the mesenteric venous system to the systemic circulation, with intermediate connections through the scrotal venous plexus and left gonadal vein. Following an outpatient consultation with interventional radiology for worsening hepatic encephalopathy, the inflow and outflow tracts of the shunt were visualized using digital-subtraction venography. Embolization with coil packs and Sotradecol infusion was achieved using an ultrasound-guided trans-scrotal approach for the inflow tract and a femoral approach for the outflow tract. The patient’s hepatic encephalopathy resolved shortly after the procedure. Conclusions Mesogonadal shunts can be a sequela to portal hypertension and leave patients susceptible to hepatic encephalopathy due to direct entry of metabolic toxins such as ammonia into the systemic circulation. Although systemic access is the standard approach for existing coil embolization and balloon-occluded retrograde transvenous obliteration (BRTO) procedures used for the treatment of mesogonadal shunts, further consideration should be given for unconventional vascular access in difficult portosystemic shunt presentations to better address shunt inflow and prevent recurrence. Future avenues for research can include comparing shunt recurrences in patients with layered sclerosant and coil embolization to patients with BRTO or coil embolization alone. Hepatic encephalopathy embolization portosystemic shunt cirrhosis portal hypertension Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Spontaneous portosystemic shunts (SPSS) are defined as venous conduits that occur in response to elevated portal venous pressure, typically in the context of cirrhotic liver disease. 1 SPSS can result in alternative outflows from the portal circulation, allowing blood to enter the systemic venous circulation while bypassing the liver, limiting ammonia metabolism and promoting the development of hepatic encephalopathy. 2 We present a case of atypical SPSS formation between the inferior mesenteric vein branches and the left testicular vein resulting in hepatic encephalopathy in a patient with a history of cirrhosis secondary to metabolic dysfunction-associated steatohepatitis (MASH), and describe the unique access technique we used for successful portosystemic shunt embolization via a right common femoral vein and trans-scrotal approach. Endovascular treatment was valuable for this patient due to the minimally invasive means through which it could shut off flow through the portosystemic shunt and reverse his encephalopathy. Case Presentation History and Physical Examination A 57-year-old male with a history of human immunodeficiency virus (HIV) on antiretroviral therapy, cirrhosis secondary to MASH, type 2 diabetes, and hypertension presented with a one-month history of progressive cognitive decline despite adherence to a medical regimen of lactulose, rifaximin, and a low-sodium diet. He was seen for an outpatient consultation with Interventional Radiology in October 2025 for recurrent encephalopathy, which appeared to be rapidly developing, characterized by episodic confusion, falls, and word finding difficulties. While an intervention was planned, he was admitted to the hospital less than two weeks later with notable dysarthria and a diminished expressive vocabulary. He had a previous history of esophageal varices secondary to portal hypertension which was managed with endoscopic band ligation in March 2025, as well as a large splenorenal shunt which was embolized with coils in 2023 for encephalopathy. His notable surgical history included bilateral inguinal hernia repairs. Diagnostic Evaluation Laboratory investigations demonstrated hyperammonemia (135 umol/L), hyperbilirubinemia (2.9 mg/dL), hypoalbuminemia (3.3 g/dL), hyperglobulinemia (3.9 g/dL), leukopenia (3800/uL), and thrombocytopenia (40,000/uL), consistent with advanced chronic liver disease. His HIV was controlled with an undetectable viral load and CD4 count of 412/uL. Initial screening for acute secondary causes—including chest radiography, head computerized tomography (CT), and esophagogastroduodenoscopy—was unremarkable. Recent outpatient screening for hepatocellular carcinoma (ultrasound and alpha-fetoprotein) was negative. A dedicated CT of the abdomen and pelvis performed one month prior demonstrated a complex portosystemic shunt arising from the sigmoid and left colic veins, extending into the left scrotum and draining via the left testicular vein into the systemic circulation. After a discussion of the risks and benefits of proceeding with intervention, notably including potential colonic venous ischemia, testicular ischemia, nontarget embolization, and uncontrolled bleeding, both the patient and his proxy agreed with proceeding to embolization. Procedure Initial sonographic evaluation revealed complex scrotal venous architecture, with a dilated pampiniform plexus as would be seen in a varicocele (Fig. 1 A). Within the left lower quadrant, two dominant afferent branches were identified originating from the descending and sigmoid colon, respectively unifying at the upper aspect of the scrotum. These vessels traversed the inguinal canal into the left scrotum, forming a high-flow venous plexus with efferent drainage via a dilated left testicular vein (Fig. 1 B). This was consistent with prior CT findings (Fig. 1 B, C). Given the anatomical complexity of this portosystemic shunt, a hybrid access strategy utilizing both systemic venous and direct trans-scrotal routes was selected to facilitate comprehensive management of the inflow and outflow components. After systemic venous access was obtained through the right common femoral vein, a 7 French sheath was placed in the left renal vein. A Fogarty balloon was then advanced into the lower aspect of the testicular vein, and a balloon-occluded retrograde venogram was performed, confirming a large, high-flow portosystemic shunt with outflow through the left testicular vein. After careful mapping with ultrasound, and under sterile sonographic guidance, trans-scrotal access of the unified inflow vein was performed using a 21-gauge needle, followed by a 4/5 French slender sheath which was placed over a 0.018-inch wire. A digital subtraction venogram displayed the entirety of the shunt, with contrast reflux demonstrating inflow branches from the descending and sigmoid colon, complex flow through the scrotum and outflow via the left testicular vein (Fig. 2 ). With the aid of a 5 French catheter, the unified inflow vein was embolized just below the confluence of the sigmoid branches and the left colic branches. Care was taken to avoid approaching these vessels as they appeared to represent the dominant outflow of the left colon and embolization would come with the risk of venous ischemia. A tight coil pack was successfully placed, followed by administration of 1% foamed Sotradecol via the same scrotal access under fluoroscopic monitoring to confirm adequate coverage and contact time with the scrotal vasculature (Fig. 3 A). A confirmatory venogram displayed contrast stasis in the scrotal venous plexus, confirming adequate inflow control (Fig. 4 A). Subsequently, four separate coil packs with intervening 1% foamed Sotradecol were placed along the course of the left testicular vein via systemic venous access in a “sandwich” technique to prevent collateral recanalization (Fig. 3 B). The confirmatory left renal venogram demonstrated no residual inflow (Fig. 4 B). After confirming adequate stasis of flow, the trans-scrotal access was removed following Gelfoam tract embolization, and hemostasis was achieved with manual compression. The patient tolerated the procedure well and was returned to the inpatient service for observation, after which he was discharged thirteen days later following improvement of his encephalopathy. Discussion SPSS are very common in the cirrhotic patient population, with studies revealing that up to 60% of patients with liver disease show evidence of portosystemic shunts. 3 Some of the most common shunt types include splenorenal, gastrorenal and paraumbilical shunts. 4 , 5 , 6 Although these are considered to be the typical presentations of SPSS, atypical shunts causing hepatic encephalopathy have also been discussed in existing literature, including mesenteric-iliac shunts, portocaval shunts and intrahepatic shunts. 7 , 8 , 9 The driving force behind SPSS formation lies in the large pressure gradient between cirrhotic portal venous pressure (12–20 mmHg) and caval pressure (2–6 mmHg). Subsequent blood flow from the portal system back into its tributaries (splenic, superior mesenteric and inferior mesenteric veins) exceeds venous capacitance in the smaller vessels, causing high flow pathways to form from pre-existing embryonal venous channels. 10 Under normal physiologic conditions, these channels are functionally collapsed and do not make significant contributions to venous return, but in the context of elevated portal pressures, Doppler studies have found high flow velocities in SPSS that exceed 30 cm/s, with shunt embolization causing further increases in portal pressures, implying that the shunts were diverting significant amounts of flow away from the liver. 11 A possible explanation for this patient’s atypical shunting may have been his history of splenorenal shunt embolization, resulting in portal blood flow seeking another low resistance pathway and subsequent development of the mesenteric-gonadal shunt, with complex scrotal venous architecture found in his imaging indicating potential dilation of his pampiniform plexus to accommodate for high levels of flow to the left gonadal vein and ultimately systemic circulation. Post-surgical changes from his prior hernia repair may have also played a role. Portosystemic shunts have historically been addressed with balloon-occluded retrograde transvenous obliteration (BRTO) or standalone coil embolization to block off high-flow vessels. 12 As part of our treatment, a trans-scrotal approach followed by a combination of coil embolization and Sotradecol sclerosant infusion was done to appropriately control the inflow into the portosystemic shunt and reduce the risk for reformation of collaterals. For outflow control, an alternating coil embolization and sclerosant infusion technique was done to extensively cover a significant segment of the left gonadal vein. We chose this approach in order to prevent recanalization of the outflow tract or the creation of a direct shunt via neoangiogenesis between the inferior mesenteric and left gonadal veins due to their close anatomical proximity and multiple small collateral pathways known to drain into the left gonadal vein. 13 Although there are existing reports of mesogonadal shunts being treated with coil embolization, a literature search did not reveal any other written reports of a mesogonadal shunt being treated with trans-scrotal access, making this case report the first of its kind. 14 Although there is a lack of evidence of colonic injury secondary to Sotradecol sclerosant infusion, technical precautions were still taken due to the proximity of the inflow tract to the descending and sigmoid colon, with no signs of complications following the procedure. 15 , 16 Historically, the stomach has tolerated Sotradecol well, both via a transvenous and endoscopic injection perspective; however, the inherent muscular and vascular structure of the stomach is absent from the colon. An additional area for consideration included risk of portosystemic shunt recurrence due to the persistence of underlying increased portal pressure following the mesogonadal shunt closure. As this patient was not a candidate for transjugular intrahepatic portosystemic shunt (TIPS) given his history of hepatic encephalopathy, definitive treatment would necessitate liver transplant, which would be unfeasible in the short-term and limited by his HIV status. As such, the mainstays of this patient’s treatment would primarily involve medical optimization with lactulose and rifaximin, and expectant management of new portosystemic shunts with periodic embolization. Conclusions SPSS is a common consequence of portal hypertension, and leaves patients susceptible to hepatic encephalopathy due to direct entry of metabolic toxins such as ammonia into the systemic circulation. Mesogonadal shunts are one such type of atypical SPSS which can occur due to abnormal communication between the inferior mesenteric vein branches and the left gonadal vein. Although systemic access is the standard approach for existing coil embolization and BRTO procedures used for the treatment of mesogonadal shunts, further consideration should be given for unconventional vascular access in difficult SPSS presentations to better address shunt inflow and prevent recurrence. Future avenues for research can include comparing shunt recurrences in patients with layered Sotradecol infusion and coil embolization to patients with BRTO or coil embolization alone. Abbreviations SPSS Spontaneous portosystemic shunts MASH Metabolic dysfunction-associated steatohepatitis HIV Human immunodeficiency virus CT Computerized tomography BRTO Balloon-occluded retrograde transvenous obliteration TIPS Transjugular intrahepatic portosystemic shunt Declarations Ethics approval and consent to participate Ethics approval and consent for participation was obtained for the development of this manuscript. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Availability of data and material Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. Competing interests The authors declare that they have no competing interests Funding Not applicable Authors’ Contributions AB, IE and SS wrote the manuscript, IE was responsible for the editing and image acquisition, SS was responsible for the initial patient consultation and associated notes, SS and IE performed the procedure. All authors read and approved the final manuscript. Acknowledgements Not applicable References Durgham A, Tessier S, Ido F, Longo S, Nanda S (2022) Acquired Portosystemic Shunts in Cirrhosis and Portal Vein Thrombosis: A Case Report. Cureus 14(11):e31587 Published 2022 Nov 16. 10.7759/cureus.31587 Butterworth RF, Giguère JF, Michaud J, Lavoie J, Layrargues GP (1987) Ammonia: key factor in the pathogenesis of hepatic encephalopathy. Neurochem Pathol 6(1–2):1–12. 10.1007/BF02833598 Simón-Talero M, Roccarina D, Martínez J et al (2018) Association Between Portosystemic Shunts and Increased Complications and Mortality in Patients With Cirrhosis. Gastroenterology 154(6):1694–1705e4. 10.1053/j.gastro.2018.01.028 ​​Uy PPD, Francisco DM, Trivedi A, O’Loughlin M, Wu GY (2017) Vascular Diseases of the Spleen: A Review. J Clin Transl Hepatol 5(2):152–164. 10.14218/JCTH.2016.00062 Nardelli S, Riggio O, Gioia S, Puzzono M, Pelle G, Ridola L (2020) Spontaneous porto-systemic shunts in liver cirrhosis: Clinical and therapeutical aspects. World J Gastroenterol 26(15):1726–1732. 10.3748/wjg.v26.i15.1726 Achiwa S, Hirota S, Kako Y, Takaki H, Kobayashi K, Yamakado K (2017) Radiological anatomy of spontaneous splenorenal shunts in patients with chronic liver disease. Jpn J Radiol 35(4):206–214. 10.1007/s11604-017-0623-1 Mori H, Hayashi K, Fukuda T et al (1987) Intrahepatic portosystemic venous shunt: occurrence in patients with and without liver cirrhosis. AJR Am J Roentgenol 149(4):711–714. 10.2214/ajr.149.4.711 Sabol Pušić M, Budimir I, Dorosulić Z et al (2017) Portal systemic shunt between the hepatic portal vein and right renal vein in a patient with multifocal hepatocellular carcinoma: Case report. J Clin Ultrasound 45(8):524–527. 10.1002/jcu.22437 Alshehre O, Alahmari F, Alammari S, Almathami A, Alobaidi H, Alrashidi I, Alosaimi M, Garad F (2021) Portosystemic encephalopathy in a noncirrhotic patient treated by vascular plug embolization of mesoiliac shunt. AJ Intervent Radiol 5(1):32–36. 10.4103/AJIR.AJIR_19_19 Bhargava P, Vaidya S, Kolokythas O, Katz DS, Dighe M (2011) Pictorial review. Hepatic vascular shunts: embryology and imaging appearances. Br J Radiol 84(1008):1142–1152. 10.1259/bjr/82649468 Wang J, Cai S, Su C, Fan H, Gai Y et al (2020) Ultrasonic Evaluation of Spontaneous Portosystemic Shunts in Patients with Budd-Chiari Syndrome. 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J Investig Med High Impact Case Rep 8:2324709620904569. 10.1177/2324709620904569 Cho SB, Choi YH, So YH, Ahn DW, Jeong JB (2016) Balloon-Occluded Retrograde Transvenous Obliteration of Jejunal Varices: A Case Report, Therapeutic Approach. Dig Dis Sci 61(3):948–951. 10.1007/s10620-015-3949-5 Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Major revision 04 Apr, 2026 Reviewers agreed at journal 16 Feb, 2026 Reviewers invited by journal 09 Feb, 2026 Editor assigned by journal 02 Feb, 2026 First submitted to journal 29 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8734542","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":588289680,"identity":"376465ca-cc41-4005-a8fd-c4f1edc785c7","order_by":0,"name":"Adil Basha","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIiWNgGAWjYFCCxMbDQDKBgb2x8eGHCiCTmbmBkJYGiBaew4eNJc6AtDAS0pLAANEikZYmwdsGEiGghb89ueFwQU1dHn9DjoGE5LzaaP52oJYfFdtwapE487Dh8Ixjh4slDpwxMCjcdjx3xmHGBsaeM7dxW3MD6BcetgOJDQd7DBIktx3LbQBqYWZsw61FHqzlX13i/MM8Bgd45xzLnU9IiwFIC28bc+KGY2yJDbwNNbkbCGkxBPllZt/hxI1nmA8zSxw7kLsRqOUgPr/IHU9/+LjgW13ivPsP239+qKnLnXf+8MEHPyrweB8NHAaTB4hWDwR1pCgeBaNgFIyCEQIAo+BrKR4nJwcAAAAASUVORK5CYII=","orcid":"https://orcid.org/0009-0002-9972-9629","institution":"Baylor University Medical Center at Dallas","correspondingAuthor":true,"prefix":"","firstName":"Adil","middleName":"","lastName":"Basha","suffix":""},{"id":588289681,"identity":"51852229-f0b1-4606-9bc2-1cbdc59cb7e7","order_by":1,"name":"Ifeadikanwa Emejulu","email":"","orcid":"","institution":"Baylor University Medical Center at Dallas","correspondingAuthor":false,"prefix":"","firstName":"Ifeadikanwa","middleName":"","lastName":"Emejulu","suffix":""},{"id":588289682,"identity":"01db98c1-5370-4ee1-b5f5-a958f1a9f516","order_by":2,"name":"Swar Shah","email":"","orcid":"https://orcid.org/0009-0009-7809-7862","institution":"Baylor University Medical Center at Dallas","correspondingAuthor":false,"prefix":"","firstName":"Swar","middleName":"","lastName":"Shah","suffix":""}],"badges":[],"createdAt":"2026-01-29 18:39:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8734542/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8734542/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102463021,"identity":"d31b0529-6632-4051-b86c-b2b036a47610","added_by":"auto","created_at":"2026-02-12 01:13:49","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":153553,"visible":true,"origin":"","legend":"\u003cp\u003eA) A transabdominal ultrasound demonstrated complex scrotal venous anatomy. B) On coronal view, a dilated left gonadal vein can be seen draining into the left renal vein (red arrows). C) The confluence (red arrow) of the sigmoid and left colic vein branches (red and blue tracings) is seen within the scrotum with complex venous flow.\u003c/p\u003e","description":"","filename":"image1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8734542/v1/521cc8aea7ee07d3e1afadc6.jpg"},{"id":102745536,"identity":"dc333c00-e02d-4cb8-914d-d62e3342486b","added_by":"auto","created_at":"2026-02-16 08:51:32","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":109739,"visible":true,"origin":"","legend":"\u003cp\u003eA) A digital subtraction venogram was performed via trans-scrotal access (blue arrow), with contrast administration resulting in reflux which demonstrated the inflow branches from the sigmoid and left colic veins (red arrows). B) A second venogram was performed via right common femoral vein access and Fogarty balloon inflation (blue arrow), demonstrating complex flow within the scrotum and outflow through the left testicular vein (red arrows).\u003c/p\u003e","description":"","filename":"image2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8734542/v1/4fea6f429fdf7ea335bb2c9e.jpg"},{"id":102463019,"identity":"46d5aa3d-cb28-4bfc-acd5-a6f6a6b37b38","added_by":"auto","created_at":"2026-02-12 01:13:49","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":102167,"visible":true,"origin":"","legend":"\u003cp\u003eA) The unified inflow vein was embolized below the confluence of the sigmoid branches and the left colic branches, and 1% Sotradecol was administered afterwards (blue arrow) to ensure adequate coverage and contact time with scrotal vasculature. B) Four coil packs were placed along the outflow tract in a “sandwich” technique (red arrows), with 1% Sotradecol administered in between them, as shown by the gaps between the coils (blue arrows).\u003c/p\u003e","description":"","filename":"image3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8734542/v1/51112b72489c17ac9d4ee55a.jpg"},{"id":102463022,"identity":"3b6362be-20fd-4873-8ff4-79b49162675e","added_by":"auto","created_at":"2026-02-12 01:13:49","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":153775,"visible":true,"origin":"","legend":"\u003cp\u003eA) Confirmatory trans-scrotal venogram displayed contrast stasis in the scrotal venous plexus (red arrow), confirming adequate inflow control. B) Confirmatory trans-femoral venogram demonstrated no residual inflow (red arrow).\u003c/p\u003e","description":"","filename":"image4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8734542/v1/c811b1e630fedf57c0f0a1ef.jpg"},{"id":102750222,"identity":"edb1cd66-147b-4bfe-99bc-bfac33404e50","added_by":"auto","created_at":"2026-02-16 09:18:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":937248,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8734542/v1/4a8da92b-b88e-4f1b-b8b3-cb6f0c0fd3e2.pdf"}],"financialInterests":"","formattedTitle":"Reversal of Hepatic Encephalopathy Following a Trans-scrotal Approach to Mesogonadal Shunt Embolization: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eSpontaneous portosystemic shunts (SPSS) are defined as venous conduits that occur in response to elevated portal venous pressure, typically in the context of cirrhotic liver disease.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e SPSS can result in alternative outflows from the portal circulation, allowing blood to enter the systemic venous circulation while bypassing the liver, limiting ammonia metabolism and promoting the development of hepatic encephalopathy.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWe present a case of atypical SPSS formation between the inferior mesenteric vein branches and the left testicular vein resulting in hepatic encephalopathy in a patient with a history of cirrhosis secondary to metabolic dysfunction-associated steatohepatitis (MASH), and describe the unique access technique we used for successful portosystemic shunt embolization via a right common femoral vein and trans-scrotal approach. Endovascular treatment was valuable for this patient due to the minimally invasive means through which it could shut off flow through the portosystemic shunt and reverse his encephalopathy.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eHistory and Physical Examination\u003c/h2\u003e \u003cp\u003eA 57-year-old male with a history of human immunodeficiency virus (HIV) on antiretroviral therapy, cirrhosis secondary to MASH, type 2 diabetes, and hypertension presented with a one-month history of progressive cognitive decline despite adherence to a medical regimen of lactulose, rifaximin, and a low-sodium diet. He was seen for an outpatient consultation with Interventional Radiology in October 2025 for recurrent encephalopathy, which appeared to be rapidly developing, characterized by episodic confusion, falls, and word finding difficulties. While an intervention was planned, he was admitted to the hospital less than two weeks later with notable dysarthria and a diminished expressive vocabulary.\u003c/p\u003e \u003cp\u003eHe had a previous history of esophageal varices secondary to portal hypertension which was managed with endoscopic band ligation in March 2025, as well as a large splenorenal shunt which was embolized with coils in 2023 for encephalopathy. His notable surgical history included bilateral inguinal hernia repairs.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDiagnostic Evaluation\u003c/h3\u003e\n\u003cp\u003eLaboratory investigations demonstrated hyperammonemia (135 umol/L), hyperbilirubinemia (2.9 mg/dL), hypoalbuminemia (3.3 g/dL), hyperglobulinemia (3.9 g/dL), leukopenia (3800/uL), and thrombocytopenia (40,000/uL), consistent with advanced chronic liver disease. His HIV was controlled with an undetectable viral load and CD4 count of 412/uL.\u003c/p\u003e \u003cp\u003eInitial screening for acute secondary causes\u0026mdash;including chest radiography, head computerized tomography (CT), and esophagogastroduodenoscopy\u0026mdash;was unremarkable. Recent outpatient screening for hepatocellular carcinoma (ultrasound and alpha-fetoprotein) was negative. A dedicated CT of the abdomen and pelvis performed one month prior demonstrated a complex portosystemic shunt arising from the sigmoid and left colic veins, extending into the left scrotum and draining via the left testicular vein into the systemic circulation.\u003c/p\u003e \u003cp\u003eAfter a discussion of the risks and benefits of proceeding with intervention, notably including potential colonic venous ischemia, testicular ischemia, nontarget embolization, and uncontrolled bleeding, both the patient and his proxy agreed with proceeding to embolization.\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eInitial sonographic evaluation revealed complex scrotal venous architecture, with a dilated pampiniform plexus as would be seen in a varicocele (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). Within the left lower quadrant, two dominant afferent branches were identified originating from the descending and sigmoid colon, respectively unifying at the upper aspect of the scrotum. These vessels traversed the inguinal canal into the left scrotum, forming a high-flow venous plexus with efferent drainage via a dilated left testicular vein (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). This was consistent with prior CT findings (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB, C). Given the anatomical complexity of this portosystemic shunt, a hybrid access strategy utilizing both systemic venous and direct trans-scrotal routes was selected to facilitate comprehensive management of the inflow and outflow components.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter systemic venous access was obtained through the right common femoral vein, a 7 French sheath was placed in the left renal vein. A Fogarty balloon was then advanced into the lower aspect of the testicular vein, and a balloon-occluded retrograde venogram was performed, confirming a large, high-flow portosystemic shunt with outflow through the left testicular vein.\u003c/p\u003e \u003cp\u003eAfter careful mapping with ultrasound, and under sterile sonographic guidance, trans-scrotal access of the unified inflow vein was performed using a 21-gauge needle, followed by a 4/5 French slender sheath which was placed over a 0.018-inch wire. A digital subtraction venogram displayed the entirety of the shunt, with contrast reflux demonstrating inflow branches from the descending and sigmoid colon, complex flow through the scrotum and outflow via the left testicular vein (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWith the aid of a 5 French catheter, the unified inflow vein was embolized just below the confluence of the sigmoid branches and the left colic branches. Care was taken to avoid approaching these vessels as they appeared to represent the dominant outflow of the left colon and embolization would come with the risk of venous ischemia. A tight coil pack was successfully placed, followed by administration of 1% foamed Sotradecol via the same scrotal access under fluoroscopic monitoring to confirm adequate coverage and contact time with the scrotal vasculature (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). A confirmatory venogram displayed contrast stasis in the scrotal venous plexus, confirming adequate inflow control (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSubsequently, four separate coil packs with intervening 1% foamed Sotradecol were placed along the course of the left testicular vein via systemic venous access in a \u0026ldquo;sandwich\u0026rdquo; technique to prevent collateral recanalization (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). The confirmatory left renal venogram demonstrated no residual inflow (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB).\u003c/p\u003e \u003cp\u003eAfter confirming adequate stasis of flow, the trans-scrotal access was removed following Gelfoam tract embolization, and hemostasis was achieved with manual compression. The patient tolerated the procedure well and was returned to the inpatient service for observation, after which he was discharged thirteen days later following improvement of his encephalopathy.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSPSS are very common in the cirrhotic patient population, with studies revealing that up to 60% of patients with liver disease show evidence of portosystemic shunts.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Some of the most common shunt types include splenorenal, gastrorenal and paraumbilical shunts.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Although these are considered to be the typical presentations of SPSS, atypical shunts causing hepatic encephalopathy have also been discussed in existing literature, including mesenteric-iliac shunts, portocaval shunts and intrahepatic shunts.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe driving force behind SPSS formation lies in the large pressure gradient between cirrhotic portal venous pressure (12\u0026ndash;20 mmHg) and caval pressure (2\u0026ndash;6 mmHg). Subsequent blood flow from the portal system back into its tributaries (splenic, superior mesenteric and inferior mesenteric veins) exceeds venous capacitance in the smaller vessels, causing high flow pathways to form from pre-existing embryonal venous channels.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Under normal physiologic conditions, these channels are functionally collapsed and do not make significant contributions to venous return, but in the context of elevated portal pressures, Doppler studies have found high flow velocities in SPSS that exceed 30 cm/s, with shunt embolization causing further increases in portal pressures, implying that the shunts were diverting significant amounts of flow away from the liver.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA possible explanation for this patient\u0026rsquo;s atypical shunting may have been his history of splenorenal shunt embolization, resulting in portal blood flow seeking another low resistance pathway and subsequent development of the mesenteric-gonadal shunt, with complex scrotal venous architecture found in his imaging indicating potential dilation of his pampiniform plexus to accommodate for high levels of flow to the left gonadal vein and ultimately systemic circulation. Post-surgical changes from his prior hernia repair may have also played a role.\u003c/p\u003e \u003cp\u003ePortosystemic shunts have historically been addressed with balloon-occluded retrograde transvenous obliteration (BRTO) or standalone coil embolization to block off high-flow vessels.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e As part of our treatment, a trans-scrotal approach followed by a combination of coil embolization and Sotradecol sclerosant infusion was done to appropriately control the inflow into the portosystemic shunt and reduce the risk for reformation of collaterals. For outflow control, an alternating coil embolization and sclerosant infusion technique was done to extensively cover a significant segment of the left gonadal vein. We chose this approach in order to prevent recanalization of the outflow tract or the creation of a direct shunt via neoangiogenesis between the inferior mesenteric and left gonadal veins due to their close anatomical proximity and multiple small collateral pathways known to drain into the left gonadal vein.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Although there are existing reports of mesogonadal shunts being treated with coil embolization, a literature search did not reveal any other written reports of a mesogonadal shunt being treated with trans-scrotal access, making this case report the first of its kind.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlthough there is a lack of evidence of colonic injury secondary to Sotradecol sclerosant infusion, technical precautions were still taken due to the proximity of the inflow tract to the descending and sigmoid colon, with no signs of complications following the procedure.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Historically, the stomach has tolerated Sotradecol well, both via a transvenous and endoscopic injection perspective; however, the inherent muscular and vascular structure of the stomach is absent from the colon.\u003c/p\u003e \u003cp\u003eAn additional area for consideration included risk of portosystemic shunt recurrence due to the persistence of underlying increased portal pressure following the mesogonadal shunt closure. As this patient was not a candidate for transjugular intrahepatic portosystemic shunt (TIPS) given his history of hepatic encephalopathy, definitive treatment would necessitate liver transplant, which would be unfeasible in the short-term and limited by his HIV status. As such, the mainstays of this patient\u0026rsquo;s treatment would primarily involve medical optimization with lactulose and rifaximin, and expectant management of new portosystemic shunts with periodic embolization.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eSPSS is a common consequence of portal hypertension, and leaves patients susceptible to hepatic encephalopathy due to direct entry of metabolic toxins such as ammonia into the systemic circulation. Mesogonadal shunts are one such type of atypical SPSS which can occur due to abnormal communication between the inferior mesenteric vein branches and the left gonadal vein. Although systemic access is the standard approach for existing coil embolization and BRTO procedures used for the treatment of mesogonadal shunts, further consideration should be given for unconventional vascular access in difficult SPSS presentations to better address shunt inflow and prevent recurrence. Future avenues for research can include comparing shunt recurrences in patients with layered Sotradecol infusion and coil embolization to patients with BRTO or coil embolization alone.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpontaneous portosystemic shunts\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMASH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMetabolic dysfunction-associated steatohepatitis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHIV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHuman immunodeficiency virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputerized tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBRTO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBalloon-occluded retrograde transvenous obliteration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTIPS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTransjugular intrahepatic portosystemic shunt\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval and consent for participation was obtained for the development of this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAB, IE and SS wrote the manuscript, IE was responsible for the editing and image acquisition, SS was responsible for the initial patient consultation and associated notes, SS and IE performed the procedure. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDurgham A, Tessier S, Ido F, Longo S, Nanda S (2022) Acquired Portosystemic Shunts in Cirrhosis and Portal Vein Thrombosis: A Case Report. Cureus 14(11):e31587 Published 2022 Nov 16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.31587\u003c/span\u003e\u003cspan address=\"10.7759/cureus.31587\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eButterworth RF, Gigu\u0026egrave;re JF, Michaud J, Lavoie J, Layrargues GP (1987) Ammonia: key factor in the pathogenesis of hepatic encephalopathy. 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J Investig Med High Impact Case Rep 8:2324709620904569. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/2324709620904569\u003c/span\u003e\u003cspan address=\"10.1177/2324709620904569\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCho SB, Choi YH, So YH, Ahn DW, Jeong JB (2016) Balloon-Occluded Retrograde Transvenous Obliteration of Jejunal Varices: A Case Report, Therapeutic Approach. Dig Dis Sci 61(3):948\u0026ndash;951. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10620-015-3949-5\u003c/span\u003e\u003cspan address=\"10.1007/s10620-015-3949-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"cvir-endovascular","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cire","sideBox":"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/cire/default.aspx","title":"CVIR Endovascular","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Hepatic encephalopathy, embolization, portosystemic shunt, cirrhosis, portal hypertension","lastPublishedDoi":"10.21203/rs.3.rs-8734542/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8734542/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpontaneous portosystemic shunts are defined as venous conduits that occur in response to elevated portal venous pressure, resulting in alternative outflows from the portal circulation. We present a case of atypical portosystemic shunt formation between the inferior mesenteric vein branches and the left testicular vein resulting in hepatic encephalopathy in a patient with a history of cirrhosis, describing the unique access technique we used for successful portosystemic shunt embolization via a combined right common femoral vein and trans-scrotal approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 57-year-old male with a history of cirrhosis presented with a one-month history of progressive cognitive decline despite adherence to a medical regimen of lactulose, rifaximin, and a low-sodium diet. Abdominal computerized tomography and scrotal ultrasound revealed shunt formation from the mesenteric venous system to the systemic circulation, with intermediate connections through the scrotal venous plexus and left gonadal vein. Following an outpatient consultation with interventional radiology for worsening hepatic encephalopathy, the inflow and outflow tracts of the shunt were visualized using digital-subtraction venography. Embolization with coil packs and Sotradecol infusion was achieved using an ultrasound-guided trans-scrotal approach for the inflow tract and a femoral approach for the outflow tract. The patient’s hepatic encephalopathy resolved shortly after the procedure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMesogonadal shunts can be a sequela to portal hypertension and leave patients susceptible to hepatic encephalopathy due to direct entry of metabolic toxins such as ammonia into the systemic circulation. Although systemic access is the standard approach for existing coil embolization and balloon-occluded retrograde transvenous obliteration (BRTO) procedures used for the treatment of mesogonadal shunts, further consideration should be given for unconventional vascular access in difficult portosystemic shunt presentations to better address shunt inflow and prevent recurrence. Future avenues for research can include comparing shunt recurrences in patients with layered sclerosant and coil embolization to patients with BRTO or coil embolization alone.\u003c/p\u003e","manuscriptTitle":"Reversal of Hepatic Encephalopathy Following a Trans-scrotal Approach to Mesogonadal Shunt Embolization: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-12 01:13:44","doi":"10.21203/rs.3.rs-8734542/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2026-04-04T09:34:15+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2026-02-16T14:39:13+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-09T12:42:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-02T12:24:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"CVIR Endovascular","date":"2026-01-29T13:38:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"cvir-endovascular","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cire","sideBox":"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/cire/default.aspx","title":"CVIR Endovascular","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"097572be-6f64-4115-b8a3-cffdd69767ca","owner":[],"postedDate":"February 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-04T13:34:53+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-12 01:13:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8734542","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8734542","identity":"rs-8734542","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}