Coil embolization of arterioportal fistula that developed after partial gastrectomy

Arterioportal fistula after partial gastrectomy treated with coil embolisation

Arterioportal fistulas are a rare complication of abdominal interventions. They can remain asymptomatic for a long time and manifest with symptoms of portal hypertension. We present the case of a 65-year-old man admitted to the emergency room with increasing fatigue and melena. He had a history of partial gastrectomy with Billroth II reconstruction 40 years earlier for peptic ulcer perforation. On physical examination, he was pale and presented a machinery-type murmur in the epigastric area. Blood tests revealed iron deficiency anaemia of 5.6 g/dL. During hospitalisation, he required several blood transfusions and maintained melenas. An abdominal CT angiography showed a fusiform aneurysm of the left gastric artery draining to the venous portal-splenic confluent. He was successfully treated with transarterial coil embolisation of the left gastric artery aneurysm. The correct diagnosis of arterioportal fistulas can be very challenging, whereas the standard treatment with coil embolisation offers a low morbidity resolution of symptoms.

Portal Hypertension and Ascites Due to an Arterioportal Fistula: Sequela of a Remote Traumatic Liver Laceration

Arterioportal fistulas (APFs) are a group of vascular disorders, in which systemic arteries communicate with the portal circulation, presenting as a congenital syndrome or more commonly acquired from iatrogenic instrumentation or abdominal trauma. We report the case of a 58-year-old man who developed ascites without underlying risk factors for portal hypertension, which was attributed to an APF found on imaging, manifesting 43 years after sustaining a liver laceration. After angiographic embolization of the APF, the patient's ascites resolved completely. The prolonged latent period between the patient's abdominal trauma and eventual presentation with ascites highlights the need to consider vascular malformations in the differential diagnosis of unexplained noncirrhotic portal hypertension.

Clinical outcomes of symptomatic arterioportal fistulas after transcatheter arterial embolization

AIM: To evaluate the complications and clinical outcomes of transcatheter arterial embolization (TAE) for symptoms related to severe arterioportal fistulas (APFs).

METHODS: Six patients (3 males, 3 females; mean age, 63.8 years; age range, 60-71 years) with chronic liver disease and severe APFs due to percutaneous intrahepatic treatment (n = 5) and portal vein (PV) tumor thrombosis of hepatocellular carcinoma (n = 1) underwent TAE for symptoms related to severe APFs [refractory ascites (n = 4), hemorrhoidal hemorrhage (n = 1), and hepatic encephalopathy (n = 1)]. Control of symptoms related to APFs and complications were evaluated during the follow-up period (range, 4-57 mo).

RESULTS: In all patients, celiac angiography revealed immediate retrograde visualization of the main PV before TAE, indicating severe APF. Selective TAE for the hepatic arteries was performed using metallic coils (MC, n = 4) and both MCs and n-butyl cyanoacrylate (n = 2). Three patients underwent repeated TAEs for residual APFs and ascites. Four patients developed PV thrombosis after TAE. During the follow-up period after TAE, APF obliteration and symptomatic improvement were obtained in all patients.

CONCLUSION: Although TAE for severe APFs may sometimes be complicated by PV thrombosis, TAE can be an effective treatment to improve clinical symptoms related to severe APFs.

Successful coil embolization of an arterioportal fistula evolving 12 years after gastrojejunostomy

Arterioportal fistula — either acquired or congenital — is a rare syndrome, which is a real challenge in gastroenterologic diagnostics. We report a case of a 76-year-old female, who was admitted to the hospital with symptoms of permanent abdominal pain and a bruit in the epigastric region. Twelve years prior she underwent Billroth II gastrojejunostomy due to a perforating duodenal ulcer, followed by cholecystectomy 6 months later. CT and MR angiography showed a fistula between the gastroduodenal artery and the portal vein. Successful treatment of the arterioportal fistula was achieved by intravascular coil embolization resulting in the resolution of the symptoms. After six years of follow-up, abdominal ultrasonography did not show any novel findings and our patient is still doing well with no recurrence.

Current Management of Mesenteric Extrahepatic Arterioportal Fistulas: Report of a Case Treated With a Gastroduodenal Artery Stent Graft and Literature Review

Spontaneous arteriovenous fistulation of a pseudoaneurysm into superior mesenteric vein (SMV) has rarely been reported. We present the case of a 61-year-old woman who presented with a post pancreatic arterioportal fistula (APF) that was successfully managed by stent graft (SG) placement in the gastroduodenal artery (GDA). We also review the published experience of the endovascular management of mesenteric extrahepatic APFs. This review demonstrates the evolution from open surgical to endovascular management for majority of these patients.

Endovascular embolization of large hepatic arteriovenous fistulas

Treatment of hepatic artery to portal vein fistulas (HAPFs) has shifted in the past two decades from surgical resection of the involved liver to embolization. A uniform technique for percutaneous intervention has not been established because the approach is influenced by the size, location, and number of feeding arteries. We report two cases of HAPFs treated with embolization at our institution. Different outcomes in these two patients illustrate several fundamental principles in the treatment of HAPFs.

[Portal hypertension in a patient with hepatitic C revealing an iatrogenic arterioportal fistula]

A 67-year-old man with anti-HCV positive serum, was admitted for hematemesis by variceal bleeding. Portal hypertension, which initially was thought to be caused by a post-hepatitis C cirrhosis, was due to a fistula between a right hepatic artery and a right branch of the portal vein. The fistula located under the right liver and the adjacent atrophic hepatic segments, were resected by a bi-segmentectomy VI-VII. The postoperative course was simple. The pathological study of the resected liver showed no cirrhosis but active hepatitis. This arterioportal fistula was probably iatrogenic. Sixteen years before, this patient had undergone a total gastrectomy for cancer, followed by a serious haemorrhage requiring a massive transfusion, which was responsible for the transmission of hepatitis C.