1
|
Taher H, Kidr E, Kamal A, ElGobashy M, Mashhour S, Nassef A, Tawfik S, El Tagy G, Shaban M, Eltantawi H, Abdullateef KS. Transhepatic ultrasound guided embolization as a successful novel technique in treatment of pediatric complex intrahepatic arterioportal fistula: a case report and review of the literature. J Med Case Rep 2023; 17:412. [PMID: 37710289 PMCID: PMC10503188 DOI: 10.1186/s13256-023-04047-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/19/2023] [Indexed: 09/16/2023] Open
Abstract
INTRODUCTION Intrahepatic vascular shunts "IHVS" are abnormal communications between intra-hepatic vasculature involving the arterial, portal, or hepatic venous system. Arterio-portal fistula "APF" is an intrahepatic communication between the hepatic arterial system and the portal venous system without any communication with the systemic venous circulation. APF is considered a rare cause of portal hypertension and gastrointestinal bleeding in infancy. CASE PRESENTATION A 3-month-old Mediterranean female with known cardiac congenital anomalies presented to us with abdominal distension and diarrhea. Ultrasonography revealed massive ascites and computerized tomography (CT) abdomen with intravenous (IV) contrast revealed a left hepatic lesion. On further evaluation, an intrahepatic arterio-portal vascular malformation was detected. Attempted trans arterial embolization failed and radiology team successfully carried out direct trans hepatic ultrasound guided coiling of the aneurysmal venous sac followed by successful resection of segment 4 of the liver with the vascular malformation avoiding life threatening intra operative bleeding. CONCLUSION Any child with recurrent gastrointestinal bleeding, failure to thrive, vomiting, diarrhea, steatorrhea, splenomegaly, or ascites should be investigated for intrahepatic arterio-portal fistula "IAPF". Our novel technique of direct trans hepatic ultrasound guided coiling is an alternative method if trans arterial embolization "TAE" failed.
Collapse
Affiliation(s)
- Heba Taher
- Pediatric Surgery Department, Specialized Pediatric Hospital, Cairo University Kasr Al Einy, Faculty of Medicine, 1 Abou El Rish Sq., El Sayeda Zeinab, Cairo, Egypt.
| | - ElSayed Kidr
- Pediatric Surgery Department, Specialized Pediatric Hospital, Cairo University Kasr Al Einy, Faculty of Medicine, 1 Abou El Rish Sq., El Sayeda Zeinab, Cairo, Egypt
| | - Ahmed Kamal
- Pediatric Surgery Department, Specialized Pediatric Hospital, Cairo University Kasr Al Einy, Faculty of Medicine, 1 Abou El Rish Sq., El Sayeda Zeinab, Cairo, Egypt
| | - Mohamed ElGobashy
- Department of Radiology, Cairo University Kasr Al Einy, Faculty of Medicine, Cairo, Egypt
| | - Shady Mashhour
- Department of Radiology, Cairo University Kasr Al Einy, Faculty of Medicine, Cairo, Egypt
| | - Amr Nassef
- Department of Radiology, Cairo University Kasr Al Einy, Faculty of Medicine, Cairo, Egypt
| | | | - Gamal El Tagy
- Department of Radiology, Cairo University Kasr Al Einy, Faculty of Medicine, Cairo, Egypt
| | - Muayad Shaban
- Pediatric Surgery Department, Specialized Pediatric Hospital, Cairo University Kasr Al Einy, Faculty of Medicine, 1 Abou El Rish Sq., El Sayeda Zeinab, Cairo, Egypt
| | - Haytham Eltantawi
- Pediatric Surgery Department, Specialized Pediatric Hospital, Cairo University Kasr Al Einy, Faculty of Medicine, 1 Abou El Rish Sq., El Sayeda Zeinab, Cairo, Egypt
| | - Khaled S Abdullateef
- Pediatric Surgery Department, Specialized Pediatric Hospital, Cairo University Kasr Al Einy, Faculty of Medicine, 1 Abou El Rish Sq., El Sayeda Zeinab, Cairo, Egypt
| |
Collapse
|
2
|
Arterioportal Fistulas (APFs) in Pediatric Patients: Single Center Experience with Interventional Radiological versus Conservative Management and Clinical Outcomes. J Clin Med 2021; 10:jcm10122612. [PMID: 34198478 PMCID: PMC8231897 DOI: 10.3390/jcm10122612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 02/07/2023] Open
Abstract
Arterioportal fistulas (APFs) are uncommon vascular abnormalities with a heterogeneous etiology. In pediatric orthotopic liver transplantation (OLT), APFs are frequently iatrogenic, following percutaneous liver interventions. The aim of this study was to report the 10-year experience of a tertiary referral center for pediatric OLT in the interventional radiological (IR) and conservative management of acquired APFs. A retrospective search was performed to retrieve pediatric patients (<18 years old) with a diagnosis of APF at color Doppler ultrasound (CDUS) or computed tomography angiography (CTA) from 2010 to 2020. Criteria for IR treatment were the presence of hemodynamic alterations at CDUS (resistive index <0.5; portal flow reversal) or clinical manifestations (bleeding; portal hypertension). Conservatively managed patients served as a control population. Clinical and imaging follow-up was analyzed. Twenty-three pediatric patients (median age, 4 years; interquartile range = 11 years; 15 males) with 24 APFs were retrieved. Twenty patients were OLT recipients with acquired APFs (16 iatrogenic). Twelve out of twenty-three patients were managed conservatively. The remaining 11 underwent angiography with confirmation of a shunt in 10, who underwent a total of 16 embolization procedures (14 endovascular; 2 transhepatic). Technical success was reached in 12/16 (75%) procedures. Clinical success was achieved in 8/11 (73%) patients; three clinical failures resulted in one death and two OLTs. After a median follow-up time of 42 months (range 1–107), successfully treated patients showed an improvement in hemodynamic parameters at CDUS. Conservatively managed patients showed a stable persistence of the shunts in six cases, spontaneous resolution in four, reduction in one and mild shunt increase in one. In pediatric patients undergoing liver interventions, APFs should be investigated. Although asymptomatic in most cases, IR treatment of APFs should be considered whenever hemodynamic changes are found at CDUS.
Collapse
|
3
|
Angelico R, Paolantonio G, Paoletti M, Grimaldi C, Saffioti MC, Monti L, Candusso M, Rollo M, Spada M. Combined endovascular-surgical treatment for complex congenital intrahepatic arterioportal fistula: A case report and review of the literature. World J Hepatol 2020; 12:160-169. [PMID: 32685108 PMCID: PMC7336291 DOI: 10.4254/wjh.v12.i4.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/17/2020] [Accepted: 02/23/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Congenital intrahepatic arterioportal fistula (IAPF) is a rare vascular malformation in infants that causes severe portal hypertension (PH) with poor prognosis if untreated. Currently, radiological embolisation is considered the first-line therapy for simple IAPF; however, it might be not resolutive for complex hepatic vascular lesions. When endovascular embolization is not sufficient to completely obliterate the IAPF, surgical intervention is needed, but it has been associated with severe morbidity and mortality in small children. Furthermore, indications are not defined.
CASE SUMMARY We present the first case of a 6-month-old girl with trisomy 21 affected by a complex congenital IAFP, which caused severe PH, successfully treated with an endovascular-surgical hybrid procedure. The novel technique comprised a multi-step endovascular embolisation, including a superselective transarterial embolisation of the afferent vessels and a direct transhepatic embolisation of the dilated portal vein segment, combined with selective surgical ligation of the arterial branches that supply the fistula, which were too small to be embolised. The complex IAPF was also associated with severe cholestasis and intra/extrahepatic biliary tree dilatation, which was successfully treated by a temporary biliary drainage. At 24-mo follow-up, the hybrid endovascular-surgical procedure achieved complete occlusion of the complex IAPF and resolution of the PH. A comprehensive review of the literature on congenital IAPF management, focussed on alternative treatment strategies, is also reported.
CONCLUSION The combined radiological-surgical approach is a safe and effective treatment option for complex IAPF and avoids major invasive surgery.
Collapse
Affiliation(s)
- Roberta Angelico
- Department of Abdominal Transplantation and Hepatobiliary and Pancreatic Surgery, Bambino Gesù Children’s Hospital IRCCS, Rome 00165, Italy
- Department of Surgery, Hepato-bilio-pancreatic Surgery and Transplant Unit, University of Rome Tor Vergata, Fondazione PVT, Rome 00133, Italy
| | - Guglielmo Paolantonio
- Interventional Radiology Unit, Department of Imaging, Bambino Gesù Children’s Hospital IRCCS, Rome 00165, Italy
| | - Monica Paoletti
- Department of Abdominal Transplantation and Hepatobiliary and Pancreatic Surgery, Bambino Gesù Children’s Hospital IRCCS, Rome 00165, Italy
| | - Chiara Grimaldi
- Department of Abdominal Transplantation and Hepatobiliary and Pancreatic Surgery, Bambino Gesù Children’s Hospital IRCCS, Rome 00165, Italy
| | - Maria Cristina Saffioti
- Department of Abdominal Transplantation and Hepatobiliary and Pancreatic Surgery, Bambino Gesù Children’s Hospital IRCCS, Rome 00165, Italy
| | - Lidia Monti
- Department of Imaging, Bambino Gesù Children’s Hospital IRCCS, Rome 00165, Italy
| | - Manila Candusso
- Division of Hepatogastroenterology, Bambino Gesù Children’s Hospital IRCCS, Rome 00165, Italy
| | - Massimo Rollo
- Interventional Radiology Unit, Department of Imaging, Bambino Gesù Children’s Hospital IRCCS, Rome 00165, Italy
| | - Marco Spada
- Department of Abdominal Transplantation and Hepatobiliary and Pancreatic Surgery, Bambino Gesù Children’s Hospital IRCCS, Rome 00165, Italy
| |
Collapse
|
4
|
Congenital arterioportal fistulas: radiological treatment and color Doppler US follow-up. Pediatr Radiol 2012; 42:1326-32. [PMID: 22699373 DOI: 10.1007/s00247-012-2443-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 05/15/2012] [Accepted: 05/16/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Congenital intrahepatic arterioportal fistulas (APFs) are a rare cause of portal hypertension in children. Doppler US is a useful diagnostic imaging modality. Transarterial embolization is a minimally invasive and effective therapy allowing occlusion of the fistula and restoration of liver hemodynamics. OBJECTIVE To describe the clinical and radiologic findings, percutaneous treatment and role of D-US in the postembolization follow-up of children with APF. MATERIALS AND METHODS Between 2002 and 2011, four children with APF were treated. Initial diagnosis and follow-up was performed with D-US and confirmed by arteriography, followed by endovascular embolization in all patients. RESULTS D-US demonstrated abnormal arterioportal communications in all patients. Six endovascular procedures were performed in these four children. In two children, no residual fistula was seen on D-US after the first procedure and symptoms resolved. In the other two children, D-US demonstrated residual flow through the fistula, with resolution of pathological D-US findings and symptoms after the second endovascular procedure. All four children were successfully treated and asymptomatic at the end of follow-up. The mean follow-up was 24 months. CONCLUSION Interventional radiology has a key role in the treatment of congenital APF. D-US is a noninvasive and effective tool for the diagnosis and follow-up of these patients.
Collapse
|
5
|
Tannuri ACA, Tannuri U, Lima FR, Ricardi LRS, Leal AJG, da Silva MM. Congenital intrahepatic arterioportal fistula presenting as severe undernutrition and chronic watery diarrhea in a 2-year-old girl. J Pediatr Surg 2009; 44:e19-22. [PMID: 19853734 DOI: 10.1016/j.jpedsurg.2009.07.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2009] [Revised: 07/10/2009] [Accepted: 07/10/2009] [Indexed: 12/26/2022]
Abstract
Intrahepatic arterioportal fistula (IAPF) is a rare cause of portal hypertension in young children. We report the case of a 2-year-old girl with severe undernutrition, chronic watery diarrhea, and gastrointestinal bleeding because of a congenital intrahepatic arterioportal fistula. Radiographic embolization and surgical ligation of the left hepatic artery were attempted, with no resolution of the symptoms. So, a left lobectomy was performed, with excellent results and prompt disappearance of the diarrhea. Hepatectomy should be considered as a definitive and reliable therapy for congenital IAPF.
Collapse
Affiliation(s)
- Ana Cristina Aoun Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil.
| | | | | | | | | | | |
Collapse
|
6
|
Coil embolization of a congenital intrahepatic arterioportal fistula: increasing experience in management. Pediatr Radiol 2008; 38:1253-6. [PMID: 18690425 DOI: 10.1007/s00247-008-0957-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2008] [Revised: 05/06/2008] [Accepted: 06/10/2008] [Indexed: 10/21/2022]
Abstract
Congenital intrahepatic arterioportal fistula (IAPF) is a rare condition and there is limited experience of transcatheter embolization. We report here the transcatheter coil embolization of an incidentally found, asymptomatic congenital IAPF in a 16-month-old patient. After demonstrating that the IAPF was fed by two branches of a dilated left hepatic artery and drained into an aneurysm of the left portal vein, the feeding arteries were superselectively catheterized and occluded by microcoils in a single session. Follow-up was uneventful for 1 year. With respect to this and previously reported cases, we believe that embolization of feeding arteries is a safe and effective method that should be the primary choice of treatment; however, further cases should be reported to confirm this belief.
Collapse
|
7
|
Norton SP, Jacobson K, Moroz SP, Culham G, Ng V, Turner J, John P. The congenital intrahepatic arterioportal fistula syndrome: elucidation and proposed classification. J Pediatr Gastroenterol Nutr 2006; 43:248-55. [PMID: 16877994 DOI: 10.1097/01.mpg.0000221890.13630.ad] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Congenital intrahepatic arterioportal fistula is a rare but treatable cause of portal hypertension for which early recognition may lead to successful radiological management. We report an infant presenting with severe failure to thrive, melena and splenomegaly due to a congenital intrahepatic arterioportal fistula, successfully ablated after multiple trials of superselective transarterial embolization. Comprehensive review of congenital cases provides an understanding of the key clinical features defining this syndrome. A classification system is proposed, upon which treatment decisions may be based.
Collapse
Affiliation(s)
- Seamus P Norton
- Department of Pediatrics, British Columbia's Children's Hospital, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | | | | | | | | | | | | |
Collapse
|