Gastroduodenal arterioportal fistula: Two case reports and review of literature

Table 1 Comparative analysis of gastroduodenal arterioportal fistula cases treated with interventional vs surgical therapy

	Case 1	Case 2
Basic information
Age	27 years	38 years
Gender	Female	Male
Chief complaint	Incidental detection on health screening	Epigastric pain, hematemesis and melena
Clinical manifestations
Main symptoms	Asymptomatic	Intermittent sharp epigastric pain, hematemesis, melena
Weight change	No significant change	Weight loss of 10 kg
Significant past history	No	No
Significant personal and family history	No smoking, alcohol, or allergies; family history unremarkable	No smoking, alcohol, or allergies; family history unremarkable
Physical examination	Soft abdomen; no tenderness or bruit	Pale; epigastric tenderness; no bruit
Imaging studies
Primary examinations	Contrast-enhanced abdominal CT, DSA, percutaneous transhepatic portal venography	MRCP, EGD, EUS, EUS-FNA, DSA
Lesion report	CT: Thickening of posterior pancreaticoduodenal vascular arcade with saccular dilatation; DSA: Thickening of branches of superior mesenteric artery and gastroduodenal artery, with “saccular” aneurysmal protrusion distally and visualization of draining veins; portal venography: Several portal branches communicating with the aneurysm	MRCP: 21 mm × 14 mm T1 hypointense lesion in pancreatic head; EGD: Fresh blood at duodenal bulb-descending junction, no ulcer/tumor; EUS: Round, well-defined hypoechoic uncinate mass with prominent peripheral flow; EUS-FNA: Hemorrhagic and inflammatory fibrinous tissue, non-diagnostic DSA: Abnormal vascular network with early portal vein opacification in the vertical course of gastroduodenal artery, supplied by gastroduodenal and superior mesenteric arteries
Laboratory tests
Hemoglobin	120 g/L	95 g/L (mild anemia)
Other labs	Fecal occult blood negative; other panels unremarkable	Fecal occult blood positive; tumor markers (CEA, CA19-9, CA-125, NSE) normal; other panels unremarkable
Complications
Surrounding organ pathology	None	Concomitant pancreatic arteriovenous malformation
Treatment plan
Interventional approach	Combined arterial and portal venous embolization	Arterial embolization alone
Treatment method	Endovascular embolization (coils + absolute ethanol sclerosant)	Endovascular embolization (coils) failed, followed by pancreaticoduodenectomy
Treatment outcome	Successful single interventional treatment	Interventional treatment failed, cured by surgery
Prognosis
Follow-up results	Satisfactory embolization with complete occlusion of lesion. Telephonic follow-up at 12 months and 24 months; patient remained entirely asymptomatic	Weight recovered and hemoglobin normalized at 1 month postoperatively. Contrast-enhanced CT at 12 months and 24 months showed no recurrent arterioportal shunt and no portal hypertension

CT: Computed tomography; DSA: Digital subtraction angiography; MRCP: Magnetic resonance cholangiopancreatography; EGD: Esophagogastroduodenoscopy; EUS: Endoscopic ultrasonography; FNA: Fine-needle aspiration; CEA: Carcinoembryonic antigen; CA19-9: Carbohydrate antigen 19-9; CA-125: Carbohydrate antigen 125; NSE: Neuron-specific enolase.

Table 2 Literature review of arterioportal fistula involving the gastroduodenal artery

Case	Ref.	Age (years)	Gender	Etiology	Symptoms	Aneurysm/pseudoaneurysm (angiographic)	Therapy	Outcome
1	[15]	48	M	Partial gastrectomy, V	Pain	-	Excision	Good
2	[15]	52	F	Partial gastrectomy, V	Pain, hematochezia	Small aneurysm	Excision	Good
3	[15]	53	M	BI, V	-	-	Excision	Good
4	[15]	48	M	Whipple pancreaticoduodenectomy	Hematemesis	Large aneurysm	Balloon + surgery	Death by exsanguination (postoperative)
5	[15]	61	F	Partial gastrectomy, BII	Diarrhea, pain, abdominal claudication	Small aneurysm	Excision	Good
6	[15]	54	M	Trauma (stab wound)	-	Large aneurysm	Spontaneous thrombosis	Good
7	[15]	62	M	Partial gastrectomy, BII	Hematemesis, melena	Venous ectasia	None, inoperable	Death by liver failure (5 months)
8	[15]	60	M	partial gastrectomy, BII	Pain	-	Excision	Good
9	[15]	36	M	Partial gastrectomy, BII	-	Small aneurysm	Coil embolization	Good
10	[15]	46	F	Gastrectomy	Pain, weight loss	-	Coil embolization	Good
11	[15]	48	M	“Congenital”	Hematemesis	-	Portocaval shunt	Good
12	[15]	53	F	Rupture of pancreatic pseudocyst	Pain, hematemesis	(40 mm, diameter of cyst)	Detachable balloon embolization	Death (20 days) by volvulus and perforation
13	[18]	44	M	Total gastrectomy	Acute variceal bleeding	Large aneurysm	Coil embolization	Good
14	[20]	45	M	Laparoscopic cholecystectomy, laparotomy	Hematemesis, pain, diarrhea, weight loss	-	Microspheres embolization	Good
15	[16]	70	M	Cholecystectomy	Pain, melena	Large aneurysm	Coil embolization	Improved after embolization; recurrent bleeding at 3 years; good after TIPS
16	[21]	39	F	Chronic pancreatitis	Pain, chills, anemia	Approximately 4.5 cm GDA pseudoaneurysm	Coil/NBCA embolization + portal vein stenting	Good
17	[22]	61	M	Chronic pancreatitis	Pain, fevers, anemia	Approximately 7 cm GDA pseudoaneurysm	Coil embolization	Good
18	Present study, case 1	27	F	-	-	Saccular aneurysm	Coil embolization + ethanol sclerotherapy	Good
19	Present study, case 2	38	M	-	Pain, hematemesis, melena, weight loss	-	Coil embolization failed; Whipple pancreaticoduodenectomy	Good

M: Male; F: Female; GDA: Gastroduodenal artery; TIPS: Transjugular intrahepatic portosystemic shunt.