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Kono Y, Yamamoto M, Yasui C, Ishiguro R, Yagyu T, Kihara K, Matsunaga T, Takano S, Tokuyasu N, Sakamoto T, Hasegawa T, Fujiwara Y. Laparoscopic resection of a cecal carcinoma with a Retzius vein shunt: A case report. Medicine (Baltimore) 2025; 104:e42456. [PMID: 40388744 PMCID: PMC12091583 DOI: 10.1097/md.0000000000042456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2024] [Accepted: 04/28/2025] [Indexed: 05/21/2025] Open
Abstract
RATIONALE A Retzius shunt between the ileocecal vein and inferior vena cava is rare. To avoid major hemorrhage due to shunt injury, it is essential to evaluate vascular abnormalities on preoperative imaging and to confirm anatomic structures in detail during the operation. PATIENT CONCERNS A 71-year-old woman with diabetes and asthma developed anaemia. DIAGNOSES She was diagnosed with cecal cancer by endoscopy and found to have a venous malformation forming a Retzius shunt from the ileocecal vein to the inferior vena cava on computed tomography. INTERVENTION Laparoscopic ileocecal resection was performed. Colonic mobilization and resection of the ileocecal vessels were performed while minimizing traction on the shunt. After confirming the anatomy, the Retzius shunt was resected without complications. OUTCOMES The patient experienced an unremarkable postoperative clinical course without complications. LESSONS This case involved a rare vascular anomaly associated with colorectal cancer, characterized by an abnormal blood vessel connecting the inferior vena cava and mesenteric veins. When abnormal vessels are detected on preoperative abdominal computed tomography, a Retzius shunt should be considered. Detailed review of the imaging, careful surgical manipulation to avoid shunt damage, and thorough anatomical verification, are important to perform a safe operation.
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Affiliation(s)
- Yusuke Kono
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Manabu Yamamoto
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Chiharu Yasui
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Ryo Ishiguro
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Takuki Yagyu
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Kyoichi Kihara
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Tomoyuki Matsunaga
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Shuichi Takano
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Naruo Tokuyasu
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Teruhisa Sakamoto
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Toshimichi Hasegawa
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Yoshiyuki Fujiwara
- Department of Surgery, Division of Gastrointestinal and Pediatric Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
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Cushman CJ, Ibrahim AF, Callahan T. Large gastroduodenal artery pseudoaneurysm and arterioportal fistula in chronic pancreatitis. Radiol Case Rep 2024; 19:5612-5618. [PMID: 39296759 PMCID: PMC11406347 DOI: 10.1016/j.radcr.2024.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Revised: 08/07/2024] [Accepted: 08/10/2024] [Indexed: 09/21/2024] Open
Abstract
Visceral artery pseudoaneurysms, particularly those in the gastroduodenal artery (GDA), are rare but serious complications associated with chronic pancreatitis, posing a significant risk of rupture due to their structural fragility. In this case, a 61-year-old male with a history of chronic pancreatitis, alcohol cirrhosis, duodenal ulcer, and COPD presented with persistent abdominal pain and recurrent fevers. Imaging revealed a 7 cm pseudoaneurysm between the GDA and superior mesenteric vein, which was successfully treated with coil embolization. This case highlights the importance of prompt recognition and intervention in managing GDA pseudoaneurysms, particularly when complicated by an arterioportal fistula, and demonstrates the efficacy of endovascular therapy as a minimally invasive treatment option that can significantly improve patient outcomes in complex vascular complications associated with chronic pancreatitis.
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Affiliation(s)
- Caroline J Cushman
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Andrew F Ibrahim
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Thomas Callahan
- Department of Interventional Radiology, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Okuhira R, Sonomura T, Tanaka R, Inagaki R, Ueda S, Fukuda K, Higashino N, Kamisako A, Sato H, Ikoma A, Minamiguchi H. Successful coil embolization of post-hepatectomy arterioportal fistula that reduced ascites and improved liver function. Radiol Case Rep 2024; 19:2206-2210. [PMID: 38515772 PMCID: PMC10955095 DOI: 10.1016/j.radcr.2024.02.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 02/14/2024] [Indexed: 03/23/2024] Open
Abstract
A 71-year-old man had previously undergone S7 + S8 dorsal segmentectomy and S5 partial hepatectomy for hepatocellular carcinomas. Six months later, he experienced abdominal distention. Abdominal computed tomography (CT) showed massive ascites and a significant hepatic arterioportal shunt. The ascites was thought to be caused by portal hypertension due to a high-flow hepatic arterioportal fistula (HAPF). The fistula, located between the right hepatic artery A7 and the right portal vein, was embolized with microcoils under flow control using a balloon catheter. After embolization, the shunt blood flow disappeared and the hepatopetal venous flow was restored. His body weight and abdominal circumference decreased immediately, and his liver function on blood tests improved after the procedure. CT performed 11 days after embolization showed decreased ascites. A HAPF after hepatectomy is extremely rare. Balloon-assisted embolization using microcoils is a useful endovascular procedure for treating a high-flow HAPF.
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Affiliation(s)
- Ryuta Okuhira
- The Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | - Tetsuo Sonomura
- The Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | - Ryota Tanaka
- The Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | - Riki Inagaki
- The Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | - Shota Ueda
- The Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | - Kodai Fukuda
- The Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | - Nobuyuki Higashino
- The Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | - Atsufumi Kamisako
- The Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | - Hirotatsu Sato
- The Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | - Akira Ikoma
- The Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | - Hiroki Minamiguchi
- The Department of Radiology, Wakayama Medical University, Wakayama, Japan
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Munechika T, Shiokawa K, Takeshita I, Shimokobe H, Sahara K, Matsumoto Y, Aisu N, Yoshimatsu G, Hasegawa S. Laparoscopic sigmoid colectomy for transverse colonic varices due to an inferior mesenteric arteriovenous fistula. Surg Case Rep 2024; 10:112. [PMID: 38700649 PMCID: PMC11068706 DOI: 10.1186/s40792-024-01911-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/25/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Colonic varices are a rare gastrointestinal anomaly often associated with portal hypertension. Arteriovenous fistula (AVF) in the inferior mesenteric artery (IMA) region is even rarer. Diagnosis and treatment of these entities present unique challenges, especially when the IMA is involved. CASE PRESENTATION A 48-year-old man with a history of cholecystectomy presented with after a positive fecal occult blood test. Investigations revealed varices from the splenic flexure to the transverse colon and suspected AVF in the IMA region. Given the high risk and low efficacy of endoscopic and radiological interventions, laparoscopic sigmoidectomy was performed. This surgical approach successfully addressed both the AVF and the associated varices. CONCLUSION This case underscores the importance of surgical intervention for AVF and colonic varices in the IMA region, particularly when other treatment options pose high risks and have limited efficacy. The favorable postoperative outcome in this case highlights the effectiveness of carefully chosen surgical methods when managing such complex and rare conditions.
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Affiliation(s)
- Taro Munechika
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka City, Fukuoka, 814-0180, Japan.
| | - Keiichi Shiokawa
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka City, Fukuoka, 814-0180, Japan
| | - Issei Takeshita
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka City, Fukuoka, 814-0180, Japan
| | - Hisaaki Shimokobe
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka City, Fukuoka, 814-0180, Japan
| | - Kurumi Sahara
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka City, Fukuoka, 814-0180, Japan
| | - Yoshiko Matsumoto
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka City, Fukuoka, 814-0180, Japan
| | - Naoya Aisu
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka City, Fukuoka, 814-0180, Japan
| | - Gumpei Yoshimatsu
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka City, Fukuoka, 814-0180, Japan
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Fukuoka University Hospital, 7-45-1 Nanakuma, Jonan-Ku, Fukuoka City, Fukuoka, 814-0180, Japan
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Klompenhouwer AJ, Moelker A, Murad SD, den Hoed CM, Maan R. Portal Embolisation as Treatment of Severe Portal Hypertension Due to Idiopathic Intrahepatic Arterioportal Fistula: A Case Report. J Clin Exp Hepatol 2024; 14:101295. [PMID: 38076444 PMCID: PMC10709512 DOI: 10.1016/j.jceh.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 10/16/2023] [Indexed: 03/03/2025] Open
Abstract
Intrahepatic arterioportal fistula (IAPF) is a rare cause of portal hypertension. Treatment is usually aimed at restoring the normal portal hemodynamics by obliterating the shunt. This report describes a case of idiopathic IAPF with severe portal hypertension complicated by portal enteropathy with vomiting, gastrointestinal hemorrhage and sepsis. The patient was successfully treated with portal embolization.
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Affiliation(s)
- Anne J. Klompenhouwer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Adriaan Moelker
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sarwa D. Murad
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- The Erasmus MC Transplant Institute, Rotterdam, The Netherlands
| | - Caroline M. den Hoed
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- The Erasmus MC Transplant Institute, Rotterdam, The Netherlands
| | - Raoel Maan
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- The Erasmus MC Transplant Institute, Rotterdam, The Netherlands
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Noorbakhsh S, Gomez L, Joung Y, Meyer C, Hanos DS, Freedberg M, Klingensmith N, Grant AA, Koganti D, Nguyen J, Smith RN, Sciarretta JD. Hepatic Arterioportal Fistula Following Liver Trauma: Case Series and Review of the Literature. Vasc Endovascular Surg 2023; 57:749-755. [PMID: 36940466 PMCID: PMC10724846 DOI: 10.1177/15385744231165155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
PURPOSE Hepatic arterioportal fistula (HAPF) is an uncommon complication of hepatic trauma, which can manifest with abdominal pain and the sequelae of portal hypertension months to years after injury. The purpose of this study is to present cases of HAPF from our busy urban trauma center and make recommendations for management. METHODS One hundred and twenty-seven patients with high-grade penetrating liver injuries (American Association for the Surgery of Trauma [AAST] - Grades IV-V) between January 2019 and October 2022 were retrospectively reviewed. Five patients were identified with an acute hepatic arterioportal fistula following abdominal trauma from our ACS-verified adult Level 1 trauma center. Institutional experience with overall surgical management is described and reviewed with the current literature. RESULTS Four of our patients presented in hemorrhagic shock requiring emergent operative intervention. The first patient had postoperative angiography and coil embolization of the HAPF. Patients 2 through 4 underwent damage control laparotomy with temporary abdominal closure followed by postoperative transarterial embolization with gelatin sponge particles (Gelfoam) or combined Gelfoam/n-butyl cyanoacrylate. The final patient went directly for angiography and Gelfoam embolization after identification of the HAPF. All 5 patients had resolution of HAPF on follow-up imaging with continued post management for traumatic injuries. CONCLUSION Hepatic arterioportal fistula can present as a complication of hepatic injury and manifest with significant hemodynamic aberrations. Although surgical intervention was required to achieve hemorrhage control in almost all cases, management of HAPF in the setting of high-grade liver injuries was achieved successfully with modern endovascular techniques. A multidisciplinary approach to such injuries is necessary to optimize care in the acute setting following traumatic injury.
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Affiliation(s)
- Soroosh Noorbakhsh
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Lissette Gomez
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Yoo Joung
- Grady Memorial Hospital, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Courtney Meyer
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Dustin S. Hanos
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Mari Freedberg
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Nathan Klingensmith
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - April A. Grant
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Deepika Koganti
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Jonathan Nguyen
- Grady Memorial Hospital, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Randi N. Smith
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Jason D. Sciarretta
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
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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: 0.5] [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.
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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
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Panda A, Narayanan D, Netaji A, Varshney VK, Agarwal L, Garg PK. Spontaneous hepatic arterioportal fistula in extrahepatic portal vein obstruction: Combined endovascular and surgical management. Ann Hepatobiliary Pancreat Surg 2023; 27:307-312. [PMID: 36944615 PMCID: PMC10472122 DOI: 10.14701/ahbps.22-126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/07/2023] [Accepted: 01/16/2023] [Indexed: 03/23/2023] Open
Abstract
Hepatic arterioportal fistulae are abnormal communications between the hepatic artery and portal vein. They are reported to be congenital or acquired secondary to trauma, iatrogenic procedures, hepatic cirrhosis, and hepatocellular carcinoma, but less likely to occur spontaneously. Extrahepatic portal venous obstruction (EHPVO) can lead to pre-hepatic portal hypertension. A spontaneous superimposed hepatic arterioportal fistula can lead to pre-sinusoidal portal hypertension, further exacerbating its physiology. This report describes a young woman with long-standing EHPVO presenting with repeated upper gastrointestinal variceal bleeding and symptomatic hypersplenism. Computed tomography scan demonstrated a cavernous transformation of the portal vein and a macroscopic hepatic arterioportal fistula between the left hepatic artery and portal vein collateral in the central liver. The hepatic arterioportal fistula was associated with a flow-related left hepatic artery aneurysm and a portal venous collateral aneurysm proximal and distal to the fistula, respectively. Endovascular coiling was performed for the hepatic arterioportal fistula, followed by proximal splenorenal shunt procedure. This case illustrates an uncommon association of a spontaneous hepatic arterioportal fistula with EHPVO and the utility of a combined endovascular and surgical approach for managing multifactorial non-cirrhotic portal hypertension in such patients.
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Affiliation(s)
- Ananya Panda
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Durgadevi Narayanan
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Arjunlokesh Netaji
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Vaibhav Kumar Varshney
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Lokesh Agarwal
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pawan Kumar Garg
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Teniere T, Palmier M, Curado A, Plissonnier D. Vascular Plug Embolization of a Superior Mesenteric Arteriovenous Fistula: Case Report and Literature Review of Endovascular Treatment. EJVES Vasc Forum 2023; 60:37-41. [PMID: 37771647 PMCID: PMC10522866 DOI: 10.1016/j.ejvsvf.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 07/04/2023] [Accepted: 08/01/2023] [Indexed: 09/30/2023] Open
Abstract
Introduction Arteriovenous fistula (AVF) rarely occurs in the portal venous system. Aetiologies include iatrogenic, surgical, and penetrating trauma of the abdomen. Clinical manifestations of superior mesenteric portal arteriovenous fistula (SMPAVF) are right heart failure, mesenteric ischaemia, or signs of portal hypertension. Report The case of a 42 year old man with a history of Crohn's disease who had a delayed symptomatic mesenteric portal AVF, occurring 20 years after ileocecal resection, which was subsequently managed by endovascular approach is reported. The patient presented with post-prandial abdominal pain for almost one year, and dyspnoea New York Heart Association stage II. There were no signs of portal hypertension. Pre-operative contrast enhanced computed tomography showed a high flow SMPAVF, with a short and wide neck (9 mm × 16 mm) at the level of the last collateral of the superior mesenteric artery. It was associated with a large aneurysm of the mesenteric vein. Vascular plug embolisation (Amplatzer 18 × 18 mm, Abbott, Chicago, IL, USA) by femoral access allowed exclusion of the SMPAVF and preserved arterial flow in the distal collaterals. During follow up, the patient developed portal vein thrombosis and required therapeutic anticoagulation for six months. Discussion In most cases, endovascular approaches are preferred in the management of SMPAVF. Endovascular approaches are based on minimally invasive techniques including embolisation (coiling or plug) and covered stenting. Vascular plug embolisation of SMPAVF is feasible and seems to be an effective technique, with the advantage of saving collaterals. Therapeutic anticoagulation should be considered post-operatively in cases with venous dilatation and reduced flow linked to exclusion of the AVF.
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Affiliation(s)
- Tom Teniere
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | - Mickael Palmier
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
| | - Adelya Curado
- Department of Radiology, Rouen University Hospital, Rouen, France
| | - Didier Plissonnier
- Department of Vascular Surgery, Rouen University Hospital, Rouen, France
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Perez MC, Kim SC, Egunsola A, Reitz A, Archer-Arroyo K, Smith RN, Williams KN, Udobi K, Sola R, Dente CJ, Cristescu MM, Grant A, Nguyen J. Bleeding From a Hepatic Artery-Portal Vein Fistula After Repair of a Stab Wound to the Liver. Am Surg 2023; 89:2089-2091. [PMID: 34171964 DOI: 10.1177/00031348211029847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Matthew C Perez
- Department of Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Steven C Kim
- Department of Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Adekemi Egunsola
- Department of Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Alexandra Reitz
- Department of Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Krystal Archer-Arroyo
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Randi N Smith
- Department of Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Keneeshia N Williams
- Department of Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Kahdi Udobi
- Department of Surgery, Morehouse School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Richard Sola
- Department of Surgery, Morehouse School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Christopher J Dente
- Department of Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Mircea M Cristescu
- Department of Vascular and Interventional Radiology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - April Grant
- Department of Surgery, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Jonathan Nguyen
- Department of Surgery, Morehouse School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
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Sanomura T, Norikane T, Uchinomura S, Takami Y, Ensako T, Nagao M, Deguchi A, Okano K, Nishiyama Y. Omental arteriovenous fistula after splenectomy treated with transarterial embolization. CVIR Endovasc 2023; 6:28. [PMID: 37099195 PMCID: PMC10133414 DOI: 10.1186/s42155-023-00374-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/18/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Laparoscopic splenectomy for patients with portal hypertension is associated with a high risk of bleeding. The use of vessel-sealing devices and automatic sutures is important for bleeding control. However, a rare complication of abdominal surgery is the direct communication between the arterial and portal circulation related to surgical procedures such as simultaneous ligature of an artery and adjacent vein. We describe a rare case of omental arteriovenous fistula (AVF) after laparoscopic splenectomy treated with transarterial embolization. CASE PRESENTATION We report a case of a 46-year-old male patient with an omental AVF after a laparoscopic splenectomy 6 years ago for splenomegaly associated with alcoholic cirrhosis. Follow-up abdominal dynamic computed tomography accidentally revealed a vascular sac (25 mm in the major axis) that formed an omental AVF with anastomosis to the left colonic vein. The communication was considered to be caused by using a vessel-sealing device. No symptoms related to the AVF were observed. The AVF was embolized with microcoils using the transarterial approach. A 4-axis catheter system was used for accurate embolization due to the long and tortuous distance from the celiac artery. No recurrence or symptoms were observed after 6 months. CONCLUSIONS Treatment of arterioportal fistula is mandatory, even in asymptomatic patients. Embolization is a less invasive alternative to surgical approaches. The 4-axis catheter system was useful for accurate embolization via a long and tortuous artery.
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Affiliation(s)
- Takayuki Sanomura
- Department of Radiology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-Cho, Kita-Gun, Kagawa, 761-0793, Japan.
| | - Takashi Norikane
- Department of Radiology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-Cho, Kita-Gun, Kagawa, 761-0793, Japan
| | - Satoshi Uchinomura
- Department of Radiology, Kagawa Rousai Hospital, 3-3-1, Joutou, Marugame, Kagawa, 763-8502, Japan
| | - Yasukage Takami
- Department of Radiology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-Cho, Kita-Gun, Kagawa, 761-0793, Japan
| | - Toshiya Ensako
- Department of Radiology, Kagawa Rousai Hospital, 3-3-1, Joutou, Marugame, Kagawa, 763-8502, Japan
| | - Mina Nagao
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-Cho, Kita-Gun, Kagawa, 761-0793, Japan
| | - Akihiro Deguchi
- Department of Gastroenterology, Kagawa Rousai Hospital, 3-3-1, Joutou, Marugame, Kagawa, 763-8502, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-Cho, Kita-Gun, Kagawa, 761-0793, Japan
| | - Yoshihiro Nishiyama
- Department of Radiology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-Cho, Kita-Gun, Kagawa, 761-0793, Japan
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Abou Yassine A, Al Moussawi H, Kreidieh M, Dahabra L, Al-Roubaie M, Satapathy S. Splenic arteriovenous fistula leading to non-cirrhotic portal hypertension: a case report: Splenic arteriovenous fistula leading to non-cirrhotic portal hypertension. Gastroenterol Rep (Oxf) 2023; 11:goad015. [PMID: 37051576 PMCID: PMC10085540 DOI: 10.1093/gastro/goad015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/12/2022] [Accepted: 11/16/2022] [Indexed: 04/14/2023] Open
Affiliation(s)
- Ahmad Abou Yassine
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, NY, USA
| | - Hassan Al Moussawi
- Division of Gastroenterology, Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, NY, USA
| | - Malek Kreidieh
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, NY, USA
| | - Loai Dahabra
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, NY, USA
| | - Mustafa Al-Roubaie
- Department of Radiology, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - Sanjaya Satapathy
- Department of Gastroenterology, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
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Riedel C, Bannas P, Lenz A, Ittrich H, Perez D, Adam G, Lohse AW, Kluwe J, Piecha F. 4D flow MRI-guided treatment of portal-hypertensive complications in a patient with multiple extrahepatic arterioportal shunts. Magn Reson Imaging 2023; 101:54-56. [PMID: 37011771 DOI: 10.1016/j.mri.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 03/29/2023] [Indexed: 04/04/2023]
Abstract
Portal hypertension is the underlying reason for complications like ascites or gastrointestinal varices in end-stage liver disease. On rare occasions, portal hypertension may be caused by extrahepatic arterioportal shunts. This report illustrates an outstanding case of extrahepatic arterioportal shunting as an uncommon cause of TIPS-refractory portal hypertension. Four-dimensional flow magnetic resonance imaging (4D flow MRI) is a novel non-invasive technique that enables the visualization of complex vascular disorders but has not been put into daily clinical practice in hepatology. In this case, 4D flow MRI enabled the visualization of three abdominal arterioportal shunts as the reason for TIPS-refractory portal hypertension. The quantification of individual shunt flow rates by 4D flow MRI guided our treatment strategy consisting of embolization during interventional angiography and surgical resection of all three arterioportal shunts. In conclusion, this case highlights the usefulness of 4D flow MRI for evaluating shunt flow in cases of complex vascular disorders and portal-hypertensive complications, thus helping to guide therapeutic decisions and monitoring the therapeutic success.
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Affiliation(s)
- Christoph Riedel
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany.
| | - Peter Bannas
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany
| | - Alexander Lenz
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany
| | - Harald Ittrich
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany
| | - Daniel Perez
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany
| | - Ansgar W Lohse
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
| | - Johannes Kluwe
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany
| | - Felix Piecha
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
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15
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Funamizu N, Uraoka M, Shine M, Utsunomiya T, Tamura K, Sakamoto K, Ogawa K, Takada Y. Intrahepatic arterioportal shunt with portal-hypertension caused by liver biopsy after living-donor liver transplantation: a case report. KANZO 2022; 63:482-490. [DOI: 10.2957/kanzo.63.482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2025]
Affiliation(s)
- Naotake Funamizu
- Department of HBP & Transplantation Surgery, Ehime University Hospital
| | - Mio Uraoka
- Department of HBP & Transplantation Surgery, Ehime University Hospital
| | - Mikiya Shine
- Department of HBP & Transplantation Surgery, Ehime University Hospital
| | | | - Kei Tamura
- Department of HBP & Transplantation Surgery, Ehime University Hospital
| | | | - Kohei Ogawa
- Department of HBP & Transplantation Surgery, Ehime University Hospital
| | - Yasutsugu Takada
- Department of HBP & Transplantation Surgery, Ehime University Hospital
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16
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Xia J, Zhao J, Chang B. Case report: Congenital arterioportal fistula: An unusual cause of variceal bleeding in adults. Front Med (Lausanne) 2022; 9:970254. [PMID: 36160178 PMCID: PMC9489925 DOI: 10.3389/fmed.2022.970254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/19/2022] [Indexed: 11/13/2022] Open
Abstract
The aberrant vascular connecting channel that forms between the portal vein and the hepatic artery is the essence of a hepatic arterioportal fistula. Congenital hepatic arterioportal fistula more frequently occurs in early childhood rather than in adults. We describe a rare instance of a large, isolated, congenital hepatic arterioportal fistula that was successfully treated following selective hepatic arteriography and transcatheter embolization. The patient presented with significant variceal bleeding when the fistula was discovered at the age of 73. The patient's condition improved during the brief postoperative follow-up period without a recurrence. Our research suggests that in older patients with portal hypertension and an unclear etiology, selective arteriography and embolization can provide a definitive diagnosis and successfully treat symptoms.
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Affiliation(s)
- Junlin Xia
- Department of Gastroenterology, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Jingwen Zhao
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Bing Chang
- Department of Gastroenterology, The First Affiliated Hospital, China Medical University, Shenyang, China
- *Correspondence: Bing Chang
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17
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Cao B, Tian K, Zhou H, Li C, Liu D, Tan Y. Hepatic Arterioportal Fistulas: A Retrospective Analysis of 97 Cases. J Clin Transl Hepatol 2022; 10:620-626. [PMID: 36062281 PMCID: PMC9396316 DOI: 10.14218/jcth.2021.00100] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 06/03/2021] [Accepted: 11/16/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND AND AIMS Hepatic arterioportal fistulas (HAPFs) are abnormal shunts or aberrant functional connections between the portal venous and the hepatic arterial systems. Detection of HAPFs has increased with the advances in diagnostic techniques. Presence of HAPFs over a prolonged period can aggravate liver cirrhosis and further deteriorate liver function. However, the underlying causes of HAPFs and the treatment outcomes are now well characterized. This study aimed to summarize the clinical characteristics of patients with HAPFs, and to compare the outcomes of different treatment modalities. METHODS Data of 97 patients with HAPFs who were admitted to the Second Xiangya Hospital between January 2010 and January 2020 were retrospectively reviewed. Demographic information, clinical manifestations, underlying causes, treatment options, and short-term outcomes were analyzed. RESULTS The main cause of HAPF in our cohort was hepatocellular carcinoma (78/97, 80.41%), followed by cirrhosis (10/97, 10.31%). The main clinical manifestations were abdominal distention and abdominal pain. Treatment methods included transcatheter arterial embolization (n=63, 64.9%), surgery (n=13, 13.4%), and liver transplantation (n=2, 2.1%); nineteen (19.6%) patients received conservative treatment. Among patients who underwent transcatheter arterial embolization, polyvinyl alcohol, lipiodol combined with gelatin sponge, and spring steel ring showed comparable efficacy. CONCLUSIONS Hepatocellular carcinoma and cirrhosis are common causes of HAPFs. Transcatheter arterial embolization is a safe and effective method for the treatment of HAPFs, and polyvinyl alcohol, lipiodol combined with gelatin sponge, and spring steel ring showed comparable efficacy in our cohort.
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Affiliation(s)
- Bendaxin Cao
- Department of Respiratory and Critical Care Medicine, Affiliated Nanhua Hospital, University of South China, Hengyang, Hunan, China
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
- Research Center of Digestive Disease, Central South University, Changsha, Hunan, China
| | - Ke Tian
- Department of Respiratory and Critical Care Medicine, Affiliated Nanhua Hospital, University of South China, Hengyang, Hunan, China
| | - Hejun Zhou
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
- Research Center of Digestive Disease, Central South University, Changsha, Hunan, China
| | - Chenjie Li
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
- Research Center of Digestive Disease, Central South University, Changsha, Hunan, China
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
- Research Center of Digestive Disease, Central South University, Changsha, Hunan, China
| | - Yuyong Tan
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
- Research Center of Digestive Disease, Central South University, Changsha, Hunan, China
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18
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Loyal P, Sagoo R. Endovascular management of a congenital hepatic arterioportal malformation in a low resource setting. CVIR Endovasc 2022; 5:38. [PMID: 35932336 PMCID: PMC9357240 DOI: 10.1186/s42155-022-00314-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 07/29/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Arterioportal malformations, a rare type of vascular malformation, have significant associated morbidity and mortality. Management requires a carefully thought out approach by a multidisciplinary team. Low resource settings have an added challenge of limited treatment options and consumables.
Case presentation
We report a case of a 14-month-old male with failure to thrive due to a congenital hepatic arterioportal fistula. He was successfully treated via an endovascular approach with metallic coil embolization.
Conclusion
Hepatoportal fistula, a rare hepatic vascular malformation, has limited treatment options which can further be restricted by overall patient wellness. Minimally invasive endovascular treatment options can offer a high rate of success and reverse the morbidity associated with the disease as was seen with our case.
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19
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Gladkikh M, Parra DA. Successful embolization of a congenital intra-hepatic arterioportal fistula in a neonate with the MVP Microvascular Plug system (MVP-3Q). Radiol Case Rep 2022; 17:991-996. [PMID: 35106111 PMCID: PMC8784292 DOI: 10.1016/j.radcr.2021.12.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 12/30/2021] [Indexed: 12/02/2022] Open
Abstract
This case report describes a neonate with an antenatally diagnosed vascular anomaly of the liver. Ultrasound at birth confirmed an arterioportal fistula communicating the left hepatic artery and an anterior branch of the right portal vein. Computer tomography angiography on day 7 of life redemonstrated the arterioportal fistula and defined the vascular anatomy for potential treatment. Transarterial embolization of the arterioportal fistula was performed at 3 weeks of life using an MVP Microvascular Plug System 3Q (Reverse Medical Corp, Irvine, CA, USA). Intra-procedural angiography showed successful occlusion of the fistula, patency of the portal vein with hepatopetal flow, and patency of the hepatic artery with no signs of arterial or venous thrombosis. There were no intra- or post-procedure complications. Multiple follow-up ultrasounds at 1-13 months showed stable occlusion of the embolized fistula with no evidence of recanalization, with the patient having a normal life and no sequelae. This case illustrates a successful novel approach to manage the rare condition of a solitary hepatic arterioportal fistula in a neonate using the MVP system. Current literature on congenital arterioportal fistulas and the MVP system is reviewed.
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Affiliation(s)
- Maria Gladkikh
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Research volunteer, Division of Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada
| | - Dimitri A. Parra
- Staff Pediatric Interventional Radiologist, Division of Image Guided Therapy, Diagnostic Imaging, The Hospital for Sick Children, Room 2230A, 555 University Avenue, Toronto, ON M5G 1X8, Canada
- Assistant Professor, Medical Imaging, University of Toronto, Toronto, ON, Canada
- Corresponding author. D.A. Parra.
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20
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Subramanian A, Jayranganath M, Bharath A, Barthur A, Sastry UK, M. Moorman A. Congenital systemic arteriovenous fistulas: Interventional strategies and embryological perspectives. Ann Pediatr Cardiol 2022; 15:138-146. [PMID: 36246751 PMCID: PMC9564402 DOI: 10.4103/apc.apc_143_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/05/2021] [Accepted: 10/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background: Data on congenital systemic arteriovenous fistulas are largely based on individual case reports. A true systemic arteriovenous fistula needs to be differentiated from other vascular malformations like capillary or venous hemangiomas, which are far more common. Objectives: We sought to identify the varied symptoms, diagnostic challenges, describe interventional treatment options, and postulate an embryological basis for this uncommonly described entity. Methods: This is a descriptive study of a cohort of systemic arteriovenous fistulas seen in the department of pediatric cardiology at a tertiary cardiac institute from 2010 to 2020, with prospective medium-term follow-up. A total of seven cases were identified. The diagnosis was confirmed by computed tomographic imaging, magnetic resonance angiography, or conventional angiography. Results: All were successfully closed using duct occluders or embolization coils with no recurrence in six cases over a median duration of follow-up of 48 months (interquartile range: 16; 36–52 months). Four of the seven cases underwent follow-up imaging using echocardiography or ultrasound. Conclusion: The incidence of congenital systemic arteriovenous fistulas is low and accounted for 0.009% of pediatric outpatients seen over 10 years at our institute. The spectrum of clinical presentation varies from an innocuous swelling or a pulsating mass to frank heart failure. Strong clinical suspicion and advanced imaging modalities have helped identify some hitherto undescribed connections. Large malformations with multiple communications may persist or recur despite transcatheter closure.
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21
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Liu GF, Wang XZ, Luo XF. Simultaneous embolization of a spontaneous porto-systemic shunt and intrahepatic arterioportal fistula: A case report. World J Clin Cases 2021; 9:9577-9583. [PMID: 34877293 PMCID: PMC8610867 DOI: 10.12998/wjcc.v9.i31.9577] [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: 03/31/2021] [Revised: 06/06/2021] [Accepted: 08/17/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hepatic encephalopathy (HE) is a frequent and debilitating complication of chronic liver disease. Recurrent HE is strongly linked with spontaneous portosystemic shunts (SPSSs). Intrahepatic arterioportal fistulas (IAPFs) occur rarely but pose a major clinical challenge and may lead to or worsen portal hypertension. Herein, we present a rare case of recurrent HE secondary to a SPSS combined with an IAPF.
CASE SUMMARY A 63-year-old female with primary biliary cirrhosis presented with recurrent disturbance of consciousness for 4 mo. SPSS communicating the superior mesenteric vein with the inferior vena cava and IAPF linking the intrahepatic artery with the portal vein were found on contrast-enhanced abdominal computed tomography. The patient did not respond well to medical treatment. Therefore, simultaneous embolization of SPSS and IAPF was scheduled. After embolization, the symptoms of HE showed obvious resolution.
CONCLUSION The presence of liver vascular disorders should not be neglected in patients with chronic liver disease, and interventional therapy is a reasonable choice in such patients.
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Affiliation(s)
- Guo-Feng Liu
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xiao-Ze Wang
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xue-Feng Luo
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Hepatic Arterioportal Fistula Is Associated with Decreased Future Liver Remnant Regeneration after Stage-I ALPPS for Hepatocellular Carcinoma. J Gastrointest Surg 2021; 25:2280-2288. [PMID: 33963498 DOI: 10.1007/s11605-021-05022-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 04/20/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) patients often developed hepatic arterioportal fistula (APF). The aim of this study is to evaluate the impact of APF on future liver remnant (FLR) regeneration and surgical outcomes after the first stage of associating liver partition and portal vein ligation for staged hepatectomy (stage-I ALPPS). METHODS Consecutive HCC patients who underwent ALPPS at our center between March 2017 and May 2019 were retrospectively studied. Data for the association between APF and clinicopathological details, liver volume, and surgical outcomes were analyzed. RESULTS The enrolled 35 HCC patients were divided into three groups: 15 patients with preoperative APF were classified as the APF I group, 10 patients developed APF after stage-I ALPPS as the APF II group, whereas the other 10 patients without APF before and after stage-I ALPPS as the control group. After stage-I ALPPS, patients in the APF I and APF II groups had lower kinetic growth rate (KGR) of FLR volume (6.1±3.2%, 11.4±8.4%, 25.0±8.8% per week, respectively, P<0.001) and took longer median time to reach the sufficient FLR volume for stage-II ALPPS (17.5 days, 12 days, 6 days, respectively, P<0.001) than those in the control group. Meanwhile, the incidence of posthepatectomy liver failure (PHLF) in the APF I and APF II groups was significantly higher than that of the control group (P=0.007). There are 27 (77.1%) patients who completed stage-II ALPPS. The overall survival (OS) rates at 1 and 3 years were 59.3% and 35.1%, whereas the disease-free survival (DFS) rates at 1 and 3 years were 44.4% and 22.9%, respectively. CONCLUSIONS Hepatic APF is significantly associated with decreased FLR regeneration and a higher risk of PHLF after stage-I ALPPS. HCC patients who are to undergo ALPPS may benefit from the timely perioperative intervention of APF.
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Arteriovenous Fistula of Superior Mesenteric Artery: An Unusual Cause of an Massive Lower Gastrointestinal Bleeding. Int Surg 2021. [DOI: 10.9738/intsurg-d-17-00014.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction
The most common causes of lower gastrointestinal (GI) hemorrhage are diverticulosis and angiodysplasia. Arteriovenous fistula (AVF) of the intestine is an uncommon cause of GI hemorrhage.
Case Presentation
Herein, we report a case of an embolization of an AVF originated from the superior mesenteric artery and vein as a cause of acute massive lower GI bleeding.
Conclusion
The patient underwent a right hemicolectomy and ileotransversostomy.
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Ede C, Cantrell J, Ramos J. Therapeutic strategies for refractory variceal bleeding due to percutaneous liver biopsy: A case report. Int J Surg Case Rep 2021; 82:105852. [PMID: 33862410 PMCID: PMC8076701 DOI: 10.1016/j.ijscr.2021.105852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/27/2021] [Accepted: 03/28/2021] [Indexed: 11/19/2022] Open
Abstract
Intrahepatic arterioportal fistula is an unusual complication of liver biopsy. Intrahepatic arterioportal fistula can cause variceal bleeding. Angioembolization is an effective treatment of variceal bleeding. Introduction and importance Variceal bleeding due to intrahepatic arterioportal fistula is an unusual complication of percutaneous liver biopsy. As majority of variceal bleeding are cirrhotic in origin, the rare occurrence of an acquired intrahepatic arterioportal fistula presents a therapeutic dilemma. Case presentation We report the case of a 57-year-old female with refractory variceal bleeding that occurred six years after a percutaneous liver biopsy. As part of the workup for placement of Transjugular Intrahepatic Portosystemic Shunt, a computed tomography hepatic arteriography was performed. This revealed a large arterioportal fistula in left lobe of liver. Variceal bleeding was controlled following successful embolisation of the arterioportal fistula. Clinical discussion Persistent intrahepatic arterioportal fistula can result in portal hypertension and variceal bleeding. This is a rare complication of percutaneous liver biopsy that warrants consideration as an aetiology of portal hypertension with variceal bleeding. The therapeutic strategy for refractory bleeding due to intrahepatic arterioportal fistula is different from cirrhotic portal hypertension and requires trans-arterial embolisation of the fistula. Conclusion This case highlights the need to consider arterioportal fistula as an aetiology of portal hypertension as therapeutic strategy in refractory variceal bleeding is different from cirrhotic portal hypertension.
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Affiliation(s)
- Chikwendu Ede
- Department of Surgery, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa.
| | - John Cantrell
- Donald Gordon Medical Centre, University of the Witwatersrand, South Africa.
| | - Jose Ramos
- Donald Gordon Medical Centre, University of the Witwatersrand, South Africa.
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Stepanyan SA, Poghosyan T, Manukyan K, Hakobyan G, Hovhannisyan H, Safaryan H, Baghdasaryan E, Gemilyan M. Coil embolization of arterioportal fistula complicated by gastrointestinal bleeding after Caesarian section: A case report. World J Clin Cases 2021; 9:403-409. [PMID: 33521108 PMCID: PMC7812888 DOI: 10.12998/wjcc.v9.i2.403] [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: 07/09/2020] [Revised: 11/26/2020] [Accepted: 12/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Most intrahepatic arterioportal fistulae (IAPF) are acquired. The few cases of congenital fistulae are diagnosed in infants and children. CASE SUMMARY We report a 31-year-old female patient presenting with haematemesis and melena three weeks after delivering her second child. The patient had a 20-year history of abdominal distention and nausea. IAPF, along with splenomegaly and ascites, was found by Doppler sonography and confirmed by computed tomography angiography. The patient was treated with endovascular coil embolization, resulting in occlusion of the fistula. CONCLUSION This was an unusual case of possible congenital IAPF that manifested during a second pregnancy and was complicated by portal hypertension.
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Affiliation(s)
- Suren Agho Stepanyan
- Department of Surgery No. 1, Yerevan State Medical University, Yerevan 0025, Armenia
| | - Tigran Poghosyan
- Department of Vascular Surgery, National Center of Oncology, Yerevan 0052, Armenia
| | - Karen Manukyan
- Department of Endoscopy, Mikaelyan University Hospital, Yerevan 0052, Armenia
| | - Gagik Hakobyan
- Department of Gastroenterology and Hepatology, Yerevan State Medical University, Yerevan 0025, Armenia
| | | | - Hayk Safaryan
- Department of Surgery No. 1, Yerevan State Medical University, Yerevan 0025, Armenia
- Department of Surgery, Mikaelyan Institute of Surgery, Yerevan 0052, Armenia
| | | | - Manik Gemilyan
- Department of Gastroenterology and Hepatology, Yerevan State Medical University, Yerevan 0025, Armenia
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Anand S, Jain V, Agarwala S, Gupta CR, Kandasamy D, Gamanagatti S. Congenital Intrahepatic Arterioportal Fistula: Extremely Rare Cause of Melena and Chronic Diarrhea in Children. J Indian Assoc Pediatr Surg 2021; 26:54-56. [PMID: 33953515 PMCID: PMC8074812 DOI: 10.4103/jiaps.jiaps_51_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/06/2020] [Accepted: 09/02/2020] [Indexed: 11/04/2022] Open
Abstract
Congenital intrahepatic arterioportal fistulas are rare causes of presinusoidal portal hypertension in children. A rare case of arterioportal fistula in an infant is being reported. This report also highlights the need for long-term surveillance in such cases, despite being a benign pathology.
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Affiliation(s)
- Sachit Anand
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Vishesh Jain
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Agarwala
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Chabi Ranu Gupta
- Department of Pediatric Surgery, Chacha Nehru Bal Chikitsalaya, New Delhi, India
| | | | - Shivanand Gamanagatti
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
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Pathanki A, Sharif K, McCafferty I, Hartley J, McGuirk S. Congenital intrahepatic aorto-portal fistula presenting with cardiac failure. BJR Case Rep 2020; 6:20200006. [PMID: 33299580 PMCID: PMC7709065 DOI: 10.1259/bjrcr.20200006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 06/21/2020] [Accepted: 06/29/2020] [Indexed: 11/05/2022] Open
Abstract
Congenital intrahepatic arterio-portal fistulae (cIAPF) are rare, high-flow vascular malformations that usually present with portal hypertension. They almost never cause heart failure, unless there is associated congenital heart disease or the ductus venosus in patent. We present an unusual case of IAPF in an 11-day-old boy, who presented with features of cardiac failure associated with increased N-terminal pro-brain natriuretic peptide (NT pro-BNP). The IAPF arose directly from the aorta, separated from the hepatic artery and divided to separately supply both left and right portal veins. The ductus venosus was occluded. The IAPF was treated with embolization of the aorto-portal fistula, accessed through a direct percutaneous puncture of the fistula. Embolization was associated with an immediate clinical improvement and a rapid and sustained normalization of the NT pro-BNP level. A similar re-presentation was noted and treated with repeat embolization. The child is well on follow-up. To our knowledge, this is the first case of cIAPF, which was presented with cardiac failure when the ductus venosus has closed and has been treated successfully with direct, percutaneous transhepatic embolization of the fistula, twice. Serial clinical follow-up and ultrasonographical examinations have proven to be an effective strategy to detect recurrent fistulae.
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Affiliation(s)
- Adithya Pathanki
- The liver unit, including small bowel transplantation, Birmingham Children’s Hospital, Steelhouse lane, Birmingham, United Kingdom
| | - Khalid Sharif
- The liver unit, including small bowel transplantation, Birmingham Children’s Hospital, Steelhouse lane, Birmingham, United Kingdom
| | - Ian McCafferty
- Department of Interventional Radiology, Queen Elizabeth Hospital Birmingham, Mindelsohn way, Birmingham, United Kingdom
| | - Jane Hartley
- The liver unit, including small bowel transplantation, Birmingham Children’s Hospital, Steelhouse lane, Birmingham, United Kingdom
| | - Simon McGuirk
- Department of Interventional Radiology, Birmingham Children’s Hospital, Steelhouse lane, Birmingham, United Kingdom
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Ruptured pancreaticoduodenal pseudoaneurysm causing arterioportal fistula: combined transarterial and transportal embolization. CVIR Endovasc 2020; 3:72. [PMID: 32990860 PMCID: PMC7524934 DOI: 10.1186/s42155-020-00165-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/24/2020] [Indexed: 11/16/2022] Open
Abstract
Background Arterioportal fistulas are rare vascular disorders of the abdominal viscera. They are arteriovenous communications between the splanchnic arteries and the portal vein or its tributaries. We herein report a case of an extrahepatic arterioportal fistula that was caused by rupture of a pseudoaneurysm of the pancreaticoduodenal artery and successfully treated with embolization using a combination of the arterial and percutaneous transhepatic portal venous approaches. Case presentation A 79-year-old man was transferred to our hospital because of the sudden appearance of a hematoma containing a large pseudoaneurysm in the mesentery of the duodenum. Emergency abdominal angiography revealed that a pseudoaneurysm of the anterior inferior pancreaticoduodenal arterial branch had perforated into the portal system (arterioportal fistula). We performed coil embolization via the inflow artery and portal vein using a percutaneous transhepatic approach. The patient recovered without complications and was discharged. Conclusion This rare vascular disorder was successfully treated with an unplanned combination therapy. We believe that flexible strategy changes led to the successful treatment in this case.
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Roy A, Taneja S, Behera A, Kaman L, Kalra N, Chaluvashetty SB, Das A, Dahiya D, Duseja AK, Singh V. Intrahepatic Arterioportal Fistula: A Rare Cause of Portal Hypertension After Deceased Donor Liver Transplant. EXP CLIN TRANSPLANT 2020; 18:645-648. [PMID: 32778016 DOI: 10.6002/ect.2020.0119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 43-year-old male patient, who received a deceased donor liver transplant for background ethanol-related decompensated cirrhosis, presented 7 months after transplant with mild abdominal distension and pain. On evaluation, the patient had thrombocytopenia, high serum-ascites albumin gradient ascites, and deranged liver functions. The Doppler study of the splenoportal axis showed hepatofugal flow in the recipient's portal vein, normal hepatic veins, a normal liver, splenomegaly, mild ascites, and multiple periportal collaterals. A transjugular liver biopsy and a hepatic venous pressure gradient measurement were done, which suggested mild portal tract inflammation with portal tract fibrosis with prominent portal venous thickening and normal hepatic venous pressure gradient (4 mm). However, the patient had a progressive increase in ascites and a dramatic increase in serum bilirubin level. A triple-phase computed tomography was done that showed rapid contrast flow in both the portal and hepatic arterial phase, suggesting arterialization of the portal flow with possible suspicion of a communicating arterioportal fistula. The patient underwent digital subtraction angiography, which was followed by an embolization of the arterioportal fistula. After embolization, serum bilirubin gradually decreased and ascites resolved. A repeat Doppler of the portal venous system showed established hepatopetal flow with progressively rising portal flow velocities.
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Affiliation(s)
- Akash Roy
- From the Division of General Surgery and Liver Transplantation, Hospital Oswaldo Cruz, Pernambuco University, Recife, Pernambuco, Brazil
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Ban EJ, Hii B, Smith M, Clements W. Early surgical management of severe liver trauma with vascular complication can lead to early discharge. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408620911492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intrahepatic arterio-portal fistulas are rare complications of blunt hepatic trauma. We describe a case of a 35-year-old male sustaining blunt abdominal trauma resulting in a grade IV liver injury complicated by arterio-portal fistula, portal venous pseudoaneurysm and concomitant bile duct injury. Although arterial embolisation is the mainstay of treatment for arterio-portal fistula, we describe a rationale for early involvement of a hepatobiliary surgeon for multidisciplinary management. Hepatic resection for acute hepatic trauma can, in selected cases, promptly manage all elements of portal triad injury, and in this particular case facilitated early uncomplicated discharge.
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31
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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.
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Affiliation(s)
- Roberta Angelico
- Department of Abdominal Transplantation and Hepatobiliary and Pancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome 00165, 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.
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Bertanha M, Moura R, Jaldin RG, Sobreira ML, Curtarelli A, Rosa FD, Sembenelli M, Yoshida WB. Tratamento endovascular da hipertensão portal e da hemorragia digestiva recorrente e secundária à síndrome da fístula arterioportal: complicação tardia de trauma abdominal penetrante. J Vasc Bras 2020; 19:e20190136. [PMID: 34178070 PMCID: PMC8202170 DOI: 10.1590/1677-5449.190136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The arterioportal fistula (APF) syndrome is a rare and reversible cause of
pre-sinusoidal portal hypertension, caused by communication between a visceral artery
and the portal venous system. Most patients are asymptomatic, but when they do
develop symptoms, these are mainly related to gastrointestinal bleeding, ascites,
congestive heart failure, and diarrhea. This therapeutic challenge presents a case of
APF caused by a 20-year-old stabbing injury with unfavorable late clinical evolution,
including significant malnutrition and severe digestive hemorrhages. The patient was
treated using an endovascular procedure to occlude of the fistula.
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Affiliation(s)
- Matheus Bertanha
- Universidade Estadual Paulista “Júlio de Mesquita Filho”, Brasil
| | - Regina Moura
- Universidade Estadual Paulista “Júlio de Mesquita Filho”, Brasil
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Oguslu U, Uyanik SA, Gümüş B. Endovascular treatment of hepatic arterioportal fistula complicated with giant portal vein aneurysm via percutaneous transhepatic US guided hepatic artery access: a case report and review of the literature. CVIR Endovasc 2019; 2:39. [PMID: 32026997 PMCID: PMC6966339 DOI: 10.1186/s42155-019-0084-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/12/2019] [Indexed: 11/23/2022] Open
Abstract
Background Hepatic arterioportal fistulas are rare, abnormal, direct communications between hepatic artery and portal venous system. Treatment options shifted from surgery to endovascular interventions. Catheterization may be challenging. We report a case of a hepatic arterioportal fistula treated successfuly with Amplatzer Vascular Plug II via percutaneous transhepatic hepatic artery access after failed transfemoral approach. Case presentation 58 year old woman presented with right heart failure, kidney insufficiency and massive ascites related to portal hypertension caused by hepatic arterioportal fistula. She had a history of previous abdominal surgery. Colour Doppler ultrasound and computed tomography revealed a giant portal vein aneurysm related to large hepatic areterioportal fistula. Endovascular treatment was planned. Catheterization of the hepatic artery could not be realized due to severe tortuosity and angulation of the celiac artery and its branches. Access to the hepatic artery was obtained directly via percutaneous transhepatic route and fistula site was embolized with Amplatzer Vascular Plug II and coils. Immediate thrombosis of the aneurysm sac and draining portal vein was observed. Patients clinical status improved dramatically. Conclusion Transcatheter embolization is the first choice of the treatment of hepatic arterioportal fistulas but the type of the therapy should be tailored to the patient and interventional radiologist should decide the access site depending on his own experience if the routine endovascular access can not be obtained.
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Affiliation(s)
- Umut Oguslu
- Department of Radiology, Okan University Hospital, Aydinli Cad. No: 2 Okan Universitesi Hastanesi Icmeler, Tuzla, Istanbul, Turkey.
| | - Sadik Ahmet Uyanik
- Department of Radiology, Okan University Hospital, Aydinli Cad. No: 2 Okan Universitesi Hastanesi Icmeler, Tuzla, Istanbul, Turkey
| | - Burçak Gümüş
- Department of Radiology, Okan University Hospital, Aydinli Cad. No: 2 Okan Universitesi Hastanesi Icmeler, Tuzla, Istanbul, Turkey
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34
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Munekage E, Maeda H, Munekage M, Uemura S, Okamoto K, Fukudome I, Fujisawa K, Yamaguchi S, Ogasawara M, Namikawa T, Hanazaki K. A case of ascites and SMV thrombosis dueto an intrahepatic arterio-portal fistula after hepatectomy. ANNALS OF CANCER RESEARCH AND THERAPY 2019; 27:83-86. [DOI: 10.4993/acrt.27.83] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Eri Munekage
- Department of Surgery, Kochi Medical School Hospital
| | | | | | - Sunao Uemura
- Department of Surgery, Kochi Medical School Hospital
| | - Ken Okamoto
- Department of Surgery, Kochi Medical School Hospital
- Cancer Treatment Center, Kochi Medical School
| | - Ian Fukudome
- Department of Surgery, Kochi Medical School Hospital
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35
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Jargiełło T, Sobstyl J, Kasztelan-Szczerbińska B, Sojka M, Pyra K. Endovascular treatment of the superior mesenteric arteriovenous fistula complicated by gastrointestinal bleeding. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2019; 30:652-654. [PMID: 30460904 PMCID: PMC6629274 DOI: 10.5152/tjg.2018.17744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 10/08/2018] [Indexed: 11/22/2022]
Affiliation(s)
- Tomasz Jargiełło
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, Lublin, Poland
| | - Jan Sobstyl
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, Lublin, Poland
| | | | - Michał Sojka
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, Lublin, Poland
| | - Krzysztof Pyra
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, Lublin, Poland
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Anand RR, Cherian P M, Mehta P, Gandhi JM, S E, Patil SB. Endovascular treatment of psuedoaneurysm arising from common hepatic artery bifurcation with complete disruption of gastroduodenal artery and high flow arterioportal fistula. Ann Hepatobiliary Pancreat Surg 2019; 23:187-191. [PMID: 31225423 PMCID: PMC6558136 DOI: 10.14701/ahbps.2019.23.2.187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 02/01/2019] [Accepted: 02/07/2019] [Indexed: 11/19/2022] Open
Abstract
Arterio-portal fistulas (APFs) are characterized by anomalous communication between arteries and the portal vein (PV) system. Treatment of APF is imperative as an emergency or if there is development of portal hypertension/heart failure in chronic cases. Both endovascular and surgical managements can be attempted, however since endovascular management carries comparatively low intra and post procedural morbidity it is mostly preferred. This is a case report on endovascular management of post-traumatic pseudoaneurysm arising from bifurcation of common hepatic artery with complete disruption of the gastroduodenal artery and high-flow APF. This report describes the intraprocedure challenges in exclusion of fistula from the circulation, without disruption of portal system and anticipation of recruitment of new collateral feeders to the fistula immediate post exclusion with its embolization, which needs appropriate positioning of the catheter prior to exclusion of the fistula.
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Affiliation(s)
- Rinoy R Anand
- Department of Neuro and Vascular Interventional Radiology, Kovai Medical Center and Hospital Coimbatore, Tamil Nadu, India
| | - Mathew Cherian P
- Department of Neuro and Vascular Interventional Radiology, Kovai Medical Center and Hospital Coimbatore, Tamil Nadu, India
| | - Pankaj Mehta
- Department of Neuro and Vascular Interventional Radiology, Kovai Medical Center and Hospital Coimbatore, Tamil Nadu, India
| | - Jenny M Gandhi
- Department of Neuro and Vascular Interventional Radiology, Kovai Medical Center and Hospital Coimbatore, Tamil Nadu, India
| | - Elango S
- Department of Neuro and Vascular Interventional Radiology, Kovai Medical Center and Hospital Coimbatore, Tamil Nadu, India
| | - Santosh B Patil
- Department of Neuro and Vascular Interventional Radiology, Kovai Medical Center and Hospital Coimbatore, Tamil Nadu, India
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Kai K, Sano K, Higuchi K, Uchiyama S, Sueta H, Nanashima A. A rare case of simultaneous rectal and gastric carcinomas accompanied with inferior mesenteric arterioportal fistula: case report. Surg Case Rep 2019; 5:82. [PMID: 31102060 PMCID: PMC6525223 DOI: 10.1186/s40792-019-0630-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 04/22/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Inferior mesenteric arterioportal fistula (APF) is rare as only 35 case reports in the literature. We herein presented a case of simultaneously double cancer in the rectum and stomach with inferior mesenteric APF, which is the first case report by searching using PubMed. Combination of interventional embolization and surgical operation seemed to be optimal treatment for avoiding postoperative complications and the curability. CASE PRESENTATION A 66-year-old male with epigastric pain was admitted to a practitioner. He underwent a gastroscopy with biopsy, and cancer located in the lesser curvature of the gastric cardia was found. Enhanced CT did not reveal wall thickening of the stomach and distant metastases, but several swollen lymph nodes were observed in the right cardia. In the arterial phase, dilation of inferior mesenteric vein (IMV) and superior rectal artery (SRA) were noted, which raised suspicions of an arterioportal communication. Colonoscopy revealed a type 2 rectal tumor located 12 cm from the anal verge. The histological diagnosis of well-differentiated tubular adenocarcinoma was confirmed by biopsy. At a first step, we planned to perform a radiological embolization of inflow vessels to APFs except for SRA. Additionally, we determined the interval time of 1 month between the first low anterior rectal resection and the sequential gastrectomy for the purpose of decreasing portal pressure. The postoperative course was uneventful without hemorrhagic complications, and S-1 was taken internally 1 year as adjuvant chemotherapy for gastric cancer. The patient still lives without recurrence of this cancer with APF and portal vein thrombosis 2.5 years after the aforementioned surgeries. CONCLUSION Inferior mesenteric APF and/or arteriovenous fistula (AVF) would be consisted of the several inflow arteries as superior rectal, internal iliac, and median sacral arteries, and outflow veins as inferior mesenteric, internal iliac, and median sacral veins. To determine the therapeutic strategy for left-sided colorectal cancers with abnormal vessel communications of the pelvis, it is significant to comprehend distribution and component vessels of APF and/or AVF.
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Affiliation(s)
- Kengo Kai
- Department of Surgery, Miyakonojo Medical Association Hospital, 1364-1 Tarobo, Miyakonojo, Miyazaki, 885-0002, Japan.
| | - Koichiro Sano
- Department of Surgery, Miyakonojo Medical Association Hospital, 1364-1 Tarobo, Miyakonojo, Miyazaki, 885-0002, Japan
| | - Kazuhiro Higuchi
- Department of Surgery, Miyakonojo Medical Association Hospital, 1364-1 Tarobo, Miyakonojo, Miyazaki, 885-0002, Japan
| | - Shuichiro Uchiyama
- Department of Surgery, Miyakonojo Medical Association Hospital, 1364-1 Tarobo, Miyakonojo, Miyazaki, 885-0002, Japan
| | - Hideto Sueta
- Department of Surgery, Miyakonojo Medical Association Hospital, 1364-1 Tarobo, Miyakonojo, Miyazaki, 885-0002, Japan
| | - Atsushi Nanashima
- Faculty of Medicine, Department of Surgery, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, Miyazaki, Japan
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Takata H, Makino H, Yokoyama T, Maruyama H, Hirakata A, Ueda J, Yoshida H. Successful surgical treatment for intrahepatic arterioportal fistula with severe portal hypertension: a case report. Surg Case Rep 2019; 5:67. [PMID: 31016545 PMCID: PMC6478780 DOI: 10.1186/s40792-019-0623-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 04/04/2019] [Indexed: 01/09/2023] Open
Abstract
Background Intrahepatic arterioportal fistula (IAPF) is a rare cause of portal hypertension. Interventional radiology (IVR) is generally selected as the first-line therapeutic option. Surgical treatment for IAPF is required in refractory cases of IVR. As the treatment success rate with IVR is high, cases requiring surgical treatment are extremely rare. Case presentation A 54-year-old man was admitted to another hospital complaining of hematemesis due to rupture of the esophageal varices. A computed tomography revealed ascites and arterioportal fistula in the left lobe of the liver. Transcatheter arterial embolization (TAE) was performed to occlude the fistula; however, it could not reach complete occlusion. Thereafter, there were a total of four hematemeses, and six endoscopic variceal ligations were required. The second TAE also failed to reach complete occlusion. He was transferred to our hospital for further treatment. Because liver function was low due to frequent hematemeses and there was also uncontrollable ascites, it was confirmed that hepatectomy could not be performed safely at this time. Therefore, we ligated the left portal branch and ligated and dissected the left gastric vein to decrease portal vein pressure. However, on the 5th day after surgery, the esophageal varices reruptured. As the disappearance of ascites was observed in the postoperative course and the general condition also improved, left hepatectomy was performed to remove IAPF. There was no recurrence of portal hypertension for 1 year and 3 months since hepatectomy. Conclusions This case was difficult to treat with IVR and required surgical treatment. Our experience in the present case suggests that hepatectomy to remove arterioportal fistula was considered effective for improving portal hypertension due to IAPF. However, careful treatment selection according to the patient’s overall condition and clinical course is necessary for IAPF presenting with severe portal hypertension.
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Affiliation(s)
- Hideyuki Takata
- Department of Surgery, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama city, Tokyo, 206-8512, Japan.
| | - Hiroshi Makino
- Department of Surgery, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama city, Tokyo, 206-8512, Japan
| | - Tadashi Yokoyama
- Department of Surgery, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama city, Tokyo, 206-8512, Japan
| | - Hiroshi Maruyama
- Department of Surgery, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama city, Tokyo, 206-8512, Japan
| | - Atsushi Hirakata
- Department of Surgery, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama city, Tokyo, 206-8512, Japan
| | - Junji Ueda
- Department of Surgery, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama city, Tokyo, 206-8512, Japan
| | - Hiroshi Yoshida
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
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Miranda RN, Leonardo Gordinho AJ, Visconti V, Oliveira I. Arterioportal fistula after partial gastrectomy treated with coil embolisation. BMJ Case Rep 2019; 12:12/2/e226721. [PMID: 30814096 DOI: 10.1136/bcr-2018-226721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - Virginia Visconti
- Internal Medicine, Hospital Beatriz Angelo, Loures, Lisboa, Portugal
| | - Isménia Oliveira
- Internal Medicine, Hospital Beatriz Angelo, Loures, Lisboa, Portugal
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Pabla B, Porayko M. Hemobilia following Percutaneous Liver Biopsy in the Setting of Malignancy (with Video): Diagnosis and Management of a Rare Cause of Upper Gastrointestinal Bleeding. Case Rep Gastrointest Med 2019; 2019:3087541. [PMID: 30906600 PMCID: PMC6398082 DOI: 10.1155/2019/3087541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 01/31/2019] [Indexed: 11/18/2022] Open
Abstract
A 57-year-old gentleman with a past medical history of well-differentiated pancreatic neuroendocrine tumor (NET) with liver metastases was transferred to our hospital with abdominal pain. He underwent percutaneous liver biopsy three days prior to admission as a part of a study protocol for treatment of his progressive NET. He developed gastrointestinal bleeding and was found to have a distended gallbladder filled with high density material on ultrasound. During initial upper endoscopy, it was noted that he had blood emanating from the duodenal papilla consistent with hemobilia and he was ultimately diagnosed with post-liver biopsy hemorrhage. At first, he was managed conservatively with supportive care, but bleeding persisted resulting in the need for arterial embolization as a more effective treatment modality. Hemobilia is a rare entity and in the modern era it is most commonly the result of iatrogenic injury. Appropriate management depends on the underlying etiology with most cases resolving with conservative management. The avoidance of unnecessary surgery and the use of embolization are key principles in management.
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Affiliation(s)
- B. Pabla
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, USA
| | - M. Porayko
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, USA
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Mukund A, Maiwall R, Kumar Condati N. Angioembolization of Post-traumatic Intrahepatic Arterioportal Fistula Presenting With Portal Hypertension. J Clin Exp Hepatol 2019; 9:541-545. [PMID: 31516271 PMCID: PMC6728541 DOI: 10.1016/j.jceh.2018.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 10/18/2018] [Indexed: 12/12/2022] Open
Abstract
Traumatic hepatic arterioportal fistula is an abnormal communication between the hepatic artery and portal vein and is a rare cause of non-cirrhotic portal hypertension with delayed presentation, usually after a remote history of abdominal trauma or an interventional procedure. This case report is of one such rare presentation, wherein a 59-year-old gentleman presented with unexplained ascites and complications of portal hypertension, eventually diagnosed with an arterioportal fistula on a computed tomography scan and managed by angioembolization. There was a remarkable improvement in the complications of portal hypertension after the coil embolization.
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Affiliation(s)
- Amar Mukund
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, India,Address for correspondence. Amar Mukund, Additional Professor, Department of Interventional Radiology, Institute of Liver and Biliary Sciences, India.
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, India
| | - Naveen Kumar Condati
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, India
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42
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Choi M, Kim H, Yoon J, Choi M. CT features of extrahepatic arterioportal fistula in two cats. J Small Anim Pract 2018; 60:697-700. [PMID: 30381839 DOI: 10.1111/jsap.12957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 06/12/2018] [Accepted: 07/05/2018] [Indexed: 11/29/2022]
Abstract
Two cats presented with large volume ascites and the cause was suspected to be portal hypertension. On contrast CT they both showed enhancement of the main portal vein during the arterial phase and an anomalous connection between the celiac artery and extrahepatic portal vasculature, prompting a diagnosis of extrahepatic arterioportal fistula. An extrahepatic arterioportal fistula is a connection between any artery and the portal vein outside the liver and, to our knowledge, this is the first report in cats.
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Affiliation(s)
- M Choi
- Department of Veterinary Medical Imaging, Haemaru Referral Animal Hospital, Seongnam 463-050, Republic of Korea
| | - H Kim
- Department of Veterinary Medical Imaging, Haemaru Referral Animal Hospital, Seongnam 463-050, Republic of Korea
| | - J Yoon
- Department of Veterinary Medical Imaging, College of Veterinary Medicine, Seoul National University, Seoul 151-742, Republic of Korea
| | - M Choi
- Department of Veterinary Medical Imaging, College of Veterinary Medicine, Seoul National University, Seoul 151-742, Republic of Korea
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Kim PH, Gwon DI, Ko HK. Portal Vein Thrombosis after Endovascular Embolization of Splenic Artery for a Symptomatic Arterioportal Fistula: A Case Report and Literature Review. Ann Vasc Surg 2018; 53:270.e7-270.e12. [DOI: 10.1016/j.avsg.2018.05.075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 05/01/2018] [Indexed: 01/27/2023]
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Chaturvedi A, Klionsky NB, Saul D. Ultrasound with Doppler evaluation of congenital hepatic vascular shunts. Pediatr Radiol 2018; 48:1658-1671. [PMID: 30194461 DOI: 10.1007/s00247-018-4247-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 06/19/2018] [Accepted: 08/24/2018] [Indexed: 12/17/2022]
Abstract
Congenital aberrant hepatic vascular communications result from intrahepatic or extrahepatic errors in vascular development or involution during the transition from fetal to newborn hepatic circulation. These hepatic vascular shunts can be fortuitously discovered and asymptomatic, or can cause symptoms of varying severity, often presenting diagnostic dilemmas. Some hepatic vascular shunts resolve spontaneously while others require interventional radiologic or surgical closure. Affected patients are often first studied with real-time and Doppler ultrasound, so radiologists should familiarize themselves with the expected ultrasound findings of these vascular shunts for effective diagnosis, triage and management. In this review, the authors focus on ultrasound and Doppler findings of hepatic vascular shunts with underlying embryology, clinical features and management strategies. Broadly, these aberrant hepatic vascular communications include portosystemic venous shunts (which can be intra- or extrahepatic and include persistent patent ductus venosus), arterioportal, arteriovenous or mixed shunts.
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Affiliation(s)
- Apeksha Chaturvedi
- Pediatric Imaging Section, Department of Imaging Sciences, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, NY, 14642, USA.
| | - Nina B Klionsky
- Pediatric Imaging Section, Department of Imaging Sciences, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, NY, 14642, USA
| | - David Saul
- Department of Pediatric Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Igarashi G, Mikami K, Sawada N, Endo T, Sueyoshi N, Sato K, Tsushima F, Kakehata S, Ono S, Aoki M, Kurose A, Iwamura H, Fukuda S. Interventional Treatment for Giant Hepatic Hemangioma Accompanied by Arterio-portal Shunt with Ascites. Intern Med 2018; 57:2847-2851. [PMID: 29709944 PMCID: PMC6207813 DOI: 10.2169/internalmedicine.0655-17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
A 73-year-old woman with massive ascites associated with a giant hepatic mass accompanied by arterio-portal (AP) shunt was admitted to our hospital. Based on contrast-enhanced computed tomography (CT) and angiography findings, hepatic hemangioma with AP shunt and ascites due to portal hypertension was diagnosed. Transcatheter arterial embolization (TAE) by N-butyl-2-cyanoacrylate (NBCA) was performed without complications. The patient's ascites disappeared, and her liver function test results improved after the treatment. The patient has maintained a steady state for two years. This case indicates that TAE with NBCA is a safe and effective treatment for hepatic hemangioma accompanied by AP shunt.
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Affiliation(s)
- Go Igarashi
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Japan
| | - Kenichiro Mikami
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Japan
| | - Naoya Sawada
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Japan
| | - Tetsu Endo
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Japan
| | - Norihiko Sueyoshi
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Japan
| | - Ken Sato
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Japan
| | - Fumiyasu Tsushima
- Department of Radiation and Radiation Oncology, Hirosaki University Graduate School of Medicine, Japan
| | - Shinya Kakehata
- Department of Radiation and Radiation Oncology, Hirosaki University Graduate School of Medicine, Japan
| | - Shuichi Ono
- Department of Radiation and Radiation Oncology, Hirosaki University Graduate School of Medicine, Japan
| | - Masahiko Aoki
- Department of Radiation and Radiation Oncology, Hirosaki University Graduate School of Medicine, Japan
| | - Akira Kurose
- Department of Anatomic Pathology, Hirosaki University Graduate School of Medicine, Japan
| | - Hideki Iwamura
- Department of Gastroenterology, Tsugaru General Hospita, Japan
| | - Shinsaku Fukuda
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Japan
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Kimura Y, Hori T, Machimoto T, Ito T, Hata T, Kadokawa Y, Kato S, Yasukawa D, Aisu Y, Takamatsu Y, Kitano T, Yoshimura T. Portal vein aneurysm associated with arterioportal fistula after hepatic anterior segmentectomy: Thought-provoking complication after hepatectomy. Surg Case Rep 2018; 4:57. [PMID: 29904893 PMCID: PMC6002328 DOI: 10.1186/s40792-018-0465-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 06/04/2018] [Indexed: 11/17/2022] Open
Abstract
Background Few cases of postoperative arterioportal fistula (APF) have been documented. APF after hepatectomy is a very rare surgery-related complication. Case presentation A 62-year-old man was diagnosed with hepatocellular carcinoma in segments 5 and 8, respectively. Anterior segmentectomy was performed as a curative surgery. Each branch of the hepatic artery, portal vein, and biliary duct for the anterior segment was ligated together as the Glissonean bundle. The patient was discharged on postoperative day 14. Three months later, dynamic magnetic resonance imaging showed an arterioportal fistula and portal vein aneurysm. Surprisingly, the patient did not have subtle symptoms. Although a perfect angiographic evaluation could not be ensured, we performed angiography with subsequent interventional radiology to avoid sudden rupture. Arteriography was immediately performed to create a portogram via the APF from the stump of the anterior hepatic artery, and portography clearly revealed hepatofugal portal vein flow. Portography also showed that the stump of the anterior portal vein had developed a 40-mm-diameter portal vein aneurysm. Selective embolization of the anterior hepatic artery was accomplished in the whole length of the stump of the anterior hepatic artery, and abnormal blood flow through the APF was drastically reduced. The portal vein aneurysm disappeared, and portal flow was normalized. Dynamic computed tomography after embolization clearly demonstrated perfect interruption of the APF. The patient maintained good health thereafter. Conclusions Post-hepatectomy APFs are very rare, and some appear to be cryptogenic. Our thought-provoking case may help to provide a possible explanation of the causes of post-hepatectomy APF.
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Affiliation(s)
- Yusuke Kimura
- Department of Digestive Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan.
| | - Tomohide Hori
- Department of Digestive Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan.
| | - Takafumi Machimoto
- Department of Digestive Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan
| | - Tatsuo Ito
- Department of Digestive Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan
| | - Toshiyuki Hata
- Department of Digestive Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan
| | - Yoshio Kadokawa
- Department of Digestive Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan
| | - Shigeru Kato
- Department of Digestive Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan
| | - Daiki Yasukawa
- Department of Digestive Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan
| | - Yuki Aisu
- Department of Digestive Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan
| | - Yuichi Takamatsu
- Department of Digestive Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan
| | - Taku Kitano
- Department of Digestive Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan
| | - Tsunehiro Yoshimura
- Department of Digestive Surgery, Tenri Hospital, 200 Mishima-cho, Tenri City, Nara Prefecture, 632-8552, Japan
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Maximus S, Milner R. Not Your Typical Steal Syndrome - Traumatic Superior Mesenteric Arteriovenous Fistula Causing Acute Bowel Ischaemia. EJVES Short Rep 2018; 39:62. [PMID: 29988833 PMCID: PMC6033212 DOI: 10.1016/j.ejvssr.2018.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 05/15/2018] [Indexed: 11/23/2022] Open
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Miller LD, Hilliard NJ, Harper SJ. Endovascular Repair of Superior Mesenteric Arteriovenous Fistula Causing Early Mesenteric Steal Syndrome Following Abdominal Gunshot Injury. EJVES Short Rep 2018; 39:58-60. [PMID: 29988873 PMCID: PMC6033256 DOI: 10.1016/j.ejvssr.2018.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 04/04/2018] [Accepted: 05/01/2018] [Indexed: 11/20/2022] Open
Abstract
Introduction Superior mesenteric arteriovenous fistulae (SMAVF) are rare, usually secondary to trauma or iatrogenic injury and typically present sometime after the initial insult. Report A 30 year old male underwent immediate laparotomy for abdominal gunshot injury. The small bowel mesentery contained a large haematoma and a palpable thrill. CT demonstrated a large SMAVF. At re-look laparotomy, small bowel ischaemia was noted and following this endovascular SMA stent graft insertion was performed, with excellent angiographic and clinical results. Conclusion The first report of immediate traumatic SMAVF leading to acute mesenteric steal syndrome and successful management with endovascular stent insertion is presented.
Traumatic superior mesenteric arteriovenous fistulae (SMAVF) are rare. They often have a delayed presentation following initial insult. Early SMAVF causing acute mesenteric steal syndrome is previously unreported. This can be managed by a combination of surgery and endovascular intervention.
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Affiliation(s)
- Lucy D. Miller
- Cambridge Clinical School, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Nicholas J. Hilliard
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Simon J.F. Harper
- Department of Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Corresponding author. Department of Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
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Chaudry G, Lillis AP, Shaikh R, Padua HM, Chewning RH, Alomari AI. Endovascular Treatment of Congenital Arterioportal Fistulas. Cardiovasc Intervent Radiol 2018; 41:1021-1028. [PMID: 29511867 DOI: 10.1007/s00270-018-1924-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 02/24/2018] [Indexed: 02/05/2023]
Abstract
PURPOSE To characterize anatomy of congenital arterioportal fistulas (CAPF) and correlate this with technique and outcomes of transcatheter embolization (TCE). MATERIALS AND METHODS Retrospective review was conducted of children with CAPF that underwent TCE in a 10-year period. Medical records, imaging and procedure details were reviewed. TCE was performed via transarterial (n = 5), portal (n = 5) or patent ductus venosus (n = 1) approach. Embolic agents used were coils (n = 10), Onyx (n = 1) and Amplatzer septal occluder (n = 1). RESULTS A total of 7 patients were included (4 female). Median age at treatment was 4 months (2 month-3 year). Most common symptoms were GI bleeding (n = 4), anemia (n = 4) and ascites (n = 3). Hepatopetal flow was seen in all on pre-procedure sonography. On angiography, a simple lesion, with direct fistulous connections, from hepatic arterial (HA) branches to portal venous (PV) system was seen in 3. A complex lesion with multiple connections was identified in 4. In simple lesions, cessation of shunting was achieved in 1 procedure, with embolization of afferent vessels. In complex lesions, multiple procedures were required in 3 of 4 patients. All 4 with complex connections required embolization of the aneurysmal PV segment. There were no major complications. Two minor complications were noted: localized biliary leak in 1 and femoral pseudoaneurysm in 1. There was resolution of symptoms in 6. CONCLUSIONS TCE is effective as primary treatment of CAPF. Patients with simple arteriovenous connections can be treated with embolization of afferent vessels, but children with multiple complex connections usually require embolization of the dilated PV segment.
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Affiliation(s)
- Gulraiz Chaudry
- Division of Vascular and Interventional Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.
| | - Anna P Lillis
- Division of Vascular and Interventional Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Raja Shaikh
- Division of Vascular and Interventional Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Horacio M Padua
- Division of Vascular and Interventional Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Rush H Chewning
- Division of Vascular and Interventional Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Ahmad I Alomari
- Division of Vascular and Interventional Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
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50
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Han P, Yang L, Huang XW, Zhu XQ, Chen L, Wang N, Li Z, Tian DA, Qin H. A traumatic hepatic artery pseudoaneurysm and arterioportal fistula, with severe diarrhea as the first symptom: A case report and review of the literature. Medicine (Baltimore) 2018; 97:e9893. [PMID: 29443759 PMCID: PMC5839813 DOI: 10.1097/md.0000000000009893] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 12/11/2017] [Accepted: 01/24/2018] [Indexed: 01/16/2023] Open
Abstract
RATIONALE Hepaticarterioportal fistula (APF) is a rare cause of portal hypertension and gastrointestinal hemorrhage, and presents as abnormal communication between the hepatic artery and portal vein. Percutaneous liver biopsy is a main iatrogenic cause of AFP. However, non-iatrogenic, abdominal, trauma-related APF is rarely reported. PATIENT CONCERNS A 29-year-old man presenting with severe, watery diarrhea was transferred to our hospital, and his condition was suspected to be acute gastroenteritis because he ate expired food and suffered a penetrating abdominal stab wound 5 years ago. After admission, the patient suffered from hematemesis, hematochezia, ascites, anuria, and kidney failure, and he developed shock. DIAGNOSES The patient was finally diagnosed as a traumatic hepatic artery pseudoaneurysm and APF. INTERVENTIONS This patient was treated with emergency transarterial embolization using coils. Since a secondary feeding vessel was exposed after the first embolization of the main feeding artery, a less-selective embolization was performed again. OUTCOMES During the 6-month follow-up period, the patient remained asymptomatic. LESSONS A penetrating abdominal stab wound is a rare cause of hepatic APFs, and occasionally leads to portal hypertension, the medical history and physical examination are the most important cornerstones of clinical diagnosis. Interventional radiology is essential for the diagnosis and treatment of an APF.
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Affiliation(s)
- Ping Han
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Lan Yang
- Department of Ultrasound, the Fifth People's Hospital of Nanchong, Nanchong
| | - Xiao-Wei Huang
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Xiu-Qin Zhu
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Li Chen
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Nan Wang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhen Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - De-An Tian
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Hua Qin
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
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