Splenic arteriovenous fistula. A rare lesion causing bleeding esophageal varices, ascites, and diarrhea

A rare case of gastric varices and splenic artery aneurysm secondary to splenic arteriovenous fistula

A 33-year-old male with no past medical history presented with a few months of fatigue and reduced exercise tolerance and was found to have iron-deficiency anemia. An esophagogastroduodenoscopy revealed a cluster of isolated gastric fundal varices with high-risk stigmata. Serologic workup for cirrhosis was negative, and a FibroScan measured liver stiffness at 4.2 kilopascals. Computed tomography (CT) of his abdomen and pelvis showed non-cirrhotic portal hypertension, as well as the presence of a splenic arteriovenous (AV) fistula and splenic artery aneurysm (SAA). Resection of the fistula, SAA, and spleen completely resolved the gastric varices and anemia.

Coil Embolization of Spontaneous Splenic Arteriovenous Fistula for Treatment of Portal Hypertension

Patient: Female, 64

Final Diagnosis: Splenic arteriovenous fistula

Symptoms: Left lower quadrant abdominal pain

Medication: —

Clinical Procedure: Coiling embolization

Specialty: Surgery

Idiopathic splenic arteriovenous fistula without splenic artery aneurysm

Splenic arteriovenous fistula (SAVF) without a splenic arterial aneurysm is a rare entity and may either be congenital or acquired. Acquired SAVFs are commonly due to adjacent splenic arterial aneurysm rupture, trauma or infection. We report a large idiopathic SAVF in a 50-year-old woman who had no symptoms. CT showed that the fistula was around the splenic hilum and no other specific findings. SAVF has a risk of sudden onset of portal hypertension and it should be treated as soon as diagnosed. Endovascular treatment for SAVF is now being performed successfully with increasing frequency, however, there is still no definitive evidence of treatment for SAVF. Treatment options should be determined appropriately depending on individual case characteristics and vascular anatomical variations. Our case was treated successfully with splenectomy, and long-term results are good without need of reintervention.

Open repair, endovascular repair, and conservative management of true splenic artery aneurysms

OBJECTIVE

True splenic artery aneurysms (SAAs) are a rare but potentially fatal pathology. For many years, open repair (OPEN) and conservative management (CONS) were the treatments of choice, but throughout the last decade endovascular repair (EV) has become increasingly used. The purpose of the present study was to perform a systematic review and meta-analysis evaluating the outcomes of the three major treatment modalities (OPEN, EV, and CONS) for the management of SAAs.

METHODS

A systematic review of all studies describing the outcomes of SAAs treated with OPEN, EV, or CONS was performed using seven large medical databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to ensure a high-quality review. All articles were subject to critical appraisal for relevance, validity, and availability of data regarding characteristics and outcomes. All data were systematically pooled, and meta-analyses were performed on several outcomes, including early and late mortality, complications, and number of reinterventions.

RESULTS

Original data of 1321 patients with true SAAs were identified in 47 articles. OPEN contained 511 patients (38.7%) in 31 articles, followed by 425 patients (32.2%) in CONS in 16 articles and 385 patients (29.1%) in EV in 33 articles. The CONS group had fewer symptomatic patients (9.5% vs 28.7% in OPEN and 28.8% in EV; P < .001) and fewer ruptured aneurysms (0.2% vs 18.4% in OPEN and 8.8% in EV; P < .001), but no significant differences were found in existing comorbidities. CONS patients were usually older and had smaller-sized aneurysms than patients in the OPEN and EV groups. The only identified difference in baseline characteristics between OPEN and EV was the number of ruptured aneurysms (18.4% vs 8.8%; P < .001). OPEN had a higher 30-day mortality than EV (5.1% vs 0.6%; P < .001), whereas minor complications occurred in a larger number of the EV patients. EV required more reinterventions per year (3.2%) compared with OPEN (0.5%) and CONS (1.2%; P < .001). The late mortality rate was higher in patients treated with CONS (4.9% vs 2.1% in OPEN and 1.4% in EV; P = .04).

CONCLUSIONS

EV of SAA has better short-term results compared with OPEN, including significantly lower perioperative mortality. OPEN is associated with fewer late complications and fewer reinterventions during follow-up. Patients treated with CONS showed a higher late mortality rate. Ruptured SAAs are predictors of a significantly higher perioperative mortality compared with nonruptured SAAs in the OPEN and EV groups.

Splenic arteriovenous fistula and sudden onset of portal hypertension as complications of a ruptured splenic artery aneurysm: Successful treatment with transcatheter arterial embolization. A case study and review of the literature

Splenic arteriovenous fistula (SAVF) accounts for an unusual but well-documented treatable cause of portal hypertension^[1-4]. A case of a 50-year-old multiparous female who developed suddenly portal hypertension due to SAVF formation is presented. The patient suffered from repeated episodes of haematemesis and melaena during the past twelve days and thus was emergently admitted to hospital for management. Clinical and laboratory investigations established the diagnosis of portal hypertension in the absence of liver parenchymal disease. Endoscopy revealed multiple esophageal bleeding varices. Abdominal computed tomography (CT) and transfemoral celiac arteriography documented the presence of a tortuous and aneurysmatic splenic artery and premature filling of an enlarged splenic vein, findings highly suggestive of an SAVF. The aforementioned vascular abnormality was successfully treated with percutaneous transcatheter embolization. Neither recurrence nor other complications were observed.

Posttraumatic splenic pseudoaneurysm and arteriovenous fistula: diagnosis by computed tomography angiography and treatment by transcatheter embolization

The current treatment of splenic injury in children is conservative. The common concern with nonoperative management of splenic injury involves increased risk of posttraumatic splenic complications. Computed tomography angiography is a noninvasive and useful technique for the detection of the vascular abnormalities in conservatively managed splenic injuries. We present a case of posttraumatic splenic pseudoaneurysm and arteriovenous fistula (AVF) in a 12-year-old boy, which were prediagnosed by color Doppler ultrasound and consecutively shown by computed tomography angiography. The treatment of splenic AVF is indicated to avoid portal hypertension, high output cardiac failure, and related complications. To preserve the splenic immune function and to avoid the risk of surgery and splenectomy complications, splenic pseudoaneurysm and AVF were successfully occluded by transcatheter embolization.

Surgical Treatment of Esophageal Varices Caused by an Arteriovenous Fistula Between an Artery of the Thyroid Gland and the Submucosal Venous Network of the Esophageal Wall

We report a case of esophageal varices caused by an arteriovenous fistula between an artery of the thyroid gland and the submucosal venous network of the esophageal wall. The fistula developed in a 51-year-old woman 24 years after she received subtotal thyroidectomy to treat Graves' disease. At the same time, gastrointestinal endoscopy revealed the presence of uncommon esophageal varices that were limited to the cervical and upper thoracic esophagus. Angiography confirmed the presence of both an arteriovenous fistula of the peripheral residual thyroid gland and the esophageal varices, after which we successfully treated the varices by surgical resection of the fistula.

Hepatocellular carcinoma in glycogen storage disease type IV

A 13 year old patient with juvenile type IV glycogen storage disease died of the complications of hepatocellular carcinoma. To our knowledge this is the first reported case of hepatocellular carcinoma in association with type IV glycogen storage disease.