Congenital intrahepatic arterioportal and portosystemic venous fistulae with jejunal arteriovenous malformation depicted on multislice spiral CT

Combined endovascular-surgical treatment for complex congenital intrahepatic arterioportal fistula: A case report and review of the literature

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.

Coil embolization of a congenital intrahepatic arterioportal fistula: increasing experience in management

Congenital intrahepatic arterioportal fistula (IAPF) is a rare condition and there is limited experience of transcatheter embolization. We report here the transcatheter coil embolization of an incidentally found, asymptomatic congenital IAPF in a 16-month-old patient. After demonstrating that the IAPF was fed by two branches of a dilated left hepatic artery and drained into an aneurysm of the left portal vein, the feeding arteries were superselectively catheterized and occluded by microcoils in a single session. Follow-up was uneventful for 1 year. With respect to this and previously reported cases, we believe that embolization of feeding arteries is a safe and effective method that should be the primary choice of treatment; however, further cases should be reported to confirm this belief.

Application of ultrasonography in the diagnosis and treatment tracing of hepatocellular carcinoma-associated arteriovenous fistulas

OBJECTIVE

Hepatic arteriovenous fistula (HAVF) can be caused by trauma, hepatic biopsy, bile duct radiology, etc. Small intrahepatic HAVF can be found in lesions of carcinoma and hepatocirrhosis. Accurate detection of HAVF was magnitude in the process to take appropriate treatment in clinic. The aim of this article is to evaluate the imaging diagnostic value on HAVF and to study the imaging character of HAVF in patients with hepatocellular carcinoma (HCC), and to evaluate the role of ultrasonographic and radiological techniques in the diagnosis and management of developmental intrahepatic shunts so as to assess the imaging diagnostic evaluation in a follow-up study.

METHODS

Seventy-eight patients diagnosed with HCC were enrolled in this study, and retrospective analysis of ultrasonographic and radiological data was carried out on all 78 patients, and 25 patients suspected of having HAVF were selected. The results from ultrasonography were compared with that from digital subtraction angiography (DSA) as a gold standard. The portal and hepatic veins, hepatic arteries and vessels around and inside the tumour patients were detected and the haemodynamic indices were recorded with ultrasonography. Ten patients with HAVF were followed up after the therapy of arterial embolization and the reversal effect of the therapy was observed. Associations of HAVF with clinical and ultrasonographic features were evaluated by stepwise logistic regression analysis.

RESULTS

Twenty-five of 78 HAVF patients were detected by ultrasonography and other imaging methods. Ultrasonographic parameters made excellent predictions for the patients with HAVF; sensitivity (SE) 83.3%, specificity (SP) 90.7%, positive predictive value (pPV, 80.0%), negative predictive value (nPV) 92.5% and accuracy 88.5%. Among the 25 HAVF patients, 16 were central hepatic artery-portal vein fistulae, seven were peri-hepatic artery-portal vein fistulae and two were hepatic artery-vein shunts. Characteristic ultrasonographic methods of hepatic artery-portal vein fistulae were as follows: 10 patients with hepatic artery-portal vein fistula were followed up after embolization. Compared with that of preembolization, seven cases returned to normal and in three patients abnormalities were still detected.

CONCLUSION

Ultrasonographic evaluation of HAVF is easy to perform, reproducible and, when present, gives a high degree of certainty for the diagnosis of HAVF. Ultrasonography is a valuable method for the diagnoses HAVF; it can offer imaging evidence after the treatment of hepatic cell cancer. HAVF in patients with HCC can be detected by ultrasonographic methods, which are characterized by changes of hepatic arteries and veins involved in fistulas. These can be used for diagnosing HAVF and evaluating its arterial embolization effect in patients with HCC.

Multidetector Row CT of the Liver

CT has always played a major role in the imaging of the liver despite continuous challenge by ultrasound and MR imaging. Introduction of multidetector row CT technology has helped CT to excel in its already established indications and has expanded its capabilities by adding new clinical indications, such as CT angiography or liver perfusion. This article discusses the advantages of multidetector row CT scanners in liver imaging, examines the guidelines to improve image quality by optimizing scanning protocols and contrast administration strategies, and reviews the current and potential clinical applications.