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

Case report: Congenital arterioportal fistula: An unusual cause of variceal bleeding in adults

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.

Coil embolization of arterioportal fistula complicated by gastrointestinal bleeding after Caesarian section: A case report

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.

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.

Infantile hepatic hemangiomas associated with high-output cardiac failure and pulmonary hypertension

BACKGROUND

Infantile hepatic hemangioma (IHH) is a rare endothelial cell neoplasm, which may be concurrent with severe complications and result in poor outcomes. Moreover, the coexistence of IHH and congenial heart disease is even rarer.

CASE PRESENTATION

We present a 10-day-old male born with IHH associated with patent ductus arteriosus (PDA), atrial septal defect (ASD) and pulmonary hypertension. Moreover, we reviewed a series of studies of IHH-associated high-output cardiac failure between 1974 and 2018, and summarized the treatment outcomes.

CONCLUSIONS

Infantile hepatic hemangioma (IHH) has been known to induce high-output heart failure. There is no literature to summarize the severity of its impact on heart, which can lead to a high mortality rate. When IHH is detected by ultrasound, the heart should be evaluated to facilitate treatment. The outcomes of IHH associated with heart failure are good.

Transarterial and Transhepatic Endovascular Intervention to Alleviate Portal Hypertension Secondary to Arterioportal Fistula in a Trisomy 21 Infant

Individuals with trisomy 21 have an 80% risk reduction of vascular anomalies compared with general population. However, an association of trisomy 21 and portal vascular and arteriovenous anomalies has been defined in the literature. The primary hemodynamic abnormality in portal hypertension is increased resistance to portal blood flow. In various case reports in adults and pediatric age group patients, transarterial coil embolization of hepatoportal fistula was described. One of the authors of this article has previously reported successful treatment of congenital arterioportal fistula (APF) with percutaneous transhepatic liquid embolization in a patient who previously had transarterial coil embolization. To date, eight patients with trisomy 21 (Down syndrome) and congenital portosystemic shunts were reported of which four were treated with embolization. Here, we describe a 3-month-old infant with trisomy 21 and intrahepatic APF associated with extrahepatic portal hypertension and massive ascites. In the current report, a rare case of a patient with a diagnosis of trisomy 21 is discussed who was attempted to be treated with transarterial coil embolization and percutaneous transhepatic liquid embolization of the congenital APF in a single session.

Hybrid technique coil embolisation for intrahepatic arterioportal fistula in a cat: case report

CASE SUMMARY

A 13-month-old, female, mixed breed, 4.0 kg cat was referred with a 6 month history of decreased appetite, loss of vigour and intermittent vomiting. Physical examination revealed no cyanosis or wasting, and no audible heart murmur was auscultated. Blood profile revealed mild anaemia and mildly elevated postprandial serum ammonia (109 µg/dl). Abdominal ultrasonography revealed dilation of an intrahepatic portal vein branch and an intrahepatic aneurysm, with splenomegaly and ascites. Hepatic arteriovenous fistula/hepatic artery-portal vein fistula with multiple acquired portosystemic shunts was strongly suspected. Medical control was achieved using antibiotics, liver-protecting agents, a low-protein diet and blood transfusions. However, because medical treatment proved ineffective, coil embolisation was performed on day 11, using a hybrid approach via the mesenteric vein. Subsequent follow-up showed good appetite, with no signs of diarrhoea or ascites. Abdominal ultrasonography revealed that the mosaic pattern around the site of coil placement in the portal vein branch had improved and pulsatility had disappeared.

RELEVANCE AND NOVEL INFORMATION

Intrahepatic arterioportal fistula involves a circulatory shunt between the hepatic artery and the hepatic or portal vein within the liver, and may be congenital or acquired. Both forms have been reported in humans, but most cases in cats have been congenital. Few reports have described treatment methods or prognosis in cats. We report here that coil embolisation using a hybrid approach is a procedure offering easy, effective treatment by blocking hepatofugal blood flow.

A successful case of deceased donor liver transplantation for a patient with intrahepatic arterioportal fistula

Intrahepatic arterioportal fistula (IAPF) is a rare cause of portal hypertension that is often difficult to treat with interventional radiology or surgery. Liver transplantation for IAPF is extremely rare. We report a case of bilateral diffuse IAPF with severe portal hypertension requiring deceased donor liver transplantation (DDLT). A 51-year-old woman with no past medical history was admitted to another hospital complaining of abdominal distension and marasmus. A computed tomography scan and digital subtraction angiography indicated a massive pleural effusion, ascites, and a very large IAPF. Several attempts of interventional embolization of the feeding artery failed to ameliorate arterioportal shunt flow. As ruptures of the esophageal varices became more frequent, hepatic encephalopathy worsened. After repeated, uncontrollable attacks of hepatic coma, the patient was referred to our facility for further treatment. Surgical approaches to IAPF other than liver transplantation were challenging because of diffuse collateralization; therefore, we placed the patient on the national waiting list for DDLT. Although her Model for End-Stage Liver Disease score was relatively low, she received a DDLT 2 months after the waiting period. The postoperative course was uneventful, and the patient was discharged 44 days after her transplant. Liver transplantation may be a valid treatment option for uncontrollable IAPF with severe portal hypertension.

Interventional embolization of congenital intrahepatic shunts in children

BACKGROUND

Congenital intrahepatic shunts in children are rare and precise treatment strategies have not been established.

OBJECTIVE

The purpose of this study was to present our experience with transcatheter embolization in a descriptive case series of congenital intrahepatic shunts in children.

MATERIALS AND METHODS

We retrospectively studied 10 children with symptomatic congenital intrahepatic shunts who were treated with embolization at our institute between January 2008 and December 2014.

RESULTS

Seven children had arteriovenous shunts in association with hepatic hemangiomas, two had arterioportal shunts and one had portosystemic shunts. The major presentations were congestive heart failure and severe anemia in the groups with arteriovenous and arterioportal shunts, respectively. Following embolization, two children died in the arteriovenous group, one from progressive liver dysfunction and the other from abdominal compartment syndrome. One child in the arterioportal group required liver transplantation after initial embolization. With mean post-procedure follow-up of 15 months (range 4-54 months), all the remaining children were well, with resolution of the symptoms.

CONCLUSION

Interventional embolization provides an alternative to surgical ligation or hepatic resection in children with clinically significant intrahepatic shunts. For lesions with complex morphology, embolization may be inadequate and liver transplantation might be the only therapeutic option.

Application of Amplatzer vascular occluder in hepatic artery closure as a method of treatment of high-flow arterioportal fistula before liver transplantation

Background:

Arterioportal fistula (APF) is an abnormal, direct connection between hepatic artery or its branch and the portal vein. Fistula can be acquired or, rarely, congenital. One of the acquired causes of fistula is a liver biopsy. Patients with liver cirrhosis are particularly vulnerable to its development due to the large number of performed biopsies. APF increases mortality and morbidity of liver transplantation procedure and may be a contraindication to it. The authors present a patient with liver cirrhosis, in whom percutaneous APF closure facilitated liver transplantation.

Case Report:

We describe a case of a 50-year-old patient with liver cirrhosis and APF, probably formed as a result of liver biopsy. Due to the presence of a high-flow fistula, which elevated portal hypertension, patient did not qualify for the liver transplantation. Patient was transferred to the interventional radiology department, where the fistula’s vascular supply was endovascularly closed using the Amplatzer occluder. This subsequently enabled the execution of transplantation.

Conclusions:

Percutaneous closure of APF should be considered a relatively simple and fast-acting tool to facilitate or even enable liver transplant surgery. Currently, there are more and more products available such as e.g. Amplatzer occluder to simplify the procedure and shorten the duration of exposure to ionizing radiation.

Sonographic diagnosis of arterioportal fistula

Aim. We aimed to identify and describe characteristic and diagnostic ultrasonographic features of arterioportal fistula cases. Patients. In this case series we describe 3 patients with arterioportal fistula. By depending on shared sonographic features of these patients we describe a “sonographic pattern” for the sonographic diagnosis of arterioportal fistula. Conclusion. In summary; both of the artery and vein related with fistula were wider than normal and seen as adjacent anechoic circles, there was an aneurismatic dilation on vein which has turbulent flow within it, the communication between the artery and aneurism can be seen sonographically, both of the vessels have arterial flow, filling of the vein was retrograde and other branches of the artery and vein unrelated with aneurism were all normal in dimension.