Portal Vein Thrombosis Secondary to Embolization of Superior Mesenteric Arteriovenous Fistula

Vascular Plug Embolization of a Superior Mesenteric Arteriovenous Fistula: Case Report and Literature Review of Endovascular Treatment

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.

Superior mesenteric arteriovenous fistula embolization with a vascular plug for upper gastrointestinal hemorrhage: a case report

Background

Superior mesenteric arteriovenous fistula is a rare vascular anomaly often presenting with sequelae of portal hypertension, heart failure, or mesenteric ischemia. This report describes a patient with a previously unidentified superior mesenteric arteriovenous fistula who presented with variceal bleeding, thought to be the leading cause of mortality associated with this condition. Although this patient was initially referred for a transjugular intrahepatic portosystemic shunt procedure, following a thorough review of her clinical history and imaging, she instead underwent embolization of the arteriovenous fistula likely responsible for her symptoms.

Case Presentation

A 75-year-old woman with a past surgical history of extensive small bowel resection presented with active variceal bleeding requiring transfusions. She was referred to vascular and interventional radiology for transjugular intrahepatic portosystemic shunt procedure; however, her clinical presentation was inconsistent with cirrhosis. This prompted a further review of her imaging, which identified a superior mesenteric arteriovenous fistula as the probable etiology of her varices. This fistula was subsequently embolized with a vascular plug and follow-up upper endoscopy at 1-month demonstrated complete resolution of her varices.

Conclusions

This report highlights a potential etiology of variceal bleeding in the acutely ill patient. Through a thorough consultation, the patient described here was able to avoid a procedure with the potential to cause catastrophic consequences, and instead receive the appropriate treatment for an uncommon condition.

Level of Evidence

Level 4, Case Report.

Superior mesenteric arteriovenous fistula presenting as gastrointestinal bleeding: case report and literature review

Superior mesenteric arteriovenous fistula (SMAVF) is a rare vascular disorder usually following penetrating abdominal trauma or gastrointestinal surgery. Percutaneous endovascular treatment such as embolization, has been widely used to treat this disease. We report a patient, who was presented with melena at the onset of his symptoms, then an acute hematemesis in shock. A SMAVF was diagnosed on an angiogram after a large mesenteric vein was seen on CT. The patient had a successful emergency endoscopic variceal ligation (EVL) to stop bleeding. Then the patient received fistula embolization with covered stent.