Endoluminal Management of Arterioportal Fistulae in Liver Transplant Recipients: A Single-Center Experience

Transplant Hepatic Artery Complications

Hepatic artery complications can be divided into 2 different categories, nonocclusive and steno-occlusive disease. Steno-occlusive disease is a collective term that encompasses hepatic artery thrombosis, hepatic artery stenosis, and hepatic arterial kinks, while nonocclusive arterial disease encompasses less than 5% of complications and is a collective term used to describe arteriovenous fistulae, pseudoaneurysms, arterial rupture and nonocclusive hepatic artery hypoperfusion syndrome. This article details the angiographic techniques and definitions needed to accurately diagnose arterial transplant complications and describes the technical aspects and results of endoluminal management of these arterial complications. In addition, this article discusses the presentation, etiology and indications for treatment, including surgical management of these various complications.

Bleeding after percutaneous transhepatic biliary drainage due to arterial injury: A case study in patient with stable hemodynamic

Percutaneous transhepatic biliary drainage (PTBD) is an effective procedure for correcting biliary obstructions. It can be performed under ultrasound and fluoroscopic equipment; however, it may entail serious complications, including bleeding, caused by arterial or venous injury. We present a 49-year-old man presented with a 1-month history of icterus, jaundice, dark urine, and right hypochondrial pain. MR imaging discovered a dilatation of the right intrahepatic bile duct due to obstruction by intrahepatic cholangiocarcinoma. PTBD procedure was performed in the right intrahepatic bile duct. After the pigtail drain device was inserted, the bile fluid color that came out from the pigtail turned sanguineous; nonetheless, the patient's hemodynamic was stable. Therefore, the second cholangiography was performed for evaluation. Some resistance was sensed during contrast injection into the bile duct, and the operator pushed the contrast media a little bit stronger and found a filling defect formed by a clot in the bile duct that suggested high suspicion of vessel injury. Although the patient's hemodynamics was still stable, the operator quickly decided to perform a hepatic arteriography procedure because bright red blood through the tube and a relatively rapid clot formed from the puncture point and distal drain, which were signs of hepatic artery injury. Hepatic arteriography confirmed the location of pseudoaneurysm caused by vessel trauma and arterio-intrahepatic bile duct fistulation. The embolization procedure was performed using PVA-300 into a ruptured hepatic artery branch through a microcatheter. Re-evaluation arteriography showed no pseudoaneurysm or arterio-intrahepatic bile duct fistulation after embolization.

Arterioportal Fistulas (APFs) in Pediatric Patients: Single Center Experience with Interventional Radiological versus Conservative Management and Clinical Outcomes

Arterioportal fistulas (APFs) are uncommon vascular abnormalities with a heterogeneous etiology. In pediatric orthotopic liver transplantation (OLT), APFs are frequently iatrogenic, following percutaneous liver interventions. The aim of this study was to report the 10-year experience of a tertiary referral center for pediatric OLT in the interventional radiological (IR) and conservative management of acquired APFs. A retrospective search was performed to retrieve pediatric patients (<18 years old) with a diagnosis of APF at color Doppler ultrasound (CDUS) or computed tomography angiography (CTA) from 2010 to 2020. Criteria for IR treatment were the presence of hemodynamic alterations at CDUS (resistive index <0.5; portal flow reversal) or clinical manifestations (bleeding; portal hypertension). Conservatively managed patients served as a control population. Clinical and imaging follow-up was analyzed. Twenty-three pediatric patients (median age, 4 years; interquartile range = 11 years; 15 males) with 24 APFs were retrieved. Twenty patients were OLT recipients with acquired APFs (16 iatrogenic). Twelve out of twenty-three patients were managed conservatively. The remaining 11 underwent angiography with confirmation of a shunt in 10, who underwent a total of 16 embolization procedures (14 endovascular; 2 transhepatic). Technical success was reached in 12/16 (75%) procedures. Clinical success was achieved in 8/11 (73%) patients; three clinical failures resulted in one death and two OLTs. After a median follow-up time of 42 months (range 1–107), successfully treated patients showed an improvement in hemodynamic parameters at CDUS. Conservatively managed patients showed a stable persistence of the shunts in six cases, spontaneous resolution in four, reduction in one and mild shunt increase in one. In pediatric patients undergoing liver interventions, APFs should be investigated. Although asymptomatic in most cases, IR treatment of APFs should be considered whenever hemodynamic changes are found at CDUS.

Intrahepatic Arterioportal Fistula: A Rare Cause of Portal Hypertension After Deceased Donor Liver Transplant

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.

Interventional radiology in the management of the liver transplant patient

Liver transplantation (LT) is commonly used to treat patients with end-stage liver disease. The evolution of surgical techniques, endovascular methods, and medical care has led to a progressive decrease in posttransplant morbidity and mortality. Despite these improvements, a multidisciplinary approach to each patient remains essential as the early diagnosis and treatment of the complications of transplantation influence graft and patient survival. The critical role of interventional radiology in the collaborative approach to the care of the LT patient will be reviewed. Liver Transplantation 23 1328-1341 2017 AASLD.

Portal Vein Thrombosis and Arterioportal Fistula in Post Liver Transplant Recipient: A Case Report

An intrahepatic Arterioportal Fistula Refers (APF) to abnormal shunt or fistulous connection between the portal venous system and a hepatic arterial system within the liver. Here, we present a case of portal vein thrombosis with APF in post-transplant liver, developed 2 years and 6 months after transplantation. The condition was diagnosed by Triphasic CT angiography. In this case report we have discussed various causes and pathophysiology of APF with its imaging findings.

Complications of transplantation. Part 1: renal transplants

Vascular complications after solid-organ transplantation are not uncommon and may lead to graft dysfunction and ultimately graft loss. A thorough understanding of the surgical anatomy, etiologies, and types of vascular complications, their presentation, and the options for management are important for managing these complex patients. This article reviews the basic surgical anatomy, vascular complications, and endovascular management options of vascular complications in patients with renal transplants.

Arterioportal fistulas in liver transplant recipients

Arterioportal fistulas (APFs) are classified into intrahepatic (>75% of all reported) and extrahepatic (<25% of all reported ). Anecdotally, investigators are more likely to report more sensational cases (typically extrahepatic APFs), so the actual prevalence of intrahepatic APFs is probably much higher (likely >90% of APFs). All reported APFs in liver transplant recipients have been intrahepatic. Hemodynamically significant APFs in liver transplant recipients are rare, occurring in 0.2%; however, APFs (hemodynamically significant or not) are not uncommonly seen in hepatic angiograms of liver transplant recipients (up to 5.4% of hepatic arteriograms in transplants). Interestingly, hemodynamically significant APFs warranting endovascular treatment are reported more commonly in the literature in native compared with transplanted livers (n >280-300 versus n = 13, respectively). This article discusses APFs that are specific to liver transplant recipients; their incidence, etiology, pathogenesis, natural history, clinical presentation, and endovascular management are discussed in detail.

Prevalence, presentation, and endovascular management of hemodynamically or clinically significant arterio-portal fistulae in living and cadaveric donor liver transplant recipients

PURPOSE

To compare the prevalence (cadaveric vs. living donor transplants), clinical features, and the effectiveness of endovascular management of significant arterio-portal fistulae (APF) in liver transplant recipients.

METHODS

A retrospective audit of liver transplant recipients in two institutions was performed (1996-2009). Significant APF were included and were defined as symptomatic and/or hemodynamically significant (causing graft dysfunction and/or having abnormal Doppler findings in the portal vein). Patients with significant APF were evaluated for presenting symptoms, imaging features, size/branch order portal vein involvement, and effectiveness of the endovascular management (coil embolization).

RESULTS

Four significant APF were found in 1992 (0.2%) liver transplants. Two were symptomatic and two were asymptomatic but were hemodynamically significant with liver function test abnormalities. All four APF were found in cadaveric donor graft recipients (0.23%, N = 4/1753) and none in 239 living donor graft recipients. However, there was no statistical difference between cadaveric and living donor graft recipients (p = 1.0, odds ratio = 1.23). Coil embolization was technically and clinically successful in all 4 without complications and causing normalization of the abnormal Doppler findings.

CONCLUSION

Significant APF are a rare diagnosis (0.2% of transplants). Coil embolization is a safe and effective treatment option for APF in transplants.

Management of nonocclusive hepatic artery complications after liver transplantation

Nonocclusive arterial disease represents less than 5% of posttransplant arterial complications. Nonocclusive arterial complications are classified into (1) nonocclusive diminished flow in the hepatic artery, (2) arteriovenous fistulae, (3) pseudoaneurysms, and (4) arterial rupture. Due to the rarity of these complications, particularly when considering them individually, many of the opinions and managements of these complications are anecdotal. Transcatheter embolization is the main mode of minimal invasive management of these uncommon complications. Other minimal invasive methods have been described such as stent placement or direct percutaneous embolization/thrombosis. The article discusses the presentation, etiology, types, treatment indications, and various modes of minimal invasive therapy used to manage these complications.