Transportal scleroembolization of hepatic arterioportal fistulas in a patient with portal hypertension: A case report

We report a rare patient with portal hypertension who presented with esophageal- and gastric varices and refractory ascites due to hepatic arterioportal fistulas. Treatment by transportal scleroembolization using ethanolamine oleate and coils were successful. Pretreatment hepatofugal flow subsequently changed to hepatopetal flow and the symptoms of portal hypertension improved. We describe our endovascular treatment option for addressing hepatic arterioportal fistulas.

Comparison of ethanol-soaked gelatin sponge and microspheres for hepatic arterioportal fistulas embolization in hepatic cellular carcinoma

BACKGROUND

Hepatic arterioportal fistulas (APFs) are common in hepatocellular carcinoma (HCC). Moreover, correlated with poor prognosis, APFs often complicate anti-tumor treatments, including transarterial chemoembolization (TACE).

AIM

To compare the efficacy of ethanol-soaked gelatin sponges (ESG) and microspheres in the management of APFs and their impact on the prognosis of HCC.

METHODS

Data from patients diagnosed with HCC or hepatic APFs between June 2016 and December 2019 were retrospectively analyzed. Furthermore, APFs were embolized with ESG (group E) or microspheres (group M) during TACE. The primary outcomes were disease control rate (DCR) and objective response rate (ORR). The secondary outcomes included immediate and first follow-up APF improvement, overall survival (OS), and progression-free survival (PFS).

RESULTS

Altogether, 91 participants were enrolled in the study, comprising 46 in group E and 45 in group M. The DCR was 93.5% and 91.1% in groups E and M, respectively (P = 0.714). The ORRs were 91.3% and 66.7% in groups E and M, respectively (P = 0.004). The APFs improved immediately after the procedure in 43 (93.5%) patients in group E and 40 (88.9%) patients in group M (P = 0.485). After 2 mo, APF improvement was achieved in 37 (80.4%) and 33 (73.3%) participants in groups E and M, respectively (P = 0.421). The OS was 26.2 ± 1.4 and 20.6 ± 1.1 mo in groups E and M, respectively (P = 0.004), whereas the PFS was 16.6 ± 1.0 and 13.8 ± 0.7 mo in groups E and M, respectively (P = 0.012).

CONCLUSION

Compared with microspheres, ESG embolization demonstrated a higher ORR and longer OS and PFS in patients of HCC with hepatic APFs.

A rare case of an iatrogenic superior mesenteric arteriovenous fistula following surgery for a midgut volvulus

Superior mesenteric arteriovenous fistula is an extremely rare vascular malformation with most cases occurring following abdominal trauma or surgery. They are often asymptomatic or present with various abdominal symptoms with or without features of portal hypertension. A 30-year-old man developed fistulising of the superior mesenteric artery into the superior mesenteric vein following bowel resection surgery for an acquired midgut volvulus. Although endovascular management remains the treatment of choice in such cases due to increased morbidity of a repeat abdominal surgery, definite risks remain, such as coil migration, which happened in this case. The open surgical approach remains the only option in such instances.

A rare case of an iatrogenic superior mesenteric arteriovenous fistula following surgery for a midgut volvulus

Superior mesenteric arteriovenous fistula is an extremely rare vascular malformation with most cases occurring following abdominal trauma or surgery. They are often asymptomatic or present with various abdominal symptoms with or without features of portal hypertension. A 30-year-old man developed fistulising of the superior mesenteric artery into the superior mesenteric vein following bowel resection surgery for an acquired midgut volvulus. Although endovascular management remains the treatment of choice in such cases due to increased morbidity of a repeat abdominal surgery, definite risks remain, such as coil migration, which happened in this case. The open surgical approach remains the only option in such instances.

Therapeutic strategies for refractory variceal bleeding due to percutaneous liver biopsy: A case report

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Intrahepatic arterioportal fistula is an unusual complication of liver biopsy.

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Intrahepatic arterioportal fistula can cause variceal bleeding.

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Angioembolization is an effective treatment of variceal bleeding.

Introduction and importance

Variceal bleeding due to intrahepatic arterioportal fistula is an unusual complication of percutaneous liver biopsy. As majority of variceal bleeding are cirrhotic in origin, the rare occurrence of an acquired intrahepatic arterioportal fistula presents a therapeutic dilemma.

Case presentation

We report the case of a 57-year-old female with refractory variceal bleeding that occurred six years after a percutaneous liver biopsy. As part of the workup for placement of Transjugular Intrahepatic Portosystemic Shunt, a computed tomography hepatic arteriography was performed. This revealed a large arterioportal fistula in left lobe of liver. Variceal bleeding was controlled following successful embolisation of the arterioportal fistula.

Clinical discussion

Persistent intrahepatic arterioportal fistula can result in portal hypertension and variceal bleeding. This is a rare complication of percutaneous liver biopsy that warrants consideration as an aetiology of portal hypertension with variceal bleeding. The therapeutic strategy for refractory bleeding due to intrahepatic arterioportal fistula is different from cirrhotic portal hypertension and requires trans-arterial embolisation of the fistula.

Conclusion

This case highlights the need to consider arterioportal fistula as an aetiology of portal hypertension as therapeutic strategy in refractory variceal bleeding is different from cirrhotic portal hypertension.

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.

Congenital Intrahepatic Arterioportal Fistula: Extremely Rare Cause of Melena and Chronic Diarrhea in Children

Congenital intrahepatic arterioportal fistulas are rare causes of presinusoidal portal hypertension in children. A rare case of arterioportal fistula in an infant is being reported. This report also highlights the need for long-term surveillance in such cases, despite being a benign pathology.

Ruptured pancreaticoduodenal pseudoaneurysm causing arterioportal fistula: combined transarterial and transportal embolization

Background

Arterioportal fistulas are rare vascular disorders of the abdominal viscera. They are arteriovenous communications between the splanchnic arteries and the portal vein or its tributaries. We herein report a case of an extrahepatic arterioportal fistula that was caused by rupture of a pseudoaneurysm of the pancreaticoduodenal artery and successfully treated with embolization using a combination of the arterial and percutaneous transhepatic portal venous approaches.

Case presentation

A 79-year-old man was transferred to our hospital because of the sudden appearance of a hematoma containing a large pseudoaneurysm in the mesentery of the duodenum. Emergency abdominal angiography revealed that a pseudoaneurysm of the anterior inferior pancreaticoduodenal arterial branch had perforated into the portal system (arterioportal fistula). We performed coil embolization via the inflow artery and portal vein using a percutaneous transhepatic approach. The patient recovered without complications and was discharged.

Conclusion

This rare vascular disorder was successfully treated with an unplanned combination therapy. We believe that flexible strategy changes led to the successful treatment in this case.

Endovascular treatment of psuedoaneurysm arising from common hepatic artery bifurcation with complete disruption of gastroduodenal artery and high flow arterioportal fistula

Arterio-portal fistulas (APFs) are characterized by anomalous communication between arteries and the portal vein (PV) system. Treatment of APF is imperative as an emergency or if there is development of portal hypertension/heart failure in chronic cases. Both endovascular and surgical managements can be attempted, however since endovascular management carries comparatively low intra and post procedural morbidity it is mostly preferred. This is a case report on endovascular management of post-traumatic pseudoaneurysm arising from bifurcation of common hepatic artery with complete disruption of the gastroduodenal artery and high-flow APF. This report describes the intraprocedure challenges in exclusion of fistula from the circulation, without disruption of portal system and anticipation of recruitment of new collateral feeders to the fistula immediate post exclusion with its embolization, which needs appropriate positioning of the catheter prior to exclusion of the fistula.

Successful surgical treatment for intrahepatic arterioportal fistula with severe portal hypertension: a case report

Background

Intrahepatic arterioportal fistula (IAPF) is a rare cause of portal hypertension. Interventional radiology (IVR) is generally selected as the first-line therapeutic option. Surgical treatment for IAPF is required in refractory cases of IVR. As the treatment success rate with IVR is high, cases requiring surgical treatment are extremely rare.

Case presentation

A 54-year-old man was admitted to another hospital complaining of hematemesis due to rupture of the esophageal varices. A computed tomography revealed ascites and arterioportal fistula in the left lobe of the liver. Transcatheter arterial embolization (TAE) was performed to occlude the fistula; however, it could not reach complete occlusion. Thereafter, there were a total of four hematemeses, and six endoscopic variceal ligations were required. The second TAE also failed to reach complete occlusion. He was transferred to our hospital for further treatment. Because liver function was low due to frequent hematemeses and there was also uncontrollable ascites, it was confirmed that hepatectomy could not be performed safely at this time. Therefore, we ligated the left portal branch and ligated and dissected the left gastric vein to decrease portal vein pressure. However, on the 5th day after surgery, the esophageal varices reruptured. As the disappearance of ascites was observed in the postoperative course and the general condition also improved, left hepatectomy was performed to remove IAPF. There was no recurrence of portal hypertension for 1 year and 3 months since hepatectomy.

Conclusions

This case was difficult to treat with IVR and required surgical treatment. Our experience in the present case suggests that hepatectomy to remove arterioportal fistula was considered effective for improving portal hypertension due to IAPF. However, careful treatment selection according to the patient’s overall condition and clinical course is necessary for IAPF presenting with severe portal hypertension.

Portal vein aneurysm associated with arterioportal fistula after hepatic anterior segmentectomy: Thought-provoking complication after hepatectomy

Background

Few cases of postoperative arterioportal fistula (APF) have been documented. APF after hepatectomy is a very rare surgery-related complication.

Case presentation

A 62-year-old man was diagnosed with hepatocellular carcinoma in segments 5 and 8, respectively. Anterior segmentectomy was performed as a curative surgery. Each branch of the hepatic artery, portal vein, and biliary duct for the anterior segment was ligated together as the Glissonean bundle. The patient was discharged on postoperative day 14. Three months later, dynamic magnetic resonance imaging showed an arterioportal fistula and portal vein aneurysm. Surprisingly, the patient did not have subtle symptoms. Although a perfect angiographic evaluation could not be ensured, we performed angiography with subsequent interventional radiology to avoid sudden rupture. Arteriography was immediately performed to create a portogram via the APF from the stump of the anterior hepatic artery, and portography clearly revealed hepatofugal portal vein flow. Portography also showed that the stump of the anterior portal vein had developed a 40-mm-diameter portal vein aneurysm. Selective embolization of the anterior hepatic artery was accomplished in the whole length of the stump of the anterior hepatic artery, and abnormal blood flow through the APF was drastically reduced. The portal vein aneurysm disappeared, and portal flow was normalized. Dynamic computed tomography after embolization clearly demonstrated perfect interruption of the APF. The patient maintained good health thereafter.

Conclusions

Post-hepatectomy APFs are very rare, and some appear to be cryptogenic. Our thought-provoking case may help to provide a possible explanation of the causes of post-hepatectomy APF.

Endovascular Treatment of Congenital Arterioportal Fistulas

PURPOSE

To characterize anatomy of congenital arterioportal fistulas (CAPF) and correlate this with technique and outcomes of transcatheter embolization (TCE).

MATERIALS AND METHODS

Retrospective review was conducted of children with CAPF that underwent TCE in a 10-year period. Medical records, imaging and procedure details were reviewed. TCE was performed via transarterial (n = 5), portal (n = 5) or patent ductus venosus (n = 1) approach. Embolic agents used were coils (n = 10), Onyx (n = 1) and Amplatzer septal occluder (n = 1).

RESULTS

A total of 7 patients were included (4 female). Median age at treatment was 4 months (2 month-3 year). Most common symptoms were GI bleeding (n = 4), anemia (n = 4) and ascites (n = 3). Hepatopetal flow was seen in all on pre-procedure sonography. On angiography, a simple lesion, with direct fistulous connections, from hepatic arterial (HA) branches to portal venous (PV) system was seen in 3. A complex lesion with multiple connections was identified in 4. In simple lesions, cessation of shunting was achieved in 1 procedure, with embolization of afferent vessels. In complex lesions, multiple procedures were required in 3 of 4 patients. All 4 with complex connections required embolization of the aneurysmal PV segment. There were no major complications. Two minor complications were noted: localized biliary leak in 1 and femoral pseudoaneurysm in 1. There was resolution of symptoms in 6.

CONCLUSIONS

TCE is effective as primary treatment of CAPF. Patients with simple arteriovenous connections can be treated with embolization of afferent vessels, but children with multiple complex connections usually require embolization of the dilated PV segment.

Massive ascites caused by intra-pancreatic arterioportal fistula: a rare complication of chronic pancreatitis

An 86-year-old man with a long-term habit of ethanol consumption was admitted due to massive transudate ascites and leg edema. Abdominal computed tomography revealed a dilated main pancreatic duct and atrophied pancreatic parenchyma, leading to the diagnosis of chronic pancreatitis. Moreover, the portal vein was enhanced in the early arterial phase, which indicated the presence of an arterioportal fistula. The fistula was located between the posterior superior pancreaticoduodenal artery and the portal vein near a pancreatic retention cyst. Transarterial coil embolization dramatically improved the ascites. Arterioportal fistula and ensuing ascites should be recognized as a complication of chronic pancreatitis.

Endovascular treatment of an arterioportal fistula following pancreaticoduodenectomy

We present a rare case of an arterioportal fistula that formed between the superior mesenteric artery and portal vein 30 days following a pancreaticoduodenectomy, which was successfully managed with endovascular procedures.

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.

Unusual case of digestive hemorrhage: Celiac axis-portal vein arteriovenous fistula

A case of intractable upper gastrointestinal-hemorrhage was reported in a patient with portal hypertension caused by an arterioportal fistula (APF), namely, celiac axis-portal vein arteriovenous fistula. Portal hypertension caused by extrahepatic-APFs is extremely rare. Trauma, malignancy, and hereditary causes are the common etiology of APFs; but were absent in our patient. Our patient represents an unusual case of unexplained APF who presented with portal hypertension and was successfully managed through endovascular aortic repair.

Successful interventional treatment for arterioportal fistula caused by radiofrequency ablation for hepatocellular carcinoma

Radiofrequency ablation (RFA) is commonly used as a treatment for small hepatocellular carcinoma (HCC). Although several complications such as intraperitoneal bleeding are often observed after RFA, hepatic arterioportal fistula (APF) is a less frequently occurring complication. In this study, we describe two cases of APF caused by RFA, which was successfully occluded by an interventional approach. Case 1 involved a 68-year-old man with solitary HCC in segment VIII of the liver. Both contrast-enhanced computed tomography and color Doppler sonography indicated an APF between the anterosuperior branch of the right hepatic artery (A8) and the portal branch (P8). Concordant with these findings, digital subtraction angiography (DSA) revealed an APF in segment VIII of the liver. Subsequently, the APF was successfully occluded by transarterial embolization (TAE) using gelatin sponge particles. Case 2 involved a 67-year-old man with solitary HCC in segment VII of the liver. Although he developed obstructive jaundice because of hemobilia after RFA, it was improved by endoscopic nasobiliary drainage and the systemic administration of antibiotics. In addition, color Doppler sonography revealed a disturbed flow of the right branch of the portal vein. Similar to case 1, DSA showed an APF between A8 and P8. The APF was successfully embolized by TAE using microcoils. In conclusion, it appears that the formation of APF should be checked after RFA. It is preferable to treat RFA-induced APF promptly by an interventional approach to avoid secondary complications such as portal hypertension and liver dysfunction.

Isolated arterioportal fistula presenting with variceal hemorrhage

We report a case of life-threatening hematemesis due to portal hypertension caused by an isolated arterioportal fistula (APF). Intrahepatic APFs are extremely rare and are a cause of presinusoidal portal hypertension. Etiologies for APFs are comprised of precipitating trauma, malignancy, and hereditary hemorrhagic telangiectasia, but these were not the case in our patient. Idiopathic APFs are usually due to congenital vascular abnormalities and thus usually present in the pediatric setting. This is one of the first cases of adult-onset isolated APF who presented with portal hypertension and was successfully managed through endoscopic hemostasis and subsequent interventional radiological embolization.

Clinical outcomes of symptomatic arterioportal fistulas after transcatheter arterial embolization

AIM: To evaluate the complications and clinical outcomes of transcatheter arterial embolization (TAE) for symptoms related to severe arterioportal fistulas (APFs).

METHODS: Six patients (3 males, 3 females; mean age, 63.8 years; age range, 60-71 years) with chronic liver disease and severe APFs due to percutaneous intrahepatic treatment (n = 5) and portal vein (PV) tumor thrombosis of hepatocellular carcinoma (n = 1) underwent TAE for symptoms related to severe APFs [refractory ascites (n = 4), hemorrhoidal hemorrhage (n = 1), and hepatic encephalopathy (n = 1)]. Control of symptoms related to APFs and complications were evaluated during the follow-up period (range, 4-57 mo).

RESULTS: In all patients, celiac angiography revealed immediate retrograde visualization of the main PV before TAE, indicating severe APF. Selective TAE for the hepatic arteries was performed using metallic coils (MC, n = 4) and both MCs and n-butyl cyanoacrylate (n = 2). Three patients underwent repeated TAEs for residual APFs and ascites. Four patients developed PV thrombosis after TAE. During the follow-up period after TAE, APF obliteration and symptomatic improvement were obtained in all patients.

CONCLUSION: Although TAE for severe APFs may sometimes be complicated by PV thrombosis, TAE can be an effective treatment to improve clinical symptoms related to severe APFs.