Angiographic embolization of intrahepatic arterioportal fistula

Abstract

Case reportA 35-year-old woman presented with upper gastrointestinal haemorrhage in September 1989. Four years earlier, chronic active hepatitis (HbAg+) had been diagnosed by percutaneous liver biopsy, the procedure being remembered as especially painful. She had no previous history of gastrointestinal bleeding, blood transfusion, alcoholism or drug addiction. Physical examination revealed moderate ascites and splenomegaly, although the blood biochemical determinations, coagulation studies and leucocyte and platelet counts were normal. Endoscopy showed large bleeding oesophageal varices which were successfully sclerosed. Ultrasonography demonstrated a central anechoic lesion in the right lobe of the liver which was interpreted as a cyst. The patient rebled from oesophageal varices 1 month later and endoscopic variceal sclerotherapy was again successful. Portohepatic echo-Doppler examination revealed hepatofugal blood flow. Splanchnic and hepatic angiography (October 1989) demonstrated a hypertrophied and tortuous hepatic artery feeding a very active intrahepatic pseudoaneurysmal arterioportal fistula located centrally in the right lobe, with immediate retrograde filling of the portal vein ( Figure I ) and reflux to the left gastric vein, with extensive collateral circulation through the oesophageal and perisplenic vascular beds. The fistula was embolized with four Gianturco (occluding string embolus, William Cook Europe, Denmark) coils. On control angiography 15 days later the fistula and its aneurysmic dilatations had disappeared ( Figure Z), and there were fewer arteriographic signs of portal hypertension. Echo-Doppler examination showed hepatopetal portal blood flow. Percutaneous liver biopsy demonstrated chronic active hepatitis and portal fibrosis.When the patient was reviewed 6 months later she was asymptomatic and routine analyses were normal. Endoscopy revealed less prominent oesophageal varices. Digital angiographic studies (April 1990) showed revascularization of the intrahepatic arterioportal fistulous sinus with filling of the portal vein in the early arterial phase and retrograde portal blood flow (Figure 3). Embolization was performed again with five Gianturco coils, almost eliminating the fistula, although some collateral vessels from the right hepatic artery or even from the left hepatic artery (which arose from the left gastric artery) bypassed the obstructive coils and still fed the fistulous area.

The Congenital Intrahepatic Arterioportal Fistula Syndrome

“…Detachable microcoils and balloons (60) alone are also suitable for smaller arterial branches. These should be positioned as close as possible to the fistula in the feeding artery (69,70). Distal positioning may minimize the risk of recanalization of the fistula by other collateral arteries and also preserve transarterial access to distal collateral arteries that are later identified (66).…”

Strategies for Intractable Ascites After Hepatic Resection: Analysis of Two Cases

“…AP shunts are a rare but well‐recognised cause of portal hypertension with ascites and variceal bleeding. They may be congenital or caused by a blunt or penetrating trauma, surgery, liver biopsy, rupture of an aneurysm, or neoplasm 16–19 . Leakage from lymphatic vessels injured at surgery which later fail to heal is another potential explanation for the development of intractable ascites 12 …”