Gastric Variceal Bleeding Caused by an Arterioportal Fistula Formation After TIPS and Related Complications

Abstract

A 70-year-old man was referred to our institution due to 2 days of vomiting and melena, 20 months after the placement of a transjugular intrahepatic portosystemic shunt (TIPS). He underwent TIPS treatment in another hospital due to repeated upper gastrointestinal variceal bleeding (GI) secondary to alcoholic cirrhosis and portal hypertension.Up until this point, abdominal ultrasound follow-up indicated intrahepatic stent patency, and gastrointestinal bleeding did not occur again. Suddenly and without an obvious trigger, he vomited approximately 1000 ml of blood and produced 500 g of black stool without blood clots, cough, sputum, or discomfort.Despite transfusion of 8 u of packed RBCs and 400 ml plasma, hemostasis, rehydration and anti-infective measures, he continued to frequently vomit large volumes and produce bright red stools. Emergency endoscopy revealed severe esophageal and gastric variceal bleeding. His esophageal varices were ligated, and the fundus varices were treated by tissue glue injection. A CT revealed arterial phase enhancement of the right portal vein which was markedly widened, and that arterial phase had developed with intrahepatic stent patency (Fig. 1). Based on these data, we surmised that an arterioportal fistula had formed. Hepatic arteriography and arterioportal fistula occlusion were performed through the femoral artery. Briefly, after the catheter was inserted into the target liver artery end of fistula, a suitable size rim (3 mm, COOK, USA) was put into the fistula, and appropriate gelatin sponge tablets were injected into the fistula. Then, another hepatic arteriography showed no portal vein development, and the hepatic artery showed significantly enhanced development compared with before fistula occlusion (Fig. 2). After fistula occlusion, hematemesis ceased, and the melena disappeared over 6 months.