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

Paolo Marra,Massimo Venturini,Lorenzo D’Antiga,Ezio Bonanomi,Pietro Andrea Bonaffini,Michele Colledan,Sandro Sironi,Riccardo Muglia,Francesco Saverio Carbone,Roberto Agazzi,Ludovico Dulcetta

doi:10.3390/jcm10122612

Abstract

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.

Highlights

Arterioportal fistulas (APF) are uncommon vascular abnormalities with a heterogeneous etiology [1]
Even though acquired APFs are less frequent in pediatric patients, their incidence in referral centers for pediatric orthotopic liver transplantation (OLT) may be increased, owing to the large number of percutaneous liver interventions performed
This research retrieved a total of 23 pediatric patients

Summary

Introduction

Arterioportal fistulas (APF) are uncommon vascular abnormalities with a heterogeneous etiology [1] They can be congenital or acquired, the latter being most frequent and related to liver neoplasms or injuries, including trauma, needle biopsy and transhepatic interventions [1,2,3,4,5]. Clinical guidelines with a moderate level of evidence were proposed by the Catalan Society of Digestology and the Spanish Association for the Study of the Liver [17]. They recommend embolization only for large or symptomatic shunts, with surgery reserved after a failed interventional radiology approach

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