Abstract
The aim of the study was to show the capabilities of endovascular occlusion of giant posttraumatic pseudo-aneurysm of superior mesenteric artery (SMA) connected to a mesenteric arteriovenous fistula (AVF) under the conditions of portal hypertension and life-threatening esophageal variceal bleeding.Materials and Methods.A 27-old male patient underwent endovascular occlusion; the patient being hospitalized with a clinical picture of gastrointestinal bleeding. The examinations: ultrasound, esophagogastroduodenoscopy, multispiral computed tomography with angiography — revealed the source of bleeding to be esophageal varices against the background of portal hypertension caused by massive arteriovenous shunt, its source being AVF with an aneurysmal component (32×35 mm in size) between SMA and superior mesenteric vein (SMV) dilated up to 50 mm in diameter. Patient’s past medical history recorded that 4.5 years ago the patient had undergone the resection of a small intestine area due to a penetrating stab wound in the abdominal cavity. Taking into consideration an extremely high operative intervention risk due to the condition severity related to blood loss, portal hypertension, and ascites, it was decided to embolize AVF with a vascular occluder — Amplatzer Vascular Plug II (USA), 14×10 mm in size.Results.A unique endovascular intervention — transcatheter occlusion of pseudo-aneurysm and AVF separation — was performed in life-threatening esophageal variceal bleeding under the condition of a giant post-traumatic aneurysm of SMA and mesenteric AVF. Due to an extremely large-sized SMV and an arterial pseudo-aneurysm, first ever we used the technique applied for transcatheter occlusion of a cardiac septum defect.Occluder implantation enabled to completely close the communication of aneurysmatic AVF with SMV, and occlude the aneurysm cavity. During an immediate postoperative period portal hypertension was arrested. No recurrent bleedings occurred within 4 postoperative months.
Highlights
Traumatic injuries of major abdominal vessels result in life-threatening complications, which are difficult to eliminate completely and safely using an open surgery or laparoscopic operations
The aim of the study was to show the capabilities of endovascular occlusion of giant posttraumatic pseudo-aneurysm of superior mesenteric artery (SMA) connected to a mesenteric arteriovenous fistula (AVF) under the conditions of portal hypertension and lifethreatening esophageal variceal bleeding
Arteriovenous fistula with anastomoses of large diameters result in marked shunting from arterial vessels with systemic pressure into venous bed, where initial pressure does not exceed 3–7 Hg mm
Summary
Traumatic injuries of major abdominal vessels result in life-threatening complications, which are difficult to eliminate completely and safely using an open surgery or laparoscopic operations. One of delayed sequelae of traumatic vessel injuries is an arteriovenous fistula (AVF) [1]. In most cases AVFs are detected in patients many years after an injury. Mesenteric AVF is a rare complication after surgeries or wounds. According to Brucher et al [2], just about 200 observations of AVF between abdominal vessels have been described in literature. Mesenteric AVFs, as a rule, are accompanied by the portal system arterialization, portal hypertension development, esophageal and gastric varicose veins, with further complications: variceal bleedings [3]
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