The role of selective angiography in the diagnosis and treatment of hepatoportal arteriovenous fistula.

Abstract

An hepatoportal arteriovenous fistula is a unique complication of abdominal trauma. Of 5 previously reported cases, 4 resulted from penetrating injury and only 1 was attributable to blunt trauma (1, 3, 4, 7, 9). The present report documents the occurrence of hepatoportal fistula following blunt abdominal trauma in a child. The case is significant not only for its rarity, but also as a demonstration of the value of selective angiography in the diagnosis, treatment, and postoperative assessment of this lesion. An 8-year-old girl sustained a fracture of the right femur and abdominal injuries as a result of an automobile accident in January 1968. The child was admitted to a local hospital in hypovolemic shock and underwent exploratory laparotomy. At operation, bleeding from liver and right kidney lacerations was controlled with chromic catgut sutures. Renal shut-down developed postoperatively and the patient was transferred to the W. A. Shands Teaching Hospital. Six weeks later, following a prolonged convalescence, an intravenous urogram showed a nonfunctioning right kidney, and a selective right renal angiogram demonstrated a renal artery aneurysm, laceration of the kidney, and renal vein thrombosis. These studies also suggested the presence of an hepatic artery aneurysm (Fig. 1). The patient was asymptomatic at this time and definitive treatment was deferred. Three months later, repeat right renal angiography showed obliteration of the renal artery aneurysm and atrophy of the lacerated kidney. Selective angiography of the superior mesenteric artery confirmed the presence of an hepatoportal fistula in association with the hepatic artery aneurysm (Fig. 2). On the basis of these findings, an exploratory laparotomy was performed. At operation, an hepatoportal arteriovenous fistula was identified by angiography in the posterior aspect of the right hepatic lobe. Blood flow into this lesion was from both the anterior and the posterior branches of the right hepatic artery. Filling of the aneurysm was no longer visible on a repeat angiogram following suture ligation of the right main hepatic artery. A concomitant right nephrectomy was also performed. The patient's postoperative convalescence was entirely uneventful, and she was discharged two weeks after surgery. Selective mesenteric angiography was performed two months later for postoperative evaluation. Although minimal residual filling of the hepatoportal arteriovenous fistula persisted through small collateral vessels from the inferior phrenic, left hepatic, and left gastric arteries, a significant decrease in blood flow through the fistula and aneurysm was evident (Fig. 3 and 4). The patient was asymptomatic, and studies of hepatic and renal function were normal. She was discharged with periodic evaluation planned for the future. Discussion Recent advances in surgery of the liver have emphasized the importance of an exact preoperative diagnosis as to the type and extent of hepatic injury.