Arterioportal Fistula Research Articles

Isolated arterioportal fistula presenting with variceal hemorrhage

We report a case of life-threatening hematemesis due to portal hypertension caused by an isolated arterioportal fistula (APF). Intrahepatic APFs are extremely rare and are a cause of presinusoidal portal hypertension. Etiologies for APFs are comprised of precipitating trauma, malignancy, and hereditary hemorrhagic telangiectasia, but these were not the case in our patient. Idiopathic APFs are usually due to congenital vascular abnormalities and thus usually present in the pediatric setting. This is one of the first cases of adult-onset isolated APF who presented with portal hypertension and was successfully managed through endoscopic hemostasis and subsequent interventional radiological embolization.

Clinical outcomes of symptomatic arterioportal fistulas after transcatheter arterial embolization

To evaluate the complications and clinical outcomes of transcatheter arterial embolization (TAE) for symptoms related to severe arterioportal fistulas (APFs). Six patients (3 males, 3 females; mean age, 63.8 years; age range, 60-71 years) with chronic liver disease and severe APFs due to percutaneous intrahepatic treatment (n = 5) and portal vein (PV) tumor thrombosis of hepatocellular carcinoma (n = 1) underwent TAE for symptoms related to severe APFs [refractory ascites (n = 4), hemorrhoidal hemorrhage (n = 1), and hepatic encephalopathy (n = 1)]. Control of symptoms related to APFs and complications were evaluated during the follow-up period (range, 4-57 mo). In all patients, celiac angiography revealed immediate retrograde visualization of the main PV before TAE, indicating severe APF. Selective TAE for the hepatic arteries was performed using metallic coils (MC, n = 4) and both MCs and n-butyl cyanoacrylate (n = 2). Three patients underwent repeated TAEs for residual APFs and ascites. Four patients developed PV thrombosis after TAE. During the follow-up period after TAE, APF obliteration and symptomatic improvement were obtained in all patients. Although TAE for severe APFs may sometimes be complicated by PV thrombosis, TAE can be an effective treatment to improve clinical symptoms related to severe APFs.

Transjugular Retrograde Cannulation of the Portal Vein via Patent Ductus Venosus: Alternative Access for Endovascular Hepatic Interventions

The use of the patent ductus venosus via a transjugular approach to access the portal system for endovascular treatment of hepatic vascular anomalies in three infants is reported. Two patients had an arterioportal fistula, and one had a rapidly involuting congenital hemangioma. All patients underwent arteriography followed by embolization of the vascular anomalies without complications. This alternative route is technically simpler and likely safer than transarterial and transhepatic approaches.

MDCT diagnosis of post-traumatic hepatic arterio-portal fistulas

The purpose of this study is to evaluate the performance of multidetector computed tomography (MDCT) in diagnosing arterioportal fistulas (APF) in high-grade liver injury. A retrospective analysis of catheter-based hepatic angiograms performed for major penetrating and blunt liver injuries identified 11 patients with APFs. Using the trauma registry, two additional demographically matched groups with and without liver injury were formed. A randomized qualitative consensus review of 33 MDCTs was performed by three trauma radiologists for the following MDCT findings of APF: transient hepatic parenchymal attenuation differences (THPAD), early increased attenuation of a peripheral or central portal vein compared with the main portal vein, and the "double-barrel" or "rail tract" signs. THPAD was the most sensitive finding and also had a high specificity for diagnosing APF. Both the early increased attenuation of a peripheral or central portal vein compared with the main portal vein and the double-barrel or rail tract signs had a100% specificity and a sensitivity of 64% and 36%, respectively. Measurement of differences in attenuation values between the APF and the contralateral central portal vein was most sensitive and specific in diagnosing APF. Traumatic APF of the liver can be optimally diagnosed with arterial phase imaging of solid organ using MDCT.

Arterioportal Fistula as a Rare Cause of Cryptogenic Portal Hypertension

Arterioportal Fistula as a Rare Cause of Cryptogenic Portal Hypertension

Congenital arterioportal fistulas: radiological treatment and color Doppler US follow-up

Congenital intrahepatic arterioportal fistulas (APFs) are a rare cause of portal hypertension in children. Doppler US is a useful diagnostic imaging modality. Transarterial embolization is a minimally invasive and effective therapy allowing occlusion of the fistula and restoration of liver hemodynamics. To describe the clinical and radiologic findings, percutaneous treatment and role of D-US in the postembolization follow-up of children with APF. Between 2002 and 2011, four children with APF were treated. Initial diagnosis and follow-up was performed with D-US and confirmed by arteriography, followed by endovascular embolization in all patients. D-US demonstrated abnormal arterioportal communications in all patients. Six endovascular procedures were performed in these four children. In two children, no residual fistula was seen on D-US after the first procedure and symptoms resolved. In the other two children, D-US demonstrated residual flow through the fistula, with resolution of pathological D-US findings and symptoms after the second endovascular procedure. All four children were successfully treated and asymptomatic at the end of follow-up. The mean follow-up was 24 months. Interventional radiology has a key role in the treatment of congenital APF. D-US is a noninvasive and effective tool for the diagnosis and follow-up of these patients.

Arterioportal Fistulas in Liver Transplant Recipients

Arterioportal fistulas (APFs) are classified into intrahepatic (>75% of all reported) and extrahepatic (<25% of all reported ). Anecdotally, investigators are more likely to report more sensational cases (typically extrahepatic APFs), so the actual prevalence of intrahepatic APFs is probably much higher (likely >90% of APFs). All reported APFs in liver transplant recipients have been intrahepatic. Hemodynamically significant APFs in liver transplant recipients are rare, occurring in 0.2%; however, APFs (hemodynamically significant or not) are not uncommonly seen in hepatic angiograms of liver transplant recipients (up to 5.4% of hepatic arteriograms in transplants). Interestingly, hemodynamically significant APFs warranting endovascular treatment are reported more commonly in the literature in native compared with transplanted livers (n >280-300 versus n = 13, respectively). This article discusses APFs that are specific to liver transplant recipients; their incidence, etiology, pathogenesis, natural history, clinical presentation, and endovascular management are discussed in detail.

Abstract No. 410: The use of the patent ductus venosus as an access for portal vascular interventions in children

The ductus venosus, a fetal communication between the portal and systemic venous circulations, spontaneously closes early in the neonatal period. The persistence of the ductus venosus is rare and can be primary (congenital) or secondary to abnormal portal hemodynamics. Vascular anomalies of the portal vein can be associated with serious clinical presentation and pose technical challenges at interventions. In such patients, the patent ductus venosus provides a safe and valuable alternative access for endovascular treatment. 4 children (age: 2 months 6 years) underwent interventional treatment of vascular anomalies of the portal vein using the patent ductus venosus as a vascular conduit to the portal vein via a transjugular approach. Two patients had arterioportal fistulae; one had a large portosystemic shunt with severe gastrointestinal bleeding and one congenital hemangioma with heart and liver failure. Mesenteric arteriography was initially performed followed by transjugular access of the patent ductus venosus and embolization of the portal anomaly. All the procedures were technically successful using the patent ductus venosus. In patient # 1 with a fistula between the inferior phrenic artery and portal vein, the shunt was embolized with coils. Patient # 2 had a complex arterioportal shunt with a giant portal aneurysm was embolized with an Amplatzer septal occluder and coils. The portosystemic shunt in patient # 3 was closed using an Amplatzer vascular plug. Embolization of the portal feeding tributaries to the liver hemangioma in patient # 4 was done with coils. The procedures were technically successful in the four children without complications. The arterioportal fistula (patient # 1) and the portosystemic shunt (patient # 3) were completely obliterated and clinically successfully. Though technically successful, the response to embolization in patients # 2 and 3 (complex arterioportal fistula and congenital liver hemangioma, respectively) was partial; largely related to other serious comorbidity. Patent ductus venosus provides an invaluable safe access for endovascular portal venous interventions in children.

Gastric variceal bleeding caused by an intrahepatic arterioportal fistula that formed after liver biopsy: a case report and review of the literature

An intrahepatic arterioportal fistula is a rare cause of portal hypertension and variceal bleeding. We report on a patient with an intrahepatic arterioportal fistula following liver biopsy who was successfully treated by hepatectomy after unsuccessful arterial embolization. We also review the literature on symptomatic intrahepatic arterioportal fistulas after liver biopsy. A 48-year-old male with bleeding gastric varices and hepatitis B virus-associated liver cirrhosis was transferred to our hospital; this patient previously underwent percutaneous liver biopsies 3 and 6 years ago. Abdominal examination revealed a bruit over the liver, tenderness in the right upper quadrant, and splenomegaly. Ultrasonographic examination, computed tomography, and angiography confirmed an arterioportal fistula between the right hepatic artery and the right portal vein with portal hypertension. After admission, the patient suffered a large hematemesis and developed shock. He was treated with emergency transarterial embolization using microcoils. Since some collateral vessels bypassed the obstructive coils and still fed the fistulous area, embolization was performed again. Despite the second embolization, the collateral vessels could not be completely controlled. Radical treatment involving resection of his right hepatic lobe was performed. For nearly 6 years postoperatively, this patient has had no further episodes of variceal bleeding.

Fluctuating portal velocity tracing with rhythmicity: ultrasonic differential diagnosis and clinical significance

BackgroundTo evaluate the usefulness of the routine sonographic evaluation of the pattern of fluctuate portal velocity tracings and the hepatic veins for the diagnosis of arterioportal fistula (APF) and cardiogenic trans-sinusoidal shunting (CTS).Materials and methods.Color Doppler flow imaging and pulsed-wave Doppler (PW) examinations of the portal vein were performed in 282 subjects. The waveforms of the velocity tracings in the portal main trunk and its branches were determined to infer APF or CTS. Suspected cases of APFs or CTSs were always confirmed by echocardiography, contrast-enhanced ultrasound, computed tomography, or digital subtraction angiography findings. The portal maximum velocity (Vmax), minimum velocity(Vmin), Vmax/Vmin, arterial peak systolic velocity and resistance index, and venous reverse and forward velocities were used to estimate their haemodynamics.ResultsThe waveform of the velocity tracing for the draining portal vein of APF was typically arterial-like or diphase, as indicated by a systolic hepatofugal dwarf peak and a diastolic hepatopetal low flat shape. The flow in the affected portal vein was always hepatofugal in an intrahepatic patient, whereas a hepatopetal flow was observed in an extrahepatic APF patient. The waveform of the velocity tracing for the portal vein of CTS patients, especially its intrahepatic branches, showed a typical hump-like shape with or without a transitory hepatofugal tracing. The PW results displayed an increase in the retrograde phase of the hepatic venous flow with increased velocities in the two phases.ConclusionsPortal velocity tracings should be evaluated during routine detecting for APF or CTS, especially in patients with gastrointestinal upsets.

Zastosowanie okludera naczyniowego Amplatzer do zamknięcia tętnicy wątrobowej jako metoda leczenia szybkoprzepływowej przetoki tętniczo-wrotnej przed przeszczepem wątroby.

Arterioportal fistula (APF) is an abnormal, direct connection between hepatic artery or its branch and the portal vein. Fistula can be acquired or, rarely, congenital. One of the acquired causes of fistula is a liver biopsy. Patients with liver cirrhosis are particularly vulnerable to its development due to the large number of performed biopsies. APF increases mortality and morbidity of liver transplantation procedure and may be a contraindication to it. The authors present a patient with liver cirrhosis, in whom percutaneous APF closure facilitated liver transplantation. We describe a case of a 50-year-old patient with liver cirrhosis and APF, probably formed as a result of liver biopsy. Due to the presence of a high-flow fistula, which elevated portal hypertension, patient did not qualify for the liver transplantation. Patient was transferred to the interventional radiology department, where the fistula's vascular supply was endovascularly closed using the Amplatzer occluder. This subsequently enabled the execution of transplantation. Percutaneous closure of APF should be considered a relatively simple and fast-acting tool to facilitate or even enable liver transplant surgery. Currently, there are more and more products available such as e.g. Amplatzer occluder to simplify the procedure and shorten the duration of exposure to ionizing radiation.

Gastrointestinal bleeding caused by extrahepatic arterioportal fistula associated with portal vein thrombosis

An extrahepatic arterioportal fistula (APF) involving the gastroduodenal artery and superior mesenteric vein is rare and mostly results from iatrogenic injuries. The clinical symptoms associated with APFs may include abdominal pain, gastrointestinal bleeding, ascites, nausea, vomiting, diarrhea, or even congestive heart failure. We present the case of a 70-year-old man who presented with chronic abdominal pain and gastrointestinal bleeding secondary to APF and portal vein thrombosis. The endovascular embolization of APF was accomplished successfully, and symptoms of portal hypertension resolved immediately after intervention. Unfortunately, the patient did not respond well to anticoagulation therapy with warfarin. Therefore, the patient underwent implantation of a transjugular intrahepatic portosystemic shunt, and the complications of portal hypertension resolved. In conclusion, the embolization of APF is technically feasible and effective and can be considered the first-choice therapy in selected patients.

Prevalence, presentation, and endovascular management of hemodynamically or clinically significant arterio‐portal fistulae in living and cadaveric donor liver transplant recipients

To compare the prevalence (cadaveric vs. living donor transplants), clinical features, and the effectiveness of endovascular management of significant arterio-portal fistulae (APF) in liver transplant recipients. A retrospective audit of liver transplant recipients in two institutions was performed (1996-2009). Significant APF were included and were defined as symptomatic and/or hemodynamically significant (causing graft dysfunction and/or having abnormal Doppler findings in the portal vein). Patients with significant APF were evaluated for presenting symptoms, imaging features, size/branch order portal vein involvement, and effectiveness of the endovascular management (coil embolization). Four significant APF were found in 1992 (0.2%) liver transplants. Two were symptomatic and two were asymptomatic but were hemodynamically significant with liver function test abnormalities. All four APF were found in cadaveric donor graft recipients (0.23%, N = 4/1753) and none in 239 living donor graft recipients. However, there was no statistical difference between cadaveric and living donor graft recipients (p = 1.0, odds ratio = 1.23). Coil embolization was technically and clinically successful in all 4 without complications and causing normalization of the abnormal Doppler findings. Significant APF are a rare diagnosis (0.2% of transplants). Coil embolization is a safe and effective treatment option for APF in transplants.

Hepatobiliary and Pancreatic: Traumatic hepatic arterioportal fistula

Hepatobiliary and Pancreatic: Traumatic hepatic arterioportal fistula

Successful Endovascular Management of Postoperative Arterio Portal Fistula

Arterioportal fistulas are rare and mostly a result of late complication of gastric and biliary surgery. Surgical excision has been the therapy of reference. Endovascular treatment is emerging as a real alternative to surgery. The present study reports a case of postsurgical arterioportal fistula involving the gastroduodenal artery, the cause of portal hypertension, which was successfully treated by transarterial embolization using embospheres. Portal hypertension improved dramatically.

Transcatheter Arterial Chemoembolization of Hepatocellular Carcinoma as a Bridge to Liver Transplantation: A Retrospective Study

Background. Transcatheter arterial lipiodol chemoembolization (TACE) can be used in cirrhotic patients with hepatocellular carcinoma to avoid tumor progression before transplantation. Objective. To evaluate the efficacy and safety of TACE used as a bridge to liver transplantation. Methods. TACE was performed in 30 cirrhotic patients with hepatocellular carcinoma. Milan criteria were used to select patients for transplant. Patients had a good or moderately impaired liver function, no arterioportal fistulae, and a good portal perfusion. Results. 48 TACE were performed in 30 patients. Before transplantation, 4 patients were dropped off the list due to tumor extension or liver failure. Complete necrosis of the tumor was observed in 11 patients and partial necrosis in 15 patients. After transplantation, 6 patients died and tumor recurrence was observed in 5 patients with a tumor beyond Milan criteria or no response to TACE. Conclusion. TACE is useful as a bridge to liver transplantation in a selected group of cirrhotic patients with hepatocellular carcinoma. A combined therapeutic approach before surgery might improve the prognosis in these patients.

An unusual presentation of a congenital intrahepatic arterioportal fistula in an infant with Down syndrome

Congenital intrahepatic arterioportal fistula is a rare entity that most often presents with symptoms of portal hypertension and malabsorption. We discuss a patient who presented with distributive shock, congestive heart failure, pulmonary hypertension, ascites, and a history of severe constipation.

Cholangiocytes of Cirrhotic Rats are More Tolerant to Ischemia than Normal Rats: A Role for Abnormal Hepatic Arteriovenous Communications?

To assess whether cholangiocytes of rats with liver cirrhosis are more tolerant to ischemic changes than normal rats, and whether this is due to arteriovenous fistulas. Ninety-eight Sprague-Dawley rats were divided into the normal group (n = 30) and the cirrhosis group (n = 68), and then each group was divided into controls and those with bile duct ischemia. At 0 h, 6 h, 3 d, and 14 d after the induction of bile duct ischemia, the liver of each rat was removed and stained with toluidine blue to compare cholangiocyte morphology. Cholangiocyteapoptosis was evaluated by a deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling (TUNEL) assay. Expression of VEGF, HIF1, NF-kB(p65) was assessed by quantitative analysis of the products of reverse-transcriptase polymerase chain reaction. Resin casts were used to reproduce the intrahepatic vasculature of cirrhotic rats, and the presence of communications between the portal vein and hepatic artery was assessed with stereomicroscopy. Rats with liver cirrhosis were more tolerant than normal rats 6 h after bile duct ischemia (P < 0.05); at 3 and 14 d after the ischemic insult, there was no significant difference between the cirrhotic rats and normal rats. Levels of expression of VEGF, HIF1, and NF-kB(p65) genes, either in normal rats or cirrhotic rats, were significantly elevated compared with those in the control group (∗, ∗∗P < 0.05), but a lower extent changes appeared in the cirrhotic rats (∗∗∗P < 0.05). Several communications could be observed between the portal vein and hepatic artery. Cholangiocytes of cirrhotic rats appear to be more tolerant to ischemia of bile duct than non-cirrhotic rats. This may be due to the protective role of arterioportal fistulas.

Portal vein aneurysms with multiple associated findings

This study was done to investigate imaging features of portal vein aneurysms (PVA) associated with multiple associated findings and discuss the value of three-dimensional multiphase contrast-enhanced MR angiography (3D DCE-MRA) in detecting PVA. 3D DCE-MRA with comprehensive use of various post processing methods was performed in 10 PVA patients. Imaging features of these PVA were analyzed. Of the 10 patients, PVA were located in the splenic vein in three cases, in the intrahepatic portal vein in three cases, at the confluence of the superior mesenteric vein and splenic vein in two cases, and in the main portal vein in two cases. The maximal diameter of the PVA varied from 2.0 cm to 8.39 cm (mean±SD, 3.72±1.84 cm). There were several cases associated with multiple associated findings, such as cavernous transformation of the portal vein, arterio-portal fistulas, arteriovenous malformation and multiple aneurysms of the splenic artery. 3D DCE-MRA proved to be effective in detecting PVA, improving the diagnosis of associated findings, and in supplying more information for clinical treatment of PVA.

Successful coil embolization of an arterioportal fistula evolving 12 years after gastrojejunostomy

Abstract Arterioportal fistula — either acquired or congenital — is a rare syndrome, which is a real challenge in gastroenterologic diagnostics. We report a case of a 76-year-old female, who was admitted to the hospital with symptoms of permanent abdominal pain and a bruit in the epigastric region. Twelve years prior she underwent Billroth II gastrojejunostomy due to a perforating duodenal ulcer, followed by cholecystectomy 6 months later. CT and MR angiography showed a fistula between the gastroduodenal artery and the portal vein. Successful treatment of the arterioportal fistula was achieved by intravascular coil embolization resulting in the resolution of the symptoms. After six years of follow-up, abdominal ultrasonography did not show any novel findings and our patient is still doing well with no recurrence.