Extrahepatic Arterioportal Fistula Research Articles

Large gastroduodenal artery pseudoaneurysm, arterioportal fistula and portal vein stenosis in chronic pancreatitis treated using combined transarterial embolization and transportal stenting: A case report.

Chronic pancreatitis is an ongoing fibroinflammatory disease of the pancreas characterized by irreversible damage to the pancreatic parenchyma and ductal system. Besides, chronic pancreatitis can present with a variety of life-threatening complications. The patients visited our hospital due to abdominal pain and anemia, and had chronic pancreatitis as an underlying disease. Computed tomography showed a large gastroduodenal artery pseudoaneurysm, arterioportal vein fistula, and portal vein stenosis. We would like to report the successful use of the coils, and N-butyl cyanoacrylate glue for the therapeutic embolization of the pseudoaneurysm and fistula between the gastroduodenal artery and the portal vein, and stenting for portal vein stenosis. On the day following the endovascular management, the patient reported remission of abdominal pain, and hemoglobin level returned to normal after transfusion. It was confirmed that it was still well maintained in the follow-up examination after 1 month. Although chronic pancreatitis causes many vascular complications, simultaneous occurrence of these lesions is extremely rare. Herein, we share our experience with a unique case of an extrahepatic arterioportal fistula induced by the rupture of gastroduodenal artery pseudoaneurysm with concomitant portal vein stenosis. In these complex cases, combined transarterial embolization and transportal stenting can be helpful.

A wrong path

Background and Aim: Obscure GI bleed in patients with cirrhosis is usually due to portal hypertension. Bleeding resulting from extrahepatic arterioportal fistulas (APFs) is extremely rare. We present a case of Obscure GI bleed secondary to APF and portal vein thrombosis successfully managed with coil embolization.

Ruptured pancreaticoduodenal pseudoaneurysm causing arterioportal fistula: combined transarterial and transportal embolization

BackgroundArterioportal fistulas are rare vascular disorders of the abdominal viscera. They are arteriovenous communications between the splanchnic arteries and the portal vein or its tributaries. We herein report a case of an extrahepatic arterioportal fistula that was caused by rupture of a pseudoaneurysm of the pancreaticoduodenal artery and successfully treated with embolization using a combination of the arterial and percutaneous transhepatic portal venous approaches.Case presentationA 79-year-old man was transferred to our hospital because of the sudden appearance of a hematoma containing a large pseudoaneurysm in the mesentery of the duodenum. Emergency abdominal angiography revealed that a pseudoaneurysm of the anterior inferior pancreaticoduodenal arterial branch had perforated into the portal system (arterioportal fistula). We performed coil embolization via the inflow artery and portal vein using a percutaneous transhepatic approach. The patient recovered without complications and was discharged.ConclusionThis rare vascular disorder was successfully treated with an unplanned combination therapy. We believe that flexible strategy changes led to the successful treatment in this case.

A Rare Cause of Intermittent, Occult Lower Gastrointestinal Bleeding

56-year-old man presented with fatigue and inAtermittent, occult lower gastrointestinal bleeding since a percutaneous transluminal coronary angioplasty with bare metal stent implantation was performed for critical stenosis of the left anterior descending. Associated medical treatment was aspirin 80 mg and clopidogrel 75 mg daily. One episode of massive lower gastrointestinal bleeding (hemoglobin 5.0 g/dL) occurred 1 day after endoscopic polypectomy, which was treated with 6 units of packed cells. Endoscopic work-up included a negative gastroscopy and colonoscopy. A double-balloon enteroscopy revealed pulsatile waves in the distal ileal mucosa. Contrast-enhanced computed tomography scan revealed a hypertrophied ileocolic artery (arrowheads) feeding a preterminal ileal small bowel loop presenting with a hyperdense contrast enhancement (small arrows); early filling of a hypertrophied ileal draining vein (large arrow) is also seen (Figure A). A catheter-directed selective angiogram showed a hypertrophied ileocolic artery (small arrows) and end-branches (arrowheads) and an early draining hypertrophied ileal vein (large arrow) (Figure B), suggesting an ileal high-flow arterioportal vascular malformation. Because of the large intestinal territory the high-flow malformation was extended, it was decided to resect the affected small bowel segment. Pathologic analysis of the resected specimen (hematoxylin-eosin; original magnification, 25) revealed a submucosal high-flow arteriovenous malformation with very large, thick-walled vessels in the submucosa (yellow arrows); the muscularis propria is indicated by a yellow star (Figure C). Clinical follow-up after surgery was uneventful. High-flow arterioportal vascular malformations are extremely rare and are mostly seen as spontaneously formed vascular lesions within a hepatocellular carcinoma; extrahepatic arterioportal fistulas are extremely rare and can be isolated or associated with a visceral aneurysm, eroding into the portal circulation. Intestinal angiodysplasia is characterized by the presence of thin, ectatic vessels with little or no smooth muscle but without early draining veins. Clinically these lesions tend to bleed intermittently, especially in patients on antiplatelet or anticoagulation drug regimens. In the present case, there was radiologic, macroscopic, and microscopic pathologic evidence of a highflow arterioportal vascular malformation located in the preterminal ileum. Because of the intermittent bleeding episodes and the potential for progression to symptomatic portal hypertension and liver cirrhosis, surgical resection seemed to be justified. These are our main findings. A small bowel highflow arterioportal vascular malformation may cause

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.

An unusual case of ascites

A 76-year-old woman with abdominal pain and diarrhoea developed ascites that did not respond to treatment. There were no signs of liver damage. Abdominal ultrasonography with colour Doppler revealed an arterial-like flow in the enlarged splenic vein. Using selective mesenteric arteriography, we were able to diagnose a shunt between the inferior mesenteric artery and the inferior mesenteric vein. This is an unusual case of ascites due to prehepatic portal hypertension secondary to an extrahepatic arterioportal fistula.