Mesenteric Arteriovenous Fistula Research Articles

Superior Mesenteric Arteriovenous Fistula Presenting as Portal Hypertension.

Superior Mesenteric Arteriovenous Fistula Presenting as Portal Hypertension.

Contemporary Outcomes Associated with the Treatment of Mesenteric Arteriovenous Fistulas

Mesenteric arteriovenous fistulas (mAVFs) are rare phenomena with majority of the literature comprised of case reports. The aim of this study was to perform a contemporary and comprehensive review of the etiology, treatment, and outcomes of mAVFs to aid in the management of this uncommon pathology. We performed a MEDLINE query for the terms arteriovenous, fistula, and mesenteric from 2010 to 2022. We included English language case reports and series. Data points of interest included treatment indications, clinical presentation, disease etiology, interventions, medical management, and postoperative outcomes. Fifty-three unique publications (all single patient) met the inclusion criteria resulting in a population of 53 subjects (Table). Mean age at presentation was 51 years with males more frequently affected than females (2:1). Etiology was most frequently classified as iatrogenic (49.1%), idiopathic (32.1%), and traumatic (17%); symptoms at presentation consisted of generalized abdominal pain (56.6%), hepatic dysfunction (45.3%), and gastrointestinal bleeding (34%). The most frequent intervention consisted of coil embolization (69.8%), stenting (13.2%), and open repair (13.2%). Open repair was undertaken in two cases due to the perceived risk of embolic agent migration into the portal venous system. Anticoagulation was the most employed medical therapy (20.8%), often related to the presence of unwanted thrombus formation in the immediate postoperative period (9.4%). The mean clinical follow-up period was 3 months (range, 0-60 months). Reintervention during follow-up (5.7%) were all secondary to incomplete fistula coiling requiring additional procedures. Perioperative mortality rate of 3.8% (n = 2) was encountered; one death due to the progression of metastatic carcinoma and the other secondary to portal venous thrombosis with subsequent congestive ischemia and multiorgan failure. The results herein suggest that mAVFs can have a wide range of clinical presentations, necessitating the importance of maintaining a high suspicion in patients with vague abdominal pain. In this series, coil embolization was the most employed treatment method, beneficial in patients who may present with multiple associated comorbidities including hepatic dysfunction and gastrointestinal bleeding.TableDemographics and Indications for RepairCharacteristicsMedian (range) or %Demographics Age, years51 (37-64) Male sex66.0 Transplant5.7 Active cancer13.2 Pancreatitis1.9 Trauma17.0 Iatrogenic49.1 Congenital1.9 Idiopathic30.2Indications for repair Hepatic dysfunction45.3 Gastrointestinal bleed34.0 Abdominal pain56.6 Mesenteric ischemia13.2 Free hemorrhage18.9 Emergent7.5 Thromboembolism0 Pseudoaneurysm17.0 Open table in a new tab

S2050 Inferior Mesenteric Arteriovenous Fistula Treated with Embolization

Introduction: Inferior mesenteric arteriovenous fistulous malformations are a rare yet reversible cause of ischemic colitis. They can cause increased outflow of blood in the venous circulation and predispose to colon ischemia. We report a case of inferior mesenteric arteriovenous fistula causing ischemic colitis in an atypical distribution in the IMA territory. Case Description/Methods: A 50-year-old gentleman presented to the emergency room with a 3-week history of abdominal pain and bloody diarrhea. His symptoms started with a dull pain, 8/10 in intensity, with radiation to his lower back. He had also been having a low appetite for the duration of his abdominal pain. He described having around 10 bowel movements daily with blood mixed with mucus. CT abdomen showed diffuse circumferential thickening involving the entire sigmoid colon, extending to the upper rectum suggesting non-specific colitis. He came to the hospital 2 weeks prior to his presentation and underwent a colonoscopy which grossly showed diffuse severe inflammation in the distal descending colon, sigmoid colon and proximal rectum, till 30 cm from the anal verge suggesting left-sided colitis. Biopsied from the region showed evidence of ischemic colitis. His CT-angiography showed engorgement of the IMA and IMV, with an early contrast in IMV which suggested IMA to IMV AV fistula within the left hemipelvis. That suggested vascular malformation as the cause of the colorectal findings. Patient subsequently underwent embolization of 2 branches of IMA with stent placement in IMA, causing closure of the AV fistula. Patient tolerated the procedure without any complication (Figure). Discussion: Ischemic colitis is most commonly seen in the watershed areas of the colon such as splenic flexure and rectosigmoid junction due to arterial anastomosis between the mesenteric arteries supplying the colon. In these situations, the colonic involvement is focal involves these specific segments. In this case, patient had diffuse gross ischemic findings from the distal rectum extending to descending colon involving the whole part of ischemic artery supply which is atypical for the distribution of colonic ischemia. In such situations, CT angiography comes as a diagnostic tool for identifying the pathology and in this situation it showed AV fistula between IMA and IMV which hampered the colonic blood supply to the extent to cause ischemic colitis with symptoms.Figure 1.: a. Early filling of dilated mesenteric veins (bottom arrow) with adjacent bowel wall edema due to venous congestion (top arrow) b & c. inferior mesenteric artery (arrows) adjacent to ill-defined area of contrast (dashed arrow) thought to represent arterio-venous fistula d. view from sigmoidoscopy showing ischemic colitis in the sigmoid colon.

Novel endovascular technique for repair of superior mesenteric arteriovenous fistula with portal vein aneurysm

BackgroundA superior mesenteric arteriovenous fistula (SMAVF) is a rare, aberrant connection between the superior mesenteric artery (SMA) and the superior mesenteric vein (SMV). Management includes either open surgical repair or endovascular repair with embolization coils or covered stents. We report a novel in-stent coil embolization technique successfully used for repair of a challenging SMAVF. Case presentationA 56-year-old man presented with an enlarging SMV and portal vein aneurysm. His history was significant for a small bowel resection of a desmoid tumor 14 years prior. Computed tomography (CT) angiography revealed a high-flow SMAVF in the midsegment of the SMA, and the patient was taken to the operating room for endovascular repair. Embolization was initially attempted with detachable coils, but this approach was aborted as the coils did not have sufficient purchase to anchor securely and would migrate into the portal venous system prior to full release and deployment. Placement of a covered stent in the SMA to exclude the fistulous connection was not feasible due to the presence of multiple adjacent major SMA branches. Therefore, a balloon-expandable covered stent was placed across the fistula and crushed distally to create a blind end into which embolization coils were able to nest without migrating. This was achieved with the use of multiple buddy wires to deploy a VBX balloon-expandable stent graft (WL Gore, Flagstaff, AZ) across the fistulous connection and crush the distal end of the stent with a buddy balloon. The funneled covered stent then served as a backstop for packing with embolization coils, and completion angiography demonstrated complete occlusion of the SMAVF and filling of all SMA branches. Both 6-month and 1-year postoperative surveillance CT scans confirmed continued resolution of the fistula. ConclusionThis case demonstrates a novel endovascular technique to create a funneled covered stent across a high-flow SMAVF as a platform to enable embolization and prevent coil migration. This in-stent coil embolization technique is a viable option for cases in which embolization coils and covered stents fail or are unsuitable.

Superior mesenteric arteriovenous fistula embolization with a vascular plug for upper gastrointestinal hemorrhage: a case report

BackgroundSuperior mesenteric arteriovenous fistula is a rare vascular anomaly often presenting with sequelae of portal hypertension, heart failure, or mesenteric ischemia. This report describes a patient with a previously unidentified superior mesenteric arteriovenous fistula who presented with variceal bleeding, thought to be the leading cause of mortality associated with this condition. Although this patient was initially referred for a transjugular intrahepatic portosystemic shunt procedure, following a thorough review of her clinical history and imaging, she instead underwent embolization of the arteriovenous fistula likely responsible for her symptoms.Case PresentationA 75-year-old woman with a past surgical history of extensive small bowel resection presented with active variceal bleeding requiring transfusions. She was referred to vascular and interventional radiology for transjugular intrahepatic portosystemic shunt procedure; however, her clinical presentation was inconsistent with cirrhosis. This prompted a further review of her imaging, which identified a superior mesenteric arteriovenous fistula as the probable etiology of her varices. This fistula was subsequently embolized with a vascular plug and follow-up upper endoscopy at 1-month demonstrated complete resolution of her varices.ConclusionsThis report highlights a potential etiology of variceal bleeding in the acutely ill patient. Through a thorough consultation, the patient described here was able to avoid a procedure with the potential to cause catastrophic consequences, and instead receive the appropriate treatment for an uncommon condition.Level of EvidenceLevel 4, Case Report.

Endovascular treatment of iatrogenic superior mesenteric arteriovenous fistula resulting in recurrent abdominal ascites

Superior mesenteric arteriovenous fistulas (AVFs) are rare and are usually caused by previous bowel surgery or blunt abdominal trauma. Patients may be asymptomatic, have non-specific symptoms of abdominal pain, nausea and vomiting or present with symptoms of portal hypertension; some patients may present years after initial surgery or trauma. Traditionally, superior mesenteric AVFs are treated by surgical ligation. However, percutaneous endovascular treatment has become increasingly popular in recent years. Different options of endovascular treatment include coil embolisation, covered stent and vascular plugs. There is a risk of coil migration with coil embolisation and covered stents may cause abnormal vessel straightening. Vascular plugs allow the fistula to be treated with fewer devices and have minimal risk of migration. Newer devices such as microvascular plugs have the added advantage of being able to be delivered through microcatheters or diagnostic catheters. The smaller profile of the microvascular plug also allows it to navigate through tortuous vessels. We report a case of a 77-year-old patient presenting with recurrent abdominal ascites three years after small bowel resection. CT and angiogram demonstrated a superior mesenteric AVF, which was successfully treated with a combination of microvascular plug and coil. He remained relatively asymptomatic four months after treatment.

Endovascular Occlusion of Giant Posttraumatic Pseudo-Aneurysm of Superior Mesenteric Artery Connected to Mesenteric Arteriovenous Fistula.

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.

1253 Rare Case of Superior Mesenteric Arteriovenous Fistula as Complication of Recurrent Pancreatitis

INTRODUCTION: Superior mesenteric arteriovenous fistula (SMAVF) is a rare entity. Most common cause of SMAVF is post-traumatic, however they may be congenital, iatrogenic or secondary to connective tissue disorders. We report a case of SMAVF in setting of acute on chronic pancreatitis. CASE DESCRIPTION/METHODS: 62-year-old male with history of pancreas divisum, infrarenal abdominal aortic aneurysm, cholelithiasis and chronic calcific pancreatitis initially presented for elective Endoscopic Retrograde Cholangiopancreatography (ERCP) for obstructing pancreatic ductal stone with stent placement. After the procedure, patient had to be admitted and treated for acute post-ERCP pancreatitis. Patient underwent repeat ERCP in four weeks for stent replacement but had recurrence of pancreatitis after the second procedure. Computerized Tomography (CT) scan of the abdomen done at that time was consistent with pancreatic pseudocyst causing minimal mass effect on Superior Mesenteric Vein (SMV) without vascular thrombosis. Patient was discharged once stable but unfortunately returned to the hospital for a third time within two weeks complaining of nausea, vomiting, severe abdominal pain and diarrhea. CT Angiogram of the abdomen and pelvis was obtained this admission which showed changes consistent with colitis, increasing size of pancreatic pseudocysts with possible necrosis, new SMV thrombosis and SMAVF in region of middle colic artery. This was confirmed on mesenteric angiogram. Patient was started on anticoagulation to treat thrombosis and clinically improved after symptomatic management. The case was discussed at multidisciplinary conference and no acute intervention for SMAVF was recommended. Patient eventually underwent laparoscopic cholecystectomy few months later for cholelithiasis and SMAVF was noted to be stable on repeat CT scan at four-month interval. DISCUSSION: SMAVFs are extremely rare. As of 2005, only 40 cases of post-traumatic SMAVF and similar number of iatrogenic cases had been cited in literature. Clinical presentation can be asymptomatic or manifest as abdominal pain, anorexia, diarrhea, gastrointestinal bleed, portal hypertension and congestive heart failure. Splanchnic venous thrombosis, as seen in our patient, develops in 50 percent cases with necrotizing pancreatitis. Such thrombosis can further lead to development of SMAVF which was also noted in this case.

A rare case of simultaneous rectal and gastric carcinomas accompanied with inferior mesenteric arterioportal fistula: case report

BackgroundInferior mesenteric arterioportal fistula (APF) is rare as only 35 case reports in the literature. We herein presented a case of simultaneously double cancer in the rectum and stomach with inferior mesenteric APF, which is the first case report by searching using PubMed. Combination of interventional embolization and surgical operation seemed to be optimal treatment for avoiding postoperative complications and the curability.Case presentationA 66-year-old male with epigastric pain was admitted to a practitioner. He underwent a gastroscopy with biopsy, and cancer located in the lesser curvature of the gastric cardia was found. Enhanced CT did not reveal wall thickening of the stomach and distant metastases, but several swollen lymph nodes were observed in the right cardia. In the arterial phase, dilation of inferior mesenteric vein (IMV) and superior rectal artery (SRA) were noted, which raised suspicions of an arterioportal communication. Colonoscopy revealed a type 2 rectal tumor located 12 cm from the anal verge. The histological diagnosis of well-differentiated tubular adenocarcinoma was confirmed by biopsy. At a first step, we planned to perform a radiological embolization of inflow vessels to APFs except for SRA. Additionally, we determined the interval time of 1 month between the first low anterior rectal resection and the sequential gastrectomy for the purpose of decreasing portal pressure. The postoperative course was uneventful without hemorrhagic complications, and S-1 was taken internally 1 year as adjuvant chemotherapy for gastric cancer. The patient still lives without recurrence of this cancer with APF and portal vein thrombosis 2.5 years after the aforementioned surgeries.ConclusionInferior mesenteric APF and/or arteriovenous fistula (AVF) would be consisted of the several inflow arteries as superior rectal, internal iliac, and median sacral arteries, and outflow veins as inferior mesenteric, internal iliac, and median sacral veins. To determine the therapeutic strategy for left-sided colorectal cancers with abnormal vessel communications of the pelvis, it is significant to comprehend distribution and component vessels of APF and/or AVF.

A Case of Congestive Colitis Caused by Inferior Mesenteric Arteriovenous Fistula 15 Months after Transverse Colectomy

A Case of Congestive Colitis Caused by Inferior Mesenteric Arteriovenous Fistula 15 Months after Transverse Colectomy

Inferior mesenteric arteriovenous fistula with nonpulsatile abdominal mass

Rationale:Inferior mesenteric arteriovenous fistula (IMAVF) is a rare condition principally characterized by portal hypertension and ischemic bowel disease. Up to now, only 30 cases have been reported. Presented here is an IMAVF patient with nonpulsatile abdominal mass as the main manifestation.Patient concerns:A 62-year-old Chinese male who complained of abdominal discomfort for a month was admitted to our hospital. Physical examination revealed a hard and hardly mobile mass.Diagnoses:Space-occupying lesions were first suspected but endoscopy did not reveal any masses. The computed tomography angiography exhibited no definite boundary between the inferior mesenteric artery and vein. The patient was diagnosed with IMAVF.Interventions:The treatment of IMAVF mainly includes intra-arterial embolization and surgery. In our case, fistulas were complex and the patient had symptoms of colon ischemia, so we suggested a surgical resection instead of embolization. And the postoperative biopsy also confirmed the diagnosis.Outcomes:After surgery, gastrointestinal symptoms disappeared and the patient began to gain weight gradually. During the follow-up, colonoscopy showed that the anastomotic astium and colonic mucosa were normal.Lessons:Analysis of the case showed that computed tomography angiography is an important auxiliary examination for establishing the diagnosis of IMAVF and surgery is an effective treatment.

Diagnosis and treatment of portal hypertension caused by superior mesenteric arteriovenous fistula

Diagnosis and treatment of portal hypertension caused by superior mesenteric arteriovenous fistula

Superior Mesenteric Arteriovenous Fistula Presenting with Massive Lethal Upper Gastrointestinal Bleeding 14 Years after Small Bowel Resection.

Arteriovenous fistulas (AVFs) of the superior mesenteric vasculature are rarely encountered. We present a case of an iatrogenic superior mesenteric AVF in a patient who had undergone a small bowel resection 14 years previously. The 45-year-old male was admitted with bloody diarrhea, fatigue, weight loss and moderate ascites. On the fifth hospital day, while being evaluated for suspected liver cirrhosis, the patient developed severe gastrointestinal (GI) bleeding. An upper GI endoscopy revealed bleeding, esophago-gastric varices. A thorough clinical examination pointed to a paraumbilical murmur and thrill, while a contrast enhanced computerized tomography (CT) scan of the abdomen revealed the presence of cystic dilatation of the superior mesenteric vein (SMV), hepatomegaly and ascites. Duplex ultrasonography and 3D-computed tomography angiography (3D-CTA) confirmed the existence of AVF between the superior mesenteric artery (SMA) and SMV, which was the cause of portal hypertension and variceal bleeding. Despite the fact that AVF was ultimately recognized, uncontrollable hypovolemic shock caused by hematemesis, precluded the probable efficiency of further therapeutic attempts. Successful management of mesenteric blood vessel AVFs involves timely and the accurate diagnosis and early treatment in order to prevent the development of life threatening complications.

Iatrogenic Superior Mesenteric Arterio-Venous Fistula as an Unusual Cause of Refractory Ascites: A Case Report

Iatrogenic Superior Mesenteric Arterio-Venous Fistula as an Unusual Cause of Refractory Ascites: A Case Report

Idiopathic inferior mesenteric arteriovenous fistula: a rare cause of pulsatile abdominal mass.

Inferior mesenteric arteriovenous fistula (AVF) is an extremely rare vascular abnormality which may be idiopathic or secondary to previous trauma or surgery, and it may result in portal hypertension or ischemic colitis if left untreated. Imaging can help accurately diagnose visceral AVFs and create a vascular map to display the feeding artery and draining vein before the surgery; however, multidetector computed tomography (MDCT) angiography of inferior mesenteric AVF is not well documented in the literature. In this article, the authors report a case of inferior mesenteric AVF in a 48-year-old woman evaluated for left-sided abdominal pain and diagnosed preoperatively by MDCT angiography. Surgical excision of the AVF was successfully performed, and the postoperative course was uneventful.

Acute lower gastrointestinal bleeding originating from an arteriovenous fistula of superior rectal artery

Dear Editor: The most common acute causes of lower gastrointestinal (GI) hemorrhage are diverticulosis and angiodysplasia [1]. Arteriovenous fistula (AVF) of the intestine is an uncommon cause of GI hemorrhage [2]. AVF originating from the distal branch of superior rectal artery has never been described before and up to date as a cause of lower GI bleeding. Herein, we report a case of embolization of an AVF originated from the superior rectal artery end branch as a cause of acute lower GI bleeding. An 80-year-old man, with prior history of acute lower GI bleeding episode resolved with supportive treatment 6 months ago, was admitted to our hospital with bright red blood per rectum bleeding. Flexible colonoscopy revealed proximal fresh bleeding without any specific bleeding site. The patient was then referred for a computed tomography (CT) scan. The CT initially suspected an abnormal vessel on the left lateral side wall of the rectum. However, as the patient’s condition remained stable the hemoglobin value decreased despite transfusion, the patient was transferred to the interventional radiology suite for a mesenteric angiography with possible embolization. Angiography showed left superior rectal artery-originated AVF with the suspicion of bleeding. The superior rectal artery branch of AVF was superselectively catheterized with a 2.7 Fr Progreat microcatheter (Terumo, Tokyo, Japan) and embolized with microcoils. Complete hemostasis was achieved after embolization. Very rare cases of inferior mesenteric AVFs have been reported, and a few of them were responsible of acute GI bleeding in the literature [2]. Most of the cases of acute lower GI hemorrhage are controlled with supportive treatment. Persistent bleeding with hemodynamic instability requires further investigation and management [1, 3]. The major risk of embolization is bowel ischemia. As advancements in microcatheter technology have allowed embolization of distal arteries smaller than 1 mm in diameter, thus, the reported rate of colonic ischemia has reduced to approximately 3–4 % in recent studies [1]. Here, we have presented a very rare case of embolization of an intestinal AVF originated from the end branch of superior rectal artery. We suggest that superselective embolization may be a more safe treatment option in some types of acute lower GI bleeding.

遺伝性出血性末梢血管拡張症に合併した下腸間膜動静脈瘻に対して手術を施行した1例

遺伝性出血性末梢血管拡張症に合併した下腸間膜動静脈瘻に対して手術を施行した1例

Inferior mesenteric arteriovenous fistula treated by percutaneous arterial embolization: A breathtaking story!

Inferior mesenteric arteriovenous fistula treated by percutaneous arterial embolization: A breathtaking story!

Endovascular management of porto-mesenteric venous thrombosis developing after trans-arterial occlusion of a superior mesenteric arteriovenous fistula

Porto-mesenteric venous thrombosis following a trans-arterial occlusion of a superior mesenteric arteriovenous fistula is a rare occurrence. We present a case of endovascular management of one such case treated pharmacomechanically with catheter-directed mesenteric thrombolysis and transjugular intrahepatic portosystemic shunt creation without long-term successful outcome.

A Case of Traumatic Inferior Mesenteric Arteriovenous Fistula

Inferior mesenteric arteriovenous fistula is rare and may be congenital or acquired. Affected patients present with abdominal pain, mass, or manifestations of portal hypertension and bowel ischemia. Until now, inferior mesenteric arteriovenous fistula due to trauma has not been reported. Herein, we report a case of a 53-year-old woman who had inferior mesenteric arteriovenous fistula considered to have originated from remote blunt trauma that was successfully treated by surgical resection of only the arteriovenous fistula without colectomy. To our knowledge, this is the first case of traumatic inferior mesenteric arteriovenous fistula.