Arterioportal shunting is observed angiographically in a wide variety of pathologic conditions. The route of flow has classically been considered to be via the hepatic sinusoids (transsinusoidal). This route occurs in cases of cirrhosis or the Budd-Chiari syndrome, and results in retrograde hepatofugal flow in portal branches. More recently, a transvasal route has been recognized angiographically, in which portal flow often remains hepatopetal. The transvasal route occurs in cases of hepatocellular carcinoma, metastases, shock, hepatic arterial obstruction, and many other conditions. Histologic confirmation of this route has been sought for many years, with other partial success. Nevertheless, angiographic evidence, as presented here, is sufficiently compelling to justify description of this pathway and its significance. Arterioportal flow may also occur via a post-traumatic fistula (disruption of adjacent portions of hepatic artery and portal vein), and via benign tumor vessels in hemangioma or hemangioendothelioma.
Transluminal angioplasty of the abdominal aorta was performed in 6 women between 49 and 69 years of age with histories of cigarette smoking. Five had a relatively small aorta. This procedure is effective in treating focal aortic stenoses.
Streptokinase was selectively infused into nine thrombosed hemodialysis access fistulas in eight patients. Lysis occurred in all but one case. Of the eight infusions producing lysis, seven resulted in some clinical benefit. Three grafts functioned adequately for 2 to 6 months after streptokinase infusion alone. A fourth patient had good function for over 11 months after streptokinase treatment and transluminal angioplasty. In a fifth patient, graft function was partially restored, but a persistent arterial defect led to elective graft replacement. Moderate fibrinolysis in the sixth case was of no clinical benefit; rethrombosis developed promptly after SK was discontinued because of bleeding from a recent puncture site. In cases 7 and 8, fibrinolysis restored arterial inflow to the graft, but surgery was needed to revise partially obstructed venous outflow. It is concluded that selective streptokinase infusion, with or without transluminal angioplasty and operation, is often effective in the treatment of acutely thrombosed vascular access fistulas.
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