Arterioportal Fistulas: Introduction of a Novel Classification With Therapeutic Implications

Guzman, Eduardo A.; McCahill, Laurence E.; Rogers, Frederick B.

doi:10.1016/j.gassur.2005.06.022

Cited by 113 publications

(111 citation statements)

References 38 publications

(109 reference statements)

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“…Guzman and colleagues classified arterioportal fistulas into three subtypes, with type one representing small peripheral asymptomatic fistulas with minimal physiological insult, type two indicating larger fistulas that result in physiological effects and type three characterising congenital fistulas. 1 Using the classification system, the fistula described in this case report would be a type two fistula. The inflow artery in an arterioportal fistula is most commonly the hepatic artery (65%), followed by the splenic artery (11%) and the superior mesenteric artery (10%).…”

Section: Discussion Classificationmentioning

confidence: 99%

Endovascular treatment of an arterioportal fistula following pancreaticoduodenectomy

Taylor

Akinkuotu

Makary

2017

annals

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We present a rare case of an arterioportal fistula that formed between the superior mesenteric artery and portal vein 30 days following a pancreaticoduodenectomy, which was successfully managed with endovascular procedures. KEYWORDSArterioportal fistula -Whipple -Pancreaticoduodenectomy -Pseudoaneurysm -Arteriovenous fistula Case reportThe patient was a 77-year-old male with a past medical history significant for hypertension, hyperlipidaemia and gout, who underwent a pancreaticoduodenectomy for a 3.5cm pancreatic ductal adenocarcinoma. He had received neoadjuvant chemotherapy and stereotactic beam radiation therapy prior to the procedure. Intraoperatively, the tumour was found to be densely adherent to a small area of the portal vein and a 1-cm segment of the superior mesenteric artery (SMA). The SMA was skeletonised and the specimen was successfully removed with negative margins. The patient had an uneventful postoperative course and was discharged home six days later.The patient was readmitted approximately three weeks later with fevers, hypotension and tachycardia. Workup included computed tomography (CT) of the abdomen and pelvis, which demonstrated multiple abdominal fluid collections. He was started on broad spectrum intravenous antibiotic therapy and underwent image guided drain placement of the fluid collections.On hospital day eight, thirty days following the original procedure, the patient had bright red bleeding per rectum in addition to acute drop in haemoglobin and hypotension. CT angiogram was performed and revealed a fistulous connection between the SMA and portal vein, as well as a gastroduodenal artery (GDA) pseudoaneurysm (Fig 1). These findings were subsequently confirmed by arteriogram (Fig 2). The GDA pseudoaneurysm was embolised and the arterioportal fistula partially embolised, in addition to a bleeding jejunal branch of the SMA (Fig 3). The patient, however continued to require transfusions and had more episodes of melaena. He underwent repeat arteriogram and the pancreatic artery was found and coiled, as well as the inferior pancreatic artery arising from the middle colic artery. He subsequently underwent an SMA stent placement at the site of the fistula and was initially stable (Fig 4) but then developed an acute drop in his haemoglobin, which prompted another arteriogram. The arteriogram suggested further extravasation near the dorsal pancreatic artery, which it was not possible to access due to tortuosity. As such, the proximal-mid splenic artery was Ann R Coll Surg Engl 2017; 99: e94-e96

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Section: Discussion Classificationmentioning

confidence: 99%

Endovascular treatment of an arterioportal fistula following pancreaticoduodenectomy

Taylor

Akinkuotu

Makary

2017

annals

View full text Add to dashboard Cite

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“…Symptoms usually develop after 1 mo of age, and these children are often investigated for generalized abdominal findings and are later noted to develop symptoms related to portal hypertension [2,3] . APF often presents in conjunction with major gastrointestinal tract bleeding and should be differentiated between small peripheral intrahepatic APF (type 1) and large central APF (type 2), whereas diffuse congenital intrahepatic APF that is difficult to manage is defined as typed 3 [6] . A few cases of congenital fistula from the hepatic artery to the portal vein have been reported [4] , but this abnormality is not a common cause of portal hypertension.…”

Section: Discussionmentioning

confidence: 99%

A large congenital and solitary intrahepatic arterioportal fistula in an old woman

Lu¹,

Ao²,

Peng³

et al. 2009

WJG

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Arterioportal fistula (APF) is a rare cause of portal hypertension and may lead to death. APF can be congenital, post-traumatic, iatrogenic (transhepatic int e rve nt ion or biopsy) or related to ruptured hepatic artery aneurysms. Congenital APF is a rare condition even in children. In this case report, we describe a 73-year-old woman diagnosed as APF by ultrasonography, computed tomography, and hepatic artery selective arteriography. The fistula was embolized twice but failed, and she still suffered from alimentary tract hemorrhage. Then, selective arteriography of the hepatic artery was performed again and venae coronaria ventriculi and short gastric vein were embolized. During the 2-year follow-up, the patient remained asymptomatic. We therefore argue that embolization of venae coronaria ventriculi and short gastric vein may be an effective treatment modality for intrahepatic APF with severe upper gastrointestinal bleeding.

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“…Although the time scale of APS appearance can depend on the severity of injury or the shunt size, most traumatic arterio-portal fistulas spontaneously resolve within several months without complication [30] (Fig. 3b).…”

Section: Aps Caused By Extrinsic Factorsmentioning

confidence: 99%

Nontumorous arterioportal shunts in the liver: CT and MRI findings considering mechanisms and fate

Ahn

Hwang

et al. 2009

Eur Radiol

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The intrahepatic non-tumorous arterioportal shunt (APS) is one of the important causes of transient hepatic enhancement differences (THED) on dynamic CT or MRI. Most small APSs are located in the peripheral portion of the liver. Because of the parenchymal distortion in the advanced cirrhotic liver, many small APSs tend to show an amorphous or nodular appearance, making them difficult to distinguish from hypervascular tumors. In addition to the use of dynamic CT or MRI, iso-attenuation densities or iso-intensities on pre-contrast and equilibrium phases, MRI using a liver-specific contrast agent can be useful to characterize the hypervascular pseudolesions. Because there is no difference in water diffusion in the hepatic parenchyma in the region of the APS, diffusion-weighted MRI also has great potential to distinguish non-tumorous shunts from true focal lesions. Larger (>2 cm) APSs of direct arterio-portal venous fistulas from extrinsic insults show typical subcapsular wedge-like THEDs that are only temporarily depicted several months after the traumatic event; most of these THEDs gradually decrease in size or vanish completely. By understanding the nature of non-tumorous APSs, radiologists will be able to provide a more accurate assessment of many THEDs during daily interpretations of CT or MR images of the liver.

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Arterioportal Fistulas: Introduction of a Novel Classification With Therapeutic Implications

Cited by 113 publications

References 38 publications

Endovascular treatment of an arterioportal fistula following pancreaticoduodenectomy

Endovascular treatment of an arterioportal fistula following pancreaticoduodenectomy

A large congenital and solitary intrahepatic arterioportal fistula in an old woman

Nontumorous arterioportal shunts in the liver: CT and MRI findings considering mechanisms and fate

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