Endoluminal Management of Arterioportal Fistulae in Liver Transplant Recipients: A Single-Center Experience

Abstract

Transcatheter embolization of arterioportal fistulae in liver transplant recipients is restricted to symptomatic arterioportal fistulae. Angiograms of liver transplant recipients from a single university medical center were retrospectively reviewed. Hemodynamically significant arterioportal fistulae were defined as those exhibiting opacification of the main portal vein of the transplanted hepatic graft or its first order branch with or without portal venous changes by Doppler ultrasound imaging. Six arterioportal fistulae were found. Doppler ultrasound imaging detected 50% of all arterioportal fistulae and all 3 hemodynamically significant arterioportal fistulae. Three successful embolizations were performed. Follow-up (37 to 67 months) demonstrated patent hepatic arteries and no parenchymal ischemic changes with graft preservation. High-throughput arterioportal fistulae may require larger intrahepatic artery branch embolization. There is a window of opportunity for embolizing significant arterioportal fistulae before their progression to large symptomatic, high through-put arterioportal fistulae with their added risk of ischemic changes before and after embolization.

Portal Vein Thrombosis and Arterioportal Fistula in Post Liver Transplant Recipient: A Case Report

“…Haemodynamically significant arterioportal fistula were defined as those exhibiting opacification of the main portal vein of the transplanted hepatic graft or its first order branch with or without portal venous changes by Doppler ultrasound imaging. Only 0.2% cases of Haemodynamically significant APFs are reported in post liver transplant patients [1]. Incidence of APFs remain same in living related or deceased donor liver transplantation.…”

“…Arterialisation of flow portal vein may be seen in some cases. In one study of APF in liver transplant recipient, Doppler was able to detect only 50% of APFs; however, it detected all haemodynamically significant APF [1]. CT or MR imaging findings include early and prolonged enhancement of the peripheral portal vein, before the main portal vein is enhanced or enhancement of main portal vein before the superior mesenteric and splenic veins are enhanced.…”

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

“…The majority of APF are asymptomatic (1–3, 6, 7). APF in transplanted and non‐transplanted livers have been known to cause a variety of symptoms and clinical findings such as portal hypertension, hemobilia, biliary obstruction, sepsis, pain, and even pulmonary hypertension (1, 6–15, 21).…”

“…Arterio‐portal fistulae (APF) have been long associated with percutaneous transhepatic procedures such as biopsies and percutaneous transhepatic cholangiography (1–10). An APF is a type of arterial injury classified as follows: one APF, two active arterial bleeding, three arterio‐hepatic venous fistulae, four pseudoaneurysms, and five non‐specific injuries such as arterial irregularities/contusions (1–5).…”

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“…Doppler ultrasonography is particularly useful because it has high sensitivity and specificity for hemodynamically significant hepatic artery to portal vein fistulas. [17][18][19] Treatment of this rare condition is mainly endovascular, with surgery reserved for complex cases. 17,20,21 Embolization is also challenging as the actual fistulous communication is very short and liver allografts are relatively hypoperfused and hence susceptible to ischemia.…”