Endovascular treatment of hepatic arterioportal fistula complicated with giant portal vein aneurysm via percutaneous transhepatic US guided hepatic artery access: a case report and review of the literature

Abstract

Background Hepatic arterioportal fistulas are rare, abnormal, direct communications between hepatic artery and portal venous system. Treatment options shifted from surgery to endovascular interventions. Catheterization may be challenging. We report a case of a hepatic arterioportal fistula treated successfuly with Amplatzer Vascular Plug II via percutaneous transhepatic hepatic artery access after failed transfemoral approach. Case presentation 58 year old woman presented with right heart failure, kidney insufficiency and massive ascites related to portal hypertension caused by hepatic arterioportal fistula. She had a history of previous abdominal surgery. Colour Doppler ultrasound and computed tomography revealed a giant portal vein aneurysm related to large hepatic areterioportal fistula. Endovascular treatment was planned. Catheterization of the hepatic artery could not be realized due to severe tortuosity and angulation of the celiac artery and its branches. Access to the hepatic artery was obtained directly via percutaneous transhepatic route and fistula site was embolized with Amplatzer Vascular Plug II and coils. Immediate thrombosis of the aneurysm sac and draining portal vein was observed. Patients clinical status improved dramatically. Conclusion Transcatheter embolization is the first choice of the treatment of hepatic arterioportal fistulas but the type of the therapy should be tailored to the patient and interventional radiologist should decide the access site depending on his own experience if the routine endovascular access can not be obtained.

Endovascular Management of a Congenital Hepatic Arterioportal Malformation in a Low Resource Setting.

“…The choice of embolization agent depends on the type of arterioportal malformation, size and number of the feeding arteries, location of the stula which further determines the accessibility (10). One of the main factors especially in developing countries, is availability as in our case where we used the metallic coils which is the most commonly used agent.…”

“…Previously, hepatic artery ligation was considered the sole intervention, but now interventional radiology has the advantage of offering minimally invasive technique which further translates to reduced mortality and morbidity with shorter in patient stay and fewer complications. The downside of the interventionalguided embolization is that it can be limited by variant anatomy, tortuosity of vessels and elongation of the vessels die to a high dynamic ow (10). The access can be transfemoral and in cases where this fails, a transhepatic approach can be attempted.…”

“…The access can be transfemoral and in cases where this fails, a transhepatic approach can be attempted. The latter is often fraught with more complications including peritoneal hemorrhage, stulization, pneumothorax (10).…”

“…Other options include Amplatzer plug, N-butyl cyanoacrylate, polyvinyl alcohol (PVA) or microsphere (11). The Amplatzer plug is also popular as it can be used solely for occlusion of large vessels (10). PVA particles in general are not the preferred embolic agent as there is a large risk of non-target embolization into the venous system in high ow malformations.…”

“…One of the complications to consider include migration of the embolization agent past the site of the arterioportal malformation and into a distal tributary of the portal vein which may cause portal venous thrombosis and subsequent infarction. The risk for migration of embolization increases with increasing size of the arterioportal malformation and high ow rates (10).…”