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

Abstract

Background Superior 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 Presentation A 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. Conclusions This 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 Evidence Level 4, Case Report.

Endovascular embolization for upper gastrointestinal bleeding due to portal hypertension caused by a superior mesenteric arteriovenous fistula

“…The primary etiologies of SMAVF are associated with traumatic or iatrogenic injury, and congenital lesions. 1,2 Although many patients remain asymptomatic after unrecognized injury to the superior mesenteric artery (SMA) for many years, most previous studies reported delayed presentation of persistent epigastric pain, vomiting and nausea, ascites, mesenteric ischemia, or bleeding. The incidence of SMAVF is 0.09%, with a mortality rate of 39%-77%.…”

“…[5][6][7] Since the first case was reported by Nusselt in 1947, there have been several case reports of SMAVF, with no randomized controlled trials. [1][2][3][4][5][6][7] Surgical ligation of the fistula was once considered the most successful treatment for traumatic SMAVF. However, this approach is associated with risks, surgical trauma, and long hospital stays.…”