Symptomatic hepatic arterioportal fistula-related portal vein hypertension

This paper presents the case of a 73-year-old female, consented to the publication of case details and images, who presented with a two-month history of progressively worsening abdominal distension. During hospitalization, she complained of vomiting and pain in the left lower abdomen, and intermittent melena was detected. Abdominal enhanced CT and celiac angiography showed a symptomatic hepatic arterio-portal fistula (HAPF). The schematic diagram (left) showed the location of the HAPF, and the schematic diagram (right) showed the fistula has been embolized and she has undergone shunt surgery (A/Cover, B [redarrow]). Therefore, the cause of refractory ascites and gastrointestinal symptoms is due to portal hypertension, which is associated with HAPF. After puncturing the portal vein via the right internal jugular vein, a microcatheter (Maestro, Merit, U.S.) was inserted into the right branch of the portal vein. Detachable microcoils (Interlock, Boston Scientific, U.S.) were then deployed to perform partial portal vein embolization from the portal side of the fistula. Gastric coronary vein embolization was carried out in a similar manner. Finally, a covered stent (Viatorr, GORE, U.S.) was deployed to create the artificial portosystemic shunt. Thus, the patient underwent successful transjugular intrahepatic portosystemic stent-shunt (TIPSS) treatment (B). Postoperative angiography revealed a significant reduction in blood flow from the HAPF, with most of the reverse blood flow entering the right atrium through the stent. At the same time, the return of the mesenteric vein and splenic vein also showed improvement. Within three days following the surgery, her melena gradually resolved, the occult blood became negative, and urine volume significantly increased. By the fifth day post-operation, the symptoms of abdominal pain, nausea, and vomiting had relieved. She was discharged on the 13th day post-surgery. Subsequently, the patient underwent abdominal enhanced CT follow-ups every six months, which consistently demonstrated maintained stent patency (C). This case highlights the innovative use of partial portal vein embolization combined with TIPSS to block the HAPF (1Lee B.B. Baumgartner I. Berlien H.P. Bianchini G. Burrows P. Do Y.S. et al.Consensus Document of the International Union of Angiology (IUA)-2013. Current concept on the management of arterio-venous management.Int Angiol. 2013; 32: 9-36PubMed Google Scholar) and effectively reduce portal vein. To the best of our knowledge, this is the first report of this novel combined technique for treating symptomatic HAPF (2Ferraioli G. Mariani G. Brunetti E. Filice C. Large intra-hepatic arterio-portal fistula following liver trauma.Ultraschall Med. 2008; 29: 339Google Scholar).