Cas clinique

DOI of or

Vascular S

CorrespondVascular Surzakibouzi@yah

Ann Vasc SurDOI: 10.1016/� Annals of V�Edit�e par ELS

Traitement endovasculaire r�eussi d’unefistule art�erio-porte postop�eratoire

Zakariyae Bouziane, Badr Ghissassi, Mohammed Bouayad, Yasser Sefiani, Brahim Lekehal,

Abbes El Mesnaoui, Younes Bensaid, Rabat, Maroc

Les fistules art�erio-portes sont rares et sont la plupart du temps une complication tardive de lachirurgie gastrique et biliaire. La cure chirurgicale en �etait le traitement de r�ef�erence. Le traite-ment endovasculaire �emerge comme vraie alternative �a la chirurgie. Ce travail pr�esente un casde fistule art�erio-porte post chirurgicale impliquant l’art�ere gastroduod�enale, cause d’unehypertension portale, trait�ee avec succ�es par embolisation trans-art�erielle utilisant desembosph�eres. L’hypertension portale am�elior�ee spectaculairement.

Extrahepatic arterioportal fistulas (APF) are rare

and can be caused by surgical procedures.

This study presents a rare case of APF including

gastroduodenal artery in a patient who sustained

three abdominal surgical interventions, emphasiz-

ing that endovascular intervention should be the

first treatment for that entity.

CASE REPORT

A 45-year-old man was referred to our institution for

management of minor hematemesis and intermittent epi-

gastric pain that were associated with watery diarrhea,

and weight loss.

The patient showed a history of laparoscopic cholecys-

tectomy performed in June 2004. He underwent laparo-

tomy for residual lithiasis 4 months later, in which a

Kehr’s tube was inserted in his main bile duct. In April

2006, the patient underwent iterative laparotomy for

peritonitis caused by perforated ulcer. All the post-

operative courses were uneventful.

On admission, the patient was normotensive, had a

normal pulse rate, and did not suffer from jaundice.

iginal article: 10.1016/j.avsg.2010.08.008.

urgery Department, Ibn Sina Hospital, Rabat, Maroc.

ence : Dr. Zakariyae Bouziane, Ibn Sina Hospital,gery Department, Souissi, Rabat, Maroc. E-mail:oo.fr

g 2011; 25: 385.e1-385.e3j.acvfr.2011.12.011ascular Surgery Inc.EVIER MASSON SAS

Abdominal examination demonstrated a supple abdomen

with hepatomegaly.

Auscultationof theabdomenrevealeda loudcontinuous

bruitwith systolic accentuation in the epigastrium,where a

distinct vascular pulsation was revealed by palpation.

Abnormal laboratory data on admission included the

following: hemoglobin 9.7 g/dL, albumin 3.4 g/dL, and

mild hypokalemia.

Serological markers of hepatitis A, B, C, and D were

negative and no antibodies were detected.

Endoscopy showedmultiple esophageal varicose veins.

The gastric mucosa was found to be congested and edema-

tous, findings consistent with mild portal gastritis.

During arterial phase, a computed tomography scan

showed a vascular structure with important contrast

enhancement just behind the cephalic part of the pan-

creas, and the portal treewas enhanced during the hepatic

arterial phase. This element raised the suspicion of anAPF.

Reconstructions analyzing the exact architecture of the

fistula disclosed a communication between the gastroduo-

denal artery and the portal vein (Fig. 1).

Selective angiography of the splanchnic vessels sho-

wed an indirect fistulous connection between the gastro-

duodenal artery and the portal vein through multiple

collaterals (Fig. 2).

A selective catheterization of the feeder artery was per-

formed using a transfemoral route. Then, several micro-

spheres embolic agents, such as Embosphere (Biosphere

medical, Rockland, MD), were mounted on Minitorquer

(Minvasys, France) and placed into the feeder collaterals.

The postprocedural arteriogram showed the complete

occlusion of the fistula and the cessation of the hyperkine-

tic portal flow (Fig. 3).

412.e1

Fig. 1. Scan reconstruction shows arterioportal fistula

arising from a dilated gastroduodenal artery.

Fig. 2. Selective angiography of the gastroduodenal

artery showing a concomitant opacification of the portal

vein (thick arrow), through many collaterals (thin arrows).

Fig. 3. Good result after embolization of the gas-

troduodenal collaterals. The fistula is excluded.

412.e2 Cas cliniques Annales de chirurgie vasculaire

The patient presented a mild pancreatitis the day

after the procedure, which resolved spontaneously,

and he was discharged 8 days later in stable clinical

condition.

DISCUSSION

APF are direct communications between the arterial

and portal circulations that may result in portal

hypertension.

The symptoms associated with APF include

lower or upper gastrointestinal bleeding, ascites,

heart failure, and diarrhea, or even hemobilia.1-3

According to Vauthey et al.,1 16% of APF result

from iatrogenic procedures. Their causes during

surgical procedures include direct injury to an artery

or a vein, mass or transfixion suture ligation of an

artery and a vein, and infection and necrosis of

vessel wall.

According to Yeo and Ernest,4 the gas-

troduodenal and right gastroepiploic arteries were

most commonly involved in 63% postgastrectomy

APF cases.

Vauthey found that the hepatic artery is most

commonly involved followed by the superior mes-

enteric and splenic arteries.

In the present case, tomodensitometric scan may

be used as the first-line diagnostic approach.1,3,5

However, angiography remains to be the optimal

study to provide an accurate preoperative evalua-

tion to define the exact location and extend of vessel

involvement.6,7

Although many patients with this type of fistula

remain asymptomatic, most patients in the pre-

viously published data have reported delayed clini-

cal presentations. This is because of the slow

development of the small traumatic vascular defect

to a wide shunting area with subsequent venous

enlargement.8

Typically 80% of cases are diagnosed within 2

years after the injury.9

A small number of APF may take months or even

years to manifest clinically.8,10,11 The patient in this

study presented with symptoms 3 years after his

latest surgery.

Thus, it is believed that a treatment of APF is

mandatory even in asymptomatic patients; all the

Vol. 25, No. 3, 2011 Cas cliniques 412.e3

more so because it will prevent the late repercussion

of portal hypertension.

Although surgical excision has been highly effec-

tive and safe, there is a clear tendency toward inter-

ventional technique as the therapy of choice for

APF. In fact, it is known in those multioperated

patients with iatrogenic APF that the laparotomy is

tedious and associated with the necessity of exten-

sive adhesiolysis and exposure of edematous and

inflamed mesentery, with subsequent blood loss

and lengthy anesthesia.

Embolization offers a less invasive alternative to

the standard surgical approach.

When a fistula develops in a large vessel, arterial

embolization is controversial because of the poten-

tial risk of arterial thrombosis; mesenteric infarction,

and migration of the metallic coils into the portal

venous system. This is especially true if the fistula

is >8 mm and there is high flow rate. Thus, covered

stent can be a suitable solution in those cases.12,13

Endovascular occlusion is less invasive, can be

performed under local anesthesia, and does not dis-

tort anatomy, thus facilitating future surgery.

In APF, arterial catheterization should be near to

the fistula site, beyond all gastric or pancreaticoduo-

denal side branches to prevent retrograde inflow. If

the fistula cannot be crossed for a retrograde occlu-

sion from the venous toward arterial portion, a

deployment of embolic agents at the arterial site is

often possible because the feeder artery presents

kinking with a narrowing at the fistula site.8

When the APF is not reachable through the arte-

rial route, it should be kept in mind that there is still

another access through a transhepatic portal vein

approach.14

The particularity of the present case is the angio-

graphic architecture of the APF, which is indirectly

fed by a multitude of gastroduodenal artery collate-

rals. Because the feeders were ‘‘end arteries,’’ it ena-

bles a safe and easy occlusion of the inflow site.

CONCLUSION

Embolization of gastroduodenal APF is technically

feasible, and can be considered as an efficient and

interesting alternative for surgical excision in multi-

operated patients.

REFERENCES

1. Vauthey JN, Tomczak RJ, Helmberger T, et coll. The arte-

rioportal fistula syndrome: clinicopathologic features,

diagnosis, and therapy. Gastroenterology 1997;113:

1390-1401.

2. Ishigami K, Yoshimitsu K, Honda H, et coll. Coil embo-

lization of arterioportal fistula that developed after partial

gastrectomy. Cardiovasc Intervent Radiol 1999;22:

328-330.

3. H€oiem L, Kvam G. Arterio-portal fistula diagnosed by

computerized tomography (CT). Eur J Radiol 1981;1:57-59.

4. Yeo CJ, Ernst CB. Arteriovenous fistulas after gastrectomy:

case report and review of the literature. Surgery 1986;99:

505-510.

5. Lawler LP, Fishman EK. Extrahepatic arterioportal venous

fistula: multidetector CT and volume-rendered angiographic

imaging. Abdom Imaging 2001;26:616-618.

6. Wu CG, Li YD, Li MH. Post-traumatic superior mesenteric

arteriovenous fistula: endovascular treatment with a cove-

red stent. J Vasc Surg 2008;47:654-656.

7. Radoni�c V, Bari�c D, Petricevi�c A, Kopli�c S, Giunio L,

Radoni�c S. Advances in diagnostics and successful repair of

proximal posttraumatic superior mesenteric arteriovenous

fistula. J Trauma 1995;38:305-312.

8. Botelberge T, Van Vlierberghe H, Voet D, Defreyne L.

Detachable balloon embolization of an arterioportal fistula

following liver biopsy in a liver transplant recipient: a case

report and review of literature. Cardiovasc Intervent Radiol

2005;28:832-835.

9. Tanaka H, Iwai A, Sugimoto H, Yoshioka T, Sugimoto T.

Intrahepatic arterioportal fistula after blunt hepatic trauma:

case reports. J Trauma 1991;31:143-146.

10. Van Way CW, Crane JM, Riddell DH, Foster JH. Arterio-

venous fistula in the portal circulation. Surgery 1971;70:

876-890.

11. Chiriano J, Abou-Zamzam AM Jr, Teruya TH, Ballard JL.

Delayed development of a traumatic superior mesenteric

arteriovenous fistula following multiple gunshot wounds to

the abdomen. Ann Vasc Surg 2005;19:470-473.

12. Isik FF, Greenfield AJ, Guben J, Birkett D, Menzoian JO.

Iatrogenic arterioportal fistulae: diagnosis and management.

Ann Vasc Surg 1989;3:52-55.

13. Deitrick J, McNeill P, Posner MP, Kellum J, Cho S,

Tisnado J, Lee HM. Traumatic superior mesenteric arteryeportal vein fistula. Ann Vasc Surg 1990;4:72-76.

14. Cekirge S, Ozmen M, Akata D, Akhan O, Balkanci F,

Besim A. Endovascular treatment of a superior mesenteric

arteriovenous fistula by a transhepatic portal venous

approach. Am J Roentgenol 1998;171:1283-1284.