Endovascular treatment of portal hypertension and recurrent digestive hemorrhage secondary to arterioportal fistula syndrome: late complication of penetrating abdominal trauma

The arterioportal fistula (APF) syndrome is a rare and reversible cause of pre-sinusoidal portal hypertension, caused by communication between a visceral artery and the portal venous system. Most patients are asymptomatic, but when they do develop symptoms, these are mainly related to gastrointestinal bleeding, ascites, congestive heart failure, and diarrhea. This therapeutic challenge presents a case of APF caused by a 20-year-old stabbing injury with unfavorable late clinical evolution, including significant malnutrition and severe digestive hemorrhages. The patient was treated using an endovascular procedure to occlude of the fistula.

Keywords:
vascular fistula; arteriovenous fistula; portal hypertension; penetrating wounds; endovascular procedures

Authorship

Matheus Bertanha

Universidade Estadual Paulista “Júlio de Mesquita Filho” – UNESP, Cirurgia e Ortopedia, Botucatu, SP, Brasil.Universidade Estadual Paulista “Júlio de Mesquita Filho”BrasilBotucatu, SP, BrasilUniversidade Estadual Paulista “Júlio de Mesquita Filho” – UNESP, Cirurgia e Ortopedia, Botucatu, SP, Brasil.

http://orcid.org/0000-0002-6851-2841

Regina Moura

Rodrigo Gibin Jaldin

http://orcid.org/0000-0003-0455-9162

Marcone Lima Sobreira

http://orcid.org/0000-0003-2271-5878

Arthur Curtarelli

Universidade Positivo, Faculdade de Medicina, Curitiba, PR, Brasil.Universidade PositivoBrasilCuritiba, PR, BrasilUniversidade Positivo, Faculdade de Medicina, Curitiba, PR, Brasil.

http://orcid.org/0000-0002-9729-0635

Felipe Damacena Rosa

Marcelo Sembenelli

Winston Bonetti Yoshida

Conflicts of interest: No conflicts of interest declared concerning the publication of this article.

Correspondence Matheus Bertanha Universidade Estadual Paulista “Júlio de Mesquita Filho” – UNESP, Faculdade de Medicina de Botucatu, Departamento de Cirurgia e Ortopedia Av. Prof. Mário Rubens Guimarães Montenegro, s/n – Unesp Campus de Botucatu CEP 18618-687 - Botucatu (SP), Brasil Tel.: +55 (14) 3880-1001 E-mail: matheus.fameca@ig.com.br

Author information MB - Assistant professor PhD in Cirurgia Vascular e Endovascular, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista “Júlio de Mesquita Filho” (UNESP). RM and MLS - Adjunct professors of Cirurgia Vascular e Endovascular, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista “Júlio de Mesquita Filho” (UNESP). RGJ - Board certified in Cirurgia Vascular, Angiorradiologia and Cirurgia Endovascular e Ecografia Vascular com Doppler; Vascular and endovascular surgeon, Hospital das Clínicas de Botucatu, Universidade Estadual Paulista “Júlio de Mesquita Filho” (UNESP). AC, FDR and MS - board certified in Cirurgia Vascular e Endovascular, Universidade Estadual Paulista “Júlio de Mesquita Filho” (UNESP). WBY - Full professor of Cirurgia Vascular e Endovascular, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista “Júlio de Mesquita Filho” (UNESP).

Author contributions Conception and design: MB, RM, AC, WBY Analysis and interpretation: MB, RM, RGJ, MLS, AC, FDR, MS, WBY Data collection: MB, AC, FDR, MS Writing the article: MB, RM, RGJ, MLS, AC, FDR, MS, WBY Critical revision of the article: MB, RM, RGJ, MLS, WBY Final approval of the article*: MB, RM, RGJ, MLS, AC, FDR, MS, WBY Statistical analysis: N/A. Overall responsibility: MB *All authors have read and approved of the final version of the article submitted to J Vasc Bras.

SCIMAGO INSTITUTIONS RANKINGS

Universidade Positivo, Faculdade de Medicina, Curitiba, PR, Brasil.Universidade PositivoBrasilCuritiba, PR, BrasilUniversidade Positivo, Faculdade de Medicina, Curitiba, PR, Brasil.

Figures

Figures (4)

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Figure 1
Preoperative angiotomography, venous phase. (A) posteroanterior volumetric rendering, showing the renal artery (arrow) and premature perfusion of the splenic (asterisk), superior mesenteric, and portal veins; (B) the same image with left anterior oblique inclination.

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Figure 2
Preoperative aortography showing premature filling of the splenic vein (arrow).

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Figure 3
Intraoperative fluoroscopic images. (A) selective arteriography of the left renal artery (arrow) and the fistula with the splenic vein; (B) positioning the vascular plug in the proximal renal artery (arrow); (C) selective arteriography of the renal artery with the vascular plug in place to check its position (arrow); (D) immediate postoperative aortography showing the treatment result, where it is possible to see the plug marked where it has been placed in the renal artery (arrow), free release coils in the splenic artery (asterisk) and the stents placed in a previous intervention for transjugular intrahepatic portosystemic shunt (arrowhead).

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Figure 4
Postoperative follow-up duplex ultrasound (6 months). (A) diameter of the splenic vein is 1.47 cm; (B) diameter of the portal vein is 1.77 cm × 1.80 cm; (C) monophasic venous flow with no signs of fistulization in the splenic vein; (D) monophasic venous flow in the portal vein; (E) normal arterial flow in the splenic artery; (F) normal arterial flow in the hepatic artery.

Figure 1 Preoperative angiotomography, venous phase. (A) posteroanterior volumetric rendering, showing the renal artery (arrow) and premature perfusion of the splenic (asterisk), superior mesenteric, and portal veins; (B) the same image with left anterior oblique inclination.

Figure 2 Preoperative aortography showing premature filling of the splenic vein (arrow).

Figure 3 Intraoperative fluoroscopic images. (A) selective arteriography of the left renal artery (arrow) and the fistula with the splenic vein; (B) positioning the vascular plug in the proximal renal artery (arrow); (C) selective arteriography of the renal artery with the vascular plug in place to check its position (arrow); (D) immediate postoperative aortography showing the treatment result, where it is possible to see the plug marked where it has been placed in the renal artery (arrow), free release coils in the splenic artery (asterisk) and the stents placed in a previous intervention for transjugular intrahepatic portosystemic shunt (arrowhead).

Figure 4 Postoperative follow-up duplex ultrasound (6 months). (A) diameter of the splenic vein is 1.47 cm; (B) diameter of the portal vein is 1.77 cm × 1.80 cm; (C) monophasic venous flow with no signs of fistulization in the splenic vein; (D) monophasic venous flow in the portal vein; (E) normal arterial flow in the splenic artery; (F) normal arterial flow in the hepatic artery.

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Endovascular treatment of portal hypertension and recurrent digestive hemorrhage secondary to arterioportal fistula syndrome: late complication of penetrating abdominal trauma

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[1] Conflicts of interest: No conflicts of interest declared concerning the publication of this article.