Gastrointest Radiol 17:324-326 (1992)
Gastrointestinal
Radiology 9 Springer-VerlagNew York Inc. 1992
Successful Arterial Embolization of Arteriovenous Fistula in the Portal Circulation Tetsuo Nakamura, Yoshinori Isobe, Eiko Ueno, Yumi Kondoh, Izumi Yoshida, and Hiroshi Obata Institute of Gastroenterology, Tokyo Women's Medical College, Tokyo, Japan
Abstract. We successfully performed arterial embolization of an arteriovenous fistula between the left gastric artery and vein. The increased blood flow in the portal vein via the left gastric vein and the arteriovenous fistula induced severe portal hypertension. After obliteration of the left gastric artery, the arteriovenous fistula was not opacified on angiography and the portal hypertension improved. Key words: Portal hypertension, arteriovenous fistula-Arterial embolization.
Several forms of arteriovenous fistula have been reported previously. Most of these cases have been treated surgically and reports of treatments using interventional radiology are very rare [1-6]. Especially in cases of arteriovenous fistula feeding into the portal circulation, successful radiological arterial embolization has not been reported [3, 4]. We have experienced a case of portal hypertension caused by an arteriovenous fistula in the portal circulation and successfully treated the portal hypertension by closure of the arteriovenous fistula with steel coils.
Case Report A 46-year-old man was admitted to our institute on December 15, 1990, complaining of generalized abdominal pain, abdominal distention, weight loss, and diarrhea lasting for about 1 year. He had a past history of partial gastrectomy with Billroth I reconstruction for duodenal ulcer in 1964, and had also received a blood transfusion. In 1989, he had undergone hemorrhoidectomy for internal hemorrhoids. On abdominal examination, the abdomen was
Address offprint requests to: Tetsuo Nakamura, M.D., Institute of Gastroenterology, Tokyo Women's Medical College, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, Japan
slightly distended with no evidence of ascites or dilated veins in the abdominal wall. The liver and spleen were palpable. No bruit was heard. Laboratory tests showed a slight elevation of the transaminases and mild thrombocytopenia. Liver biopsy revealed no evidence of fibrosis. An upper gastrointestinal series showed esophageal telangiectasia, whereas abdominal computed tomographic (CT) scan showed mild hepatosplenomegaly, a small amount of ascites, and dilatation of the portal venous system. Celiac arteriography then demonstrated an arteriovenous fistula between the elongated left gastric artery and the enlarged left gastric vein, and early filling of an enlarged portal vein was also noted (Fig. 1A). Selective superior mesenteric arteriography showed no opacification of the portal vein, suggesting that there was marked delay of the venous return from the small intestine (Fig. 1B). The wedged hepatic venous pressure (WHVP) was 220 mmHzO. The left gastric artery was selectively embolized with four steel coils (5 mm in diameter). Angiography performed after embolization demonstrated no filling of the fistula (Fig. 2A), and transarterial portography showed normal filling of the portal vein, suggesting the improvement of intestinal congestion (Fig. 2B). By the second day after the procedure, the WHVP had fallen to 88 mmHzO. After a few days, his ascites resolved and all his symptoms including the abdominal pain and diarrhea showed improvement. During the l-year follow-up, the patient remains well and has gained 3 kg in weight. CT scanning has not detected any evidence of recanalization of the arteriovenous fistula.
Discussion A variety of iatrogenic arteriovenous fistulas formed after surgical procedures has been reported [1-4]. Since our patient had a partial gastrectomy 26 years ago, it may be suggested that the arteriovenous fistula was iatrogenic. He had received a blood transfusion during the previous operation, and his serum anti-HCV was positive. However, liver function tests were almost normal and liver biopsy did not show fibrosis, so his portal hypertension was thought to be caused by increased blood flow through the portal vein from the arteriovenous fistula. Several cases of portal hypertension due to an iatrogenic arteriovenous fistula have been reported.
T. Nakamura et al.: Arterial Embolization of AV Fistula
Fig. 1. A Arterial phase of celiac arteriography. Dilatated portal vein {arrowheadl and left gastric vein larrow) are opacified through a fistula formed between left gastric artery and vein. B Venous phase of superior mesenteric arteriogram. Disturbed return of intestinal efferent flow and intestinal congestion are seen. Portal vein is not opacified.
Fig. 2. A Arterial phase of celiac arteriography after embolization. The fistula between the left gastric artery and vein is completely occluded and no further filling of the portal vein through a fistula is demonstrated. B Venous phase of superior mesenteric arterio-
325
gram after embolization. Normal filling of portal vein and improvement of intestinal congestion are seen.
Direct surgical closure of the fistula is generally thought to be the best form of treatment, although arterial embolization has been done in some cases of arteriovenous fistula without portal hypertension [5, 6]. We successfully eliminated the arteriovenous fis-
326
tula in this patient with portal hypertension by embolization with steel coils.
References 1. Rossi P, Carillo FJ, Alfidi RJ, Ruzicka FF. Iatrogenic arteriovenous fistulas. Radiology 1974;111:47-52 2. Yeo CJ, Ernst CB. Arteriovenous fistulas after gastrectomy: case report and review of the literature. Surgery 1986;99:505509 3. Imamura M, Matsumoto T, Minematsu S, Takahashi K, Tobe
T. Nakamura et al.: Arterial Embolization of AV Fistula T. Portal arteriovenous fistula following partial gastrectomy.
Jpn J Surg 1985;15:483-487 4. van Way CW, Crane JM, Riddell DH, Foster JH, Arteriovenous fistula in the portal circulation. Surgery 1971 ;70:876-890 5. Keller FS, Rosch J, Banner RL, Dotter CT. Iatrogenic internal mammary artery-to-innominate vein fistula. Chest 1982 ;81:255-257 6. Nakamura T, Nakashima Y, Yu K, et al. Iatrogenic arteriovenous fistula of the internal mammary artery. Arch Intern Med 1985;145:140-141
Received." February 12, 1992; accepted: March 17, 1992
Gastrointestinal
Radiology 9 Springer-VerlagNew York Inc. 1992
Successful Arterial Embolization of Arteriovenous Fistula in the Portal Circulation Tetsuo Nakamura, Yoshinori Isobe, Eiko Ueno, Yumi Kondoh, Izumi Yoshida, and Hiroshi Obata Institute of Gastroenterology, Tokyo Women's Medical College, Tokyo, Japan
Abstract. We successfully performed arterial embolization of an arteriovenous fistula between the left gastric artery and vein. The increased blood flow in the portal vein via the left gastric vein and the arteriovenous fistula induced severe portal hypertension. After obliteration of the left gastric artery, the arteriovenous fistula was not opacified on angiography and the portal hypertension improved. Key words: Portal hypertension, arteriovenous fistula-Arterial embolization.
Several forms of arteriovenous fistula have been reported previously. Most of these cases have been treated surgically and reports of treatments using interventional radiology are very rare [1-6]. Especially in cases of arteriovenous fistula feeding into the portal circulation, successful radiological arterial embolization has not been reported [3, 4]. We have experienced a case of portal hypertension caused by an arteriovenous fistula in the portal circulation and successfully treated the portal hypertension by closure of the arteriovenous fistula with steel coils.
Case Report A 46-year-old man was admitted to our institute on December 15, 1990, complaining of generalized abdominal pain, abdominal distention, weight loss, and diarrhea lasting for about 1 year. He had a past history of partial gastrectomy with Billroth I reconstruction for duodenal ulcer in 1964, and had also received a blood transfusion. In 1989, he had undergone hemorrhoidectomy for internal hemorrhoids. On abdominal examination, the abdomen was
Address offprint requests to: Tetsuo Nakamura, M.D., Institute of Gastroenterology, Tokyo Women's Medical College, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, Japan
slightly distended with no evidence of ascites or dilated veins in the abdominal wall. The liver and spleen were palpable. No bruit was heard. Laboratory tests showed a slight elevation of the transaminases and mild thrombocytopenia. Liver biopsy revealed no evidence of fibrosis. An upper gastrointestinal series showed esophageal telangiectasia, whereas abdominal computed tomographic (CT) scan showed mild hepatosplenomegaly, a small amount of ascites, and dilatation of the portal venous system. Celiac arteriography then demonstrated an arteriovenous fistula between the elongated left gastric artery and the enlarged left gastric vein, and early filling of an enlarged portal vein was also noted (Fig. 1A). Selective superior mesenteric arteriography showed no opacification of the portal vein, suggesting that there was marked delay of the venous return from the small intestine (Fig. 1B). The wedged hepatic venous pressure (WHVP) was 220 mmHzO. The left gastric artery was selectively embolized with four steel coils (5 mm in diameter). Angiography performed after embolization demonstrated no filling of the fistula (Fig. 2A), and transarterial portography showed normal filling of the portal vein, suggesting the improvement of intestinal congestion (Fig. 2B). By the second day after the procedure, the WHVP had fallen to 88 mmHzO. After a few days, his ascites resolved and all his symptoms including the abdominal pain and diarrhea showed improvement. During the l-year follow-up, the patient remains well and has gained 3 kg in weight. CT scanning has not detected any evidence of recanalization of the arteriovenous fistula.
Discussion A variety of iatrogenic arteriovenous fistulas formed after surgical procedures has been reported [1-4]. Since our patient had a partial gastrectomy 26 years ago, it may be suggested that the arteriovenous fistula was iatrogenic. He had received a blood transfusion during the previous operation, and his serum anti-HCV was positive. However, liver function tests were almost normal and liver biopsy did not show fibrosis, so his portal hypertension was thought to be caused by increased blood flow through the portal vein from the arteriovenous fistula. Several cases of portal hypertension due to an iatrogenic arteriovenous fistula have been reported.
T. Nakamura et al.: Arterial Embolization of AV Fistula
Fig. 1. A Arterial phase of celiac arteriography. Dilatated portal vein {arrowheadl and left gastric vein larrow) are opacified through a fistula formed between left gastric artery and vein. B Venous phase of superior mesenteric arteriogram. Disturbed return of intestinal efferent flow and intestinal congestion are seen. Portal vein is not opacified.
Fig. 2. A Arterial phase of celiac arteriography after embolization. The fistula between the left gastric artery and vein is completely occluded and no further filling of the portal vein through a fistula is demonstrated. B Venous phase of superior mesenteric arterio-
325
gram after embolization. Normal filling of portal vein and improvement of intestinal congestion are seen.
Direct surgical closure of the fistula is generally thought to be the best form of treatment, although arterial embolization has been done in some cases of arteriovenous fistula without portal hypertension [5, 6]. We successfully eliminated the arteriovenous fis-
326
tula in this patient with portal hypertension by embolization with steel coils.
References 1. Rossi P, Carillo FJ, Alfidi RJ, Ruzicka FF. Iatrogenic arteriovenous fistulas. Radiology 1974;111:47-52 2. Yeo CJ, Ernst CB. Arteriovenous fistulas after gastrectomy: case report and review of the literature. Surgery 1986;99:505509 3. Imamura M, Matsumoto T, Minematsu S, Takahashi K, Tobe
T. Nakamura et al.: Arterial Embolization of AV Fistula T. Portal arteriovenous fistula following partial gastrectomy.
Jpn J Surg 1985;15:483-487 4. van Way CW, Crane JM, Riddell DH, Foster JH, Arteriovenous fistula in the portal circulation. Surgery 1971 ;70:876-890 5. Keller FS, Rosch J, Banner RL, Dotter CT. Iatrogenic internal mammary artery-to-innominate vein fistula. Chest 1982 ;81:255-257 6. Nakamura T, Nakashima Y, Yu K, et al. Iatrogenic arteriovenous fistula of the internal mammary artery. Arch Intern Med 1985;145:140-141
Received." February 12, 1992; accepted: March 17, 1992
