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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.
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