Severe portal hypertension secondary to arterio-portal fistula: salvage surgical treatment.
BACKGROUND
Arterio-portal fistulas (APFs) are rare vascular disorders of various origins that can lead to severe portal hypertension. Even if surgery was initially the treatment of choice, more recently, interventional radiological procedures have been considered as the first line therapeutic option.


METHODS
A man with no history of liver disease was admitted for abdominal pain and distension. Abdominal ultrasonography with Doppler, magnetic resonance imaging and computed tomography (CT) scan showed ascites, splenomegaly and a probable APF between the left branches of both the hepatic artery and portal vein, associated with hepatofugal portal flow. Upper gastrointestinal endoscopy revealed large oesophageal varices without bleeding. A celiac and mesenteric arteriography and a splenic arteriography were performed and confirmed the existence of multiple intrahepatic APFs. The initial treatment consisted of two sessions of percutaneous transcatheter endovascular embolization. Unfortunately, ascites worsened, and the patient did not respond to diuretic treatment. Therefore, a surgical treatment was considered to be the only suitable treatment because of the absence of improvement after embolization procedures. A left hepatectomy with hepatic artery ligation was performed. Clinical evolution was favourable; an improvement of ascites was obtained; control ultrasonography and CT scan disclosed no residual haemodynamic abnormality; and the portal vein was normal with a hepatopedal flow. Currently, 12 months after surgery, the clinical condition of the patient is good.


CONCLUSIONS
Percutaneous treatment of portal hypertension by embolizing multiple large APF has been described to be an effective method. Nevertheless, failure of such conservative treatment is possible and must lead to a salvage surgery.
Dumortier
Jérôme
J
Fédération des Spécialités Digestives, Lyon, France. jerome.dumortier@chu-lyon.fr
Pilleul
Frank
F
Adham
Mustapha
M
Vochelle
Véronique
V
Hervieu
Valérie
V
Bouffard
Yves
Y
Valette
Pierre-Jean
PJ
Scoazec
Jean-Yves
JY
Boillot
Olivier
O
D001164:Arteriovenous Fistula / Q000150:complications / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D004621:Embolization, Therapeutic; D004932:Esophageal and Gastric Varices / Q000209:etiology / Q000601:surgery / Q000628:therapy; D006498:Hepatectomy; D006499:Hepatic Artery / Q000473:pathology / Q000601:surgery; D006801:Humans; D006975:Hypertension, Portal / Q000150:complications / Q000209:etiology* / Q000473:pathology / Q000601:surgery / Q000628:therapy; D008026:Ligation; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D011169:Portal Vein / Q000473:pathology; D016879:Salvage Therapy; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed; D017211:Treatment Failure; D014656:Vascular Surgical Procedures