Ann Hepatobiliary Pancreat Surg.  2019 May;23(2):187-191. 10.14701/ahbps.2019.23.2.187.

Endovascular treatment of psuedoaneurysm arising from common hepatic artery bifurcation with complete disruption of gastroduodenal artery and high flow arterioportal fistula

• Anand RR
• Cherian P
• Mehta P
• Gandhi JM
• S E
• Patil SB

• KMID: 2448775
• DOI: http://doi.org/10.14701/ahbps.2019.23.2.187

Abstract

Arterio-portal fistulas (APFs) are characterized by anomalous communication between arteries and the portal vein (PV) system. Treatment of APF is imperative as an emergency or if there is development of portal hypertension/heart failure in chronic cases. Both endovascular and surgical managements can be attempted, however since endovascular management carries comparatively low intra and post procedural morbidity it is mostly preferred. This is a case report on endovascular management of post-traumatic pseudoaneurysm arising from bifurcation of common hepatic artery with complete disruption of the gastroduodenal artery and high-flow APF. This report describes the intraprocedure challenges in exclusion of fistula from the circulation, without disruption of portal system and anticipation of recruitment of new collateral feeders to the fistula immediate post exclusion with its embolization, which needs appropriate positioning of the catheter prior to exclusion of the fistula.

Keyword

Psuedoaneurysm; Arterioportal fistula; Endovascular

MeSH Terms

Aneurysm, False
Arteries*
Catheters
Emergencies
Fistula*
Hepatic Artery*
Portal System
Portal Vein

Figure

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  Fig. 1 Computed tomography (CT) images: Axial (A) and coronal (B) section in arterial phase of contrast CT scan showing pseudoaneurysm (white arrow) anterior to the proximal main portal vein with early filling of the entire portal system.

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  Fig. 2 Celiac angiogram demonstrating pseudoaneurysm (big arrow) at the common hepatic artery bifurcation and filling of portal vein (small arrow).

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  Fig. 3 Superior mesenteric artery angiogram showing filling of pseudoaneurysm (big arrow) through inferior pancreaticoduodenal collateral. Filling of main portal vein (small arrow) can also be seen.

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  Fig. 4 Post stent graft deployment in gastro duodenal artery (stent–white arrow). Angiogram from common hepatic artery revealing residual filling of pseudoaneurysm.

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  Fig. 5 Post stent graft deployment in common hepatic artery (stent graft in common hepatic artery–white arrow). Celiac angiogram shows no residual filling of the pseudoaneurysm from celiac branches.

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  Fig. 6 SMA angiogram: (A) Post stent deployment superior mesenteric artery (SMA) injection revealing residual filling (white arrow) of the pseudoaneurysm through collateral from pancretico duodenal arcade; (B) Post coiling status of gastroduodenal artery with angiogram from SMA showing no residual filling of pseudoaneurysm.

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  Fig. 7 Computed tomography (CT) images: Axial (A) and coronal (B) maximum intensity projection (MIP) sections of follow-up CT (arterial phase) showing stent in common hepatic artery without residual filling of pseudoaneurysm or arterio-portal fistula. Normal filling of branches of common hepatic artery and coils in gastroduodenal artery (B) are also seen.

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