A 58 year old female patient was admitted to a local hospital complaining of abdominal swelling, right upper quadrant pain, bruit, dyspnea, effort intolerance and diffuse oedema formation. The patient had no history of alcohol abuse but a history of ovarian cyst surgery and multiple pregnancies.
Physical examination revealed a large volume of ascites. Echocardiography showed cardiomegaly and signs of high – output heart failure. Ultrasound (US) and Computed Tomography (CT) scan demonstrated a large APF between replaced left hepatic artery of the left gastric artery draining into the left portal vein causing a giant aneurysm formation.
Phsyical and labarotory examination was as follows; pulse rate was 80 beats/min and arterial blood pressure was 160/90 mmHg, no sign of jaundice. Liver function tests were within normal limits. Serum creatitine level was 2,5 mg/dl (normal range 0.5–1.1 mg/dl). Hepatitis viral markers were negative for HBV, HCV and HIV.
US examination demonstrated massive ascites, macrolobulation of the liver contour demonstrating chronic liver disease, splenomegaly (16 cm) and large tubuler structures in the left lobe of the liver. Color Doppler Ultrasound (CDUS) showed direct arteriovenous fistulae between dilated left hepatic artery and left portal vein. There was a giant saccular aneurysm (130x90mm) originating from left portal vein. Right portal vein was dilated too and main portal vein showed hepatopedal flow direction (Fig. 1a,b). Triphasic computed tomography comfirmed US and RDUS findings (Fig. 1c,d).
A diagnostic celiac angiography was initially performed. Celiac artery was selectively catheterized with 5F Simmons 1 catheter (Terumo, Leuven, Belgium). Angiography showed the direct fistulae between the left hepatic artery and the left portal vein through single large window (Fig. 2a). The selective catheterization of the left hepatic artery could not be realized despite all attempts because of the severe tortuosity and angulation of the celiac and common hepatic artery. 8F catheter was placed in the right lower quadrant of the peritoneal cavity and a total of 24,000 cc (6000 cc/d) ascites fluid was drained prior to the next session.
At the following session an US guided percutaneous transhepatic puncture of the left hepatic artery was planned. We eliminate the option of transhepatic portal venous access because of the aneurysmal dilation of the portal vein, the risk of AVP migration was relatively high. At first step, a celiac artery catheterization was performed and baseline angiograms were obtained. Doppler examination demonstrated that portal vein showed aneurysmal dilation (33 mm) and tortuous course immediately after the fistula localisation. Hepatic artery showed straight course and smaller diameter (17 mm). Arterial access was achived under US guidance with AccuStick II introducer system (Boston Scientific, Marlborough, USA). After arterial puncture with 21G needle 0.018″ guidewire was advanced (Fig. 2b). System was upsized to exhange 0.035″ guidewire and 7F introducer sheath (Boston Scientific, Marlborough, USA) was advanced into the hepatic artery. After check angiograms were obtained (Fig. 2c), 22x18mm Amplatzer II vascular plug (AVP II) (AGA Medical Corporation, Plymouth, MN, USA) was deployed through the vascular sheath in the left hepatic artery proximal to the fistula localization (Fig. 2d). Coil embolization was performed for the complete occlusion of the remnant sac and the access tract with 10x14mm and 10x30mm Complex Helical pushable coils (Boston Scientific, Marlborough, USA). Completion angiography images demonstrated complete cessation of flow through the fistula (Fig. 3a). US showed immediate thrombosis in the draining portal vein segment and the aneurysm sac distal to the fistula location (Fig. 3b).
Patient’s status was stable during the postoperative period. Liver function tests showed no abnormality, and serum creatinin level decreased dramatically. First month follow up laboratory tests were normal and check CT angiography showed complete cessation of flow and no filling of the aneurysm was observed (Fig. 3c,d). The patients is now at 9. month follow up, she is symptom free, her blood test are within normal range. Check RDUS and CTA showed totally thrombosed aneurysmal sac and portal flow was preserved.