Comparison of ethanol-soaked gelatin sponge and microspheres for hepatic arterioportal fistulas embolization in hepatic cellular carcinoma

Hepatic arterioportal fistulas(APFs)are common in hepatocellular carcinoma(HCC).Moreover,correlated with poor prognosis,APFs often complicate antitumor treatments,including transarterial chemoembolization(TACE).AIM To compare the efficacy of ethanol-soaked gelatin sponges(ESG)and microspheres in the management of APFs and their impact on the prognosis of HCC.METHODS Data from patients diagnosed with HCC or hepatic APFs between June 2016 and December 2019 were retrospectively analyzed.Furthermore,APFs were embolized with ESG(group E)or microspheres(group M)during TACE.The primary outcomes were disease control rate(DCR)and objective response rate(ORR).The secondary outcomes included immediate and first follow-up APF improvement,overall survival(OS),and progression-free survival(PFS).RESULTS Altogether,91 participants were enrolled in the study,comprising 46 in group E and 45 in group M.The DCR was 93.5%and 91.1%in groups E and M,respectively(P=0.714).The ORRs were 91.3%and 66.7%in groups E and M,respectively(P=0.004).The APFs improved immediately after the procedure in 43(93.5%)patients in group E and 40(88.9%)patients in group M(P=0.485).After 2 mo,APF improvement was achieved in 37(80.4%)and 33(73.3%)participants in groups E and M,respectively(P=0.421).The OS was 26.2±1.4 and 20.6±1.1 mo in groups E and M,respectively(P=0.004),whereas the PFS was 16.6±1.0 and 13.8±0.7 mo in groups E and M,respectively(P=0.012).CONCLUSION Compared with microspheres,ESG embolization demonstrated a higher ORR and longer OS and PFS in patients of HCC with hepatic APFs.

Hepatic Arterioportal Fistulas: A Retrospective Analysis of 97 Cases

Background and Aims:Hepatic arterioportal fistulas(HAPFs)are abnormal shunts or aberrant functional con-nections between the portal venous and the hepatic arte-rial systems.Detection of HAPFs has increased with the ad-vances in diagnostic techniques.Presence of HAPFs over a prolonged period can aggravate liver cirrhosis and further deteriorate liver function.However,the underlying causes of HAPFs and the treatment outcomes are now well character-ized.This study aimed to summarize the clinical character-istics of patients with HAPFs,and to compare the outcomes of different treatment modalities.Methods:Data of 97 pa-tients with HAPFs who were admitted to the Second Xiang-ya Hospital between January 2010 and January 2020 were retrospectively reviewed.Demographic information,clinical manifestations,underlying causes,treatment options,and short-term outcomes were analyzed.Results:The main cause of HAPF in our cohort was hepatocellular carcinoma(78/97,80.41%),followed by cirrhosis(10/97,10.31%).The main clinical manifestations were abdominal distention and abdominal pain.Treatment methods included transcath-eter arterial embolization(n=63,64.9%),surgery(n=13,13.4%),and liver transplantation(n=2,2.1%);nineteen(19.6%)patients received conservative treatment.Among patients who underwent transcatheter arterial embolization,polyvinyl alcohol,lipiodol combined with gelatin sponge,and spring steel ring showed comparable efficacy.Conclusions:Hepatocellular carcinoma and cirrhosis are common causes of HAPFs.Transcatheter arterial embolization is a safe and effective method for the treatment of HAPFs,and polyvinyl alcohol,lipiodol combined with gelatin sponge,and spring steel ring showed comparable efficacy in our cohort.

A large congenital and solitary intrahepatic arterioportal fistula in an old woman

Arterioportal fistula(APF)is a rare cause of portal hypertension and may lead to death.APF can be congenital,post-traumatic,iatrogenic(transhepatic intervention or biopsy)or related to ruptured hepatic artery aneurysms.Congenital APF is a rare condition even in children.In this case report,we describe a 73-year-old woman diagnosed as APF by ultrasonography,computed tomography,and hepatic artery selective arteriography.The fistula was embolized twice but failed,and she still suffered from alimentary tract hemorrhage.Then,selective arteriography of the hepatic artery was performed again and venae coronaria ventriculi and short gastric vein were embolized.During the 2-year follow-up,the patient remained asymptomatic.We therefore argue that embolization of venae coronaria ventriculi and short gastric vein may be an effective treatment modality for intrahepatic APF with severe upper gastrointestinal bleeding.

Gastrointestinal bleeding caused by extrahepatic arterioportal fistula associated with portal vein thrombosis

An extrahepatic arterioportal fistula(APF) involving the gastroduodenal artery and superior mesenteric vein is rare and mostly results from iatrogenic injuries.The clinical symptoms associated with APFs may include abdominal pain,gastrointestinal bleeding,ascites,nausea,vomiting,diarrhea,or even congestive heart failure.We present the case of a 70-year-old man who presented with chronic abdominal pain and gastrointestinal bleeding secondary to APF and portal vein thrombosis.The endovascular embolization of APF was accomplished successfully,and symptoms of portal hypertension resolved immediately after intervention.Unfortunately,the patient did not respond well to anticoagulation therapy with warfarin.Therefore,the patient underwent implantation of a transjugular intrahepatic portosystemic shunt,and the complications of portal hypertension resolved.In conclusion,the embolization of APF is technically feasible and effective and can be considered the first-choice therapy in selected patients.

Diagnosis and management of arterioportal fistula occurring after percutaneous transhepatic portal vein cannula-assisted TIPS

To the Editor:Transjugularintrahepaticportosystemicshunt(TIPS)isusuallyconsideredthechoiceformanagingcomplicationsofportal hypertensionsuchasrefractoryascites,esophagogastricvariceal bleedingandrecurrentbleedinguncontrolledwithfirstline treatment.Inrecentyears,TIPShasbeensuccessfullyusedto treat Budd-Chiari syndrome, hepatic hydrothorax, and portal vein thrombosis.One of the key steps during TIPS is the portal vein puncture.

Simultaneous embolization of a spontaneous porto-systemic shunt and intrahepatic arterioportal fistula:A case report

BACKGROUND Hepatic encephalopathy(HE)is a frequent and debilitating complication of chronic liver disease.Recurrent HE is strongly linked with spontaneous portosystemic shunts(SPSSs).Intrahepatic arterioportal fistulas(IAPFs)occur rarely but pose a major clinical challenge and may lead to or worsen portal hypertension.Herein,we present a rare case of recurrent HE secondary to a SPSS combined with an IAPF.CASE SUMMARY A 63-year-old female with primary biliary cirrhosis presented with recurrent disturbance of consciousness for 4 mo.SPSS communicating the superior mesenteric vein with the inferior vena cava and IAPF linking the intrahepatic artery with the portal vein were found on contrast-enhanced abdominal computed tomography.The patient did not respond well to medical treatment.Therefore,simultaneous embolization of SPSS and IAPF was scheduled.After embolization,the symptoms of HE showed obvious resolution.CONCLUSION The presence of liver vascular disorders should not be neglected in patients with chronic liver disease,and interventional therapy is a reasonable choice in such patients.

Coil embolization of arterioportal fistula complicated by gastrointestinal bleeding after Caesarian section: A case report

BACKGROUND Most intrahepatic arterioportal fistulae(IAPF)are acquired.The few cases of congenital fistulae are diagnosed in infants and children.CASE SUMMARY We report a 31-year-old female patient presenting with haematemesis and melena three weeks after delivering her second child.The patient had a 20-year history of abdominal distention and nausea.IAPF,along with splenomegaly and ascites,was found by Doppler sonography and confirmed by computed tomography angiography.The patient was treated with endovascular coil embolization,resulting in occlusion of the fistula.CONCLUSION This was an unusual case of possible congenital IAPF that manifested during a second pregnancy and was complicated by portal hypertension.

A case of agnogenic intrahepatic arterioportal fistula complicated by gastric ulcer bleeding and progressive portal thrombosis

Arterioportal fistulas(APFs)are defined as vascular communications between the systemic arteries and portal circulation.APFs are classified as congenital or acquired,large or small,intrahepatic or extrahepatic,and traumatic or spontaneous.The consistent abnormal connection may result in severe presinusoidal portal hypertension,leading to gastrointestinal bleeding(GIB),ascites,elevated liver function enzymes,heart failure,diarrhea,and even pancreatitis or hematobilia in some unusual cases.Indeed,less than half reported cases have GIB,predominately caused by variceal rupture.Peptic ulcer bleeding has rarely been reported in the setting of APFs.Herein,we describe a case in which intrahepatic APF manifested as gastric ulcer bleeding,progressive portal thrombosis,and massive ascites,with these symptoms successfully relieved by endovascular treatment.