Clinical outcomes of symptomatic arterioportal fistulas after transcatheter arterial embolization

Figure 2 Case 6: A 60-year-old woman with arterioportal fistula and refractory ascites related to liver biopsy performed 6 years earlier. A: Celiac arteriogram before transcatheter arterial embolization (TAE) shows enlarged, tortuous hepatic artery and immediate retrograde visualization of the main portal vein (PV). Note the right hepatic arteries (A7 and A6) supplying the fistulous connection to the right PV branch; B: Superselective hepatic arteriogram before TAE shows immediate retrograde visualization of the main PV trunk (arrow). The tip of the microcatheter was placed at the distal site of arterioportal fistula (APF) in A7. A7 was superselectively embolized using microcoils and interlocking detachable coils; C: Right hepatic arteriogram after TAE for the main feeding artery, A7, still shows retrograde flow of the right PV branch (arrow). An additional feeding artery from A6 was also detected (arrowhead). A6 was superselectively embolized using 0.5 mL of n-butyl-2-cyanoacrylate-lipiodol mixed with lipiodol at a 1:4 ratio (arrowhead); D: Right hepatic arteriogram after TAE illustrates complete obliteration of the APF; E: Superior mesenteric artery (SMA) portogram before TAE shows an extrahepatic portosystemic shunt (arrow) and inferior vena cava (arrowhead). The main PV trunk is not visualized; F: SMA portogram after TAE illustrates the main trunk and intrahepatic branches of PV. Note the disappearance of the extrahepatic portosystemic shunt; G: Computed tomography (CT) on admission (hepatic arterial phase) shows simultaneous enhancement of the aorta and the right branch of PV (arrow), demonstrating severe APF. Note prominent PV thrombi in the umbilical portion (arrowhead); H: CT 6 d after TAE (portal venous phase) shows deteriorated PV thrombi (curved arrow) and cavernous transformation (arrows) while ascites have decreased. Note microcoils and glue in the right hepatic arteries (arrowheads). Hepatopetal flow signal in the main PV without arterial pulsation was demonstrated on color-Doppler ultrasound (not shown).