Teniere Tom, Palmier Mickael, Curado Adelya, Plissonnier Didier
Department of Vascular Surgery, Rouen University Hospital, Rouen, France.
Department of Radiology, Rouen University Hospital, Rouen, France.
EJVES Vasc Forum. 2023 Aug 10;60:37-41. doi: 10.1016/j.ejvsvf.2023.08.001. eCollection 2023.
Arteriovenous fistula (AVF) rarely occurs in the portal venous system. Aetiologies include iatrogenic, surgical, and penetrating trauma of the abdomen. Clinical manifestations of superior mesenteric portal arteriovenous fistula (SMPAVF) are right heart failure, mesenteric ischaemia, or signs of portal hypertension.
The case of a 42 year old man with a history of Crohn's disease who had a delayed symptomatic mesenteric portal AVF, occurring 20 years after ileocecal resection, which was subsequently managed by endovascular approach is reported. The patient presented with post-prandial abdominal pain for almost one year, and dyspnoea New York Heart Association stage II. There were no signs of portal hypertension. Pre-operative contrast enhanced computed tomography showed a high flow SMPAVF, with a short and wide neck (9 mm × 16 mm) at the level of the last collateral of the superior mesenteric artery. It was associated with a large aneurysm of the mesenteric vein. Vascular plug embolisation (Amplatzer 18 × 18 mm, Abbott, Chicago, IL, USA) by femoral access allowed exclusion of the SMPAVF and preserved arterial flow in the distal collaterals. During follow up, the patient developed portal vein thrombosis and required therapeutic anticoagulation for six months.
In most cases, endovascular approaches are preferred in the management of SMPAVF. Endovascular approaches are based on minimally invasive techniques including embolisation (coiling or plug) and covered stenting. Vascular plug embolisation of SMPAVF is feasible and seems to be an effective technique, with the advantage of saving collaterals. Therapeutic anticoagulation should be considered post-operatively in cases with venous dilatation and reduced flow linked to exclusion of the AVF.
动静脉瘘（AVF）很少发生于门静脉系统。病因包括医源性、手术及腹部穿透伤。肠系膜上静脉动静脉瘘（SMPAVF）的临床表现为右心衰竭、肠系膜缺血或门静脉高压体征。
报道一例42岁克罗恩病病史男性，在回盲部切除术后20年出现延迟性有症状的肠系膜门静脉AVF，随后采用血管内介入方法治疗。患者出现餐后腹痛近一年，纽约心脏协会心功能分级为II级呼吸困难。无门静脉高压体征。术前增强CT显示高流量SMPAVF，在肠系膜上动脉最后一级分支水平有短而宽的颈部（9mm×16mm）。其与肠系膜静脉大动脉瘤相关。经股动脉途径行血管封堵栓塞术（美国伊利诺伊州芝加哥雅培公司的Amplatzer 18×18mm封堵器）可排除SMPAVF并保留远端分支的动脉血流。随访期间，患者发生门静脉血栓形成，需要进行6个月的抗凝治疗。
在大多数情况下，血管内介入方法是治疗SMPAVF的首选。血管内介入方法基于微创技术，包括栓塞（弹簧圈或封堵器）和覆膜支架置入。SMPAVF的血管封堵栓塞术是可行的，似乎是一种有效的技术，具有保留分支的优点。对于因AVF排除导致静脉扩张和血流减少的病例，术后应考虑抗凝治疗。
