A rare case of hyperkinetic portal hypertension presenting with UGI Bleed secondary to SMA-SMV arteriovenous fistula

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Submission ID :
GEST2021-112
Submission Type
Submission Topic
Purpose :
Superior mesenteric arteriovenous fistula (SMAVF) is an extremely infrequent vascular disorder. It is characterized by abnormal, direct communication between high-pressure superior mesenteric artery (SMA) and low-pressure superior mesenteric vein (SMV). This shunt allows blood to bypass the intestinal capillary bed and produces hypertension in the portal circulation. Although SMAVF can be congenital, the majority of cases reported have been due to abdominal trauma or iatrogenic causes. These fistulas originate from an undetected injury to SMA and SMV and can present several days to several years later, usually following bowel-related surgery. Manifestations of SMAVF include a wide variety of symptoms such as mild abdominal pain, diarrhea and weight loss. Due to the often obscured presence of the fistula, complications related to long-standing arteriovenous (AV) shunt and high portal blood pressure are potentially fatal. The most serious complications are congestive heart failure and portal hypertension, which may lead to gastro-esophageal variceal bleeding. General mortality for untreated cases of portal arteriovenous fistula (AVF) is estimated at about 26%
Materials & Methods :
We report a case of SMAVF in a 48 year old male who presented with history of hematemesis and melaena. In view of respiratory distress, he was intubated/ventilated along with commencement of inotropes. He underwent endoscopy which showed esophageal varices, which were banded. In view of persistent melaena despite banding, he was transferred to our center for further management.
He underwent CT angiogram which showed fistulous connection between superior mesenteric vein and superior mesenteric artery with engorgement of portal vein. There was no obvious active extravasation. Given history of melaena and more than 10 units of transfusion, He was advised embolization of SMAVF.
Results :
SMA angiogram revealed an abnormal communication between two jejunal branches of SMA and jejunal branch of SMV with two feeders draining into common collector venous sac. The venous sac was draining into the grossly dilated superior mesenteric vein and portal vein. The venous sac was cannulated using Berenstein catheter through the first feeder. The collector sac was embolized with a concerto detachable coil followed pushable nester coils. Check angiogram showed persistent filling of the venous sac through the second feeder.
The second feeder branch was intubated using combination of Bernstein catheter- headway 21 microcatheter and embolized using 75 % glue-lipdiol mixture close to the fistula site. Check angiogram showed obliteration of the fistula with normal filling of the mesenteric arteries and preserved bowel arcades.

Following embolization, he underwent OGD which showed stable banded varices. After the 2 procedures, he become hemodynamically stable and we were able to extubate him gradually.
Conclusions :
Because of the patients' SMAVF clinical symptoms being often nonspecific and physical examination may not reveal the presence of abdominal bruit. SMAVF needs to be considered in portal hypertension and has had previous abdominal surgery/ major blunt abdominal trauma; The diagnosis is usually made by CT scan or mesenteric angiography. Multiphasic CT often clinches the diagnosis. While multiphasic CT scans are useful for preoperative planning as they can determine the three-dimensional relationship of the fistula with the surrounding structures, angiography provides full anatomical details and provides better guidance for potential endovascular management. Endovascular embolization can be safely performed with excellent results in these patients
Poster Abstract :
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Resident
,
KMCH
Kovai Medical Centre
Kovai Medical Centre
Kovai Medical Centre
IR resident
,
Kovai Medical Centre
Kovai Medical Centre

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