As the indications for the nonoperative management (NOM) of hepatic injury have expanded, the incidence of complications of NOM has increased. Among such complications, arterioportal fistula (APF) formation is rare, although dangerous, due to the potential for portal hypertension. Embolization is performed in APF patients with clinical signs suggestive of portal hypertension. Meanwhile, no indications for treatment have been established in APF patients without symptoms, as the natural history of posttraumatic APF is not well understood. We herein report the case of a 35-year-old female with severe hepatic injury (Grade IV on the Organ Injury Scale of the American Association for the Surgery of Trauma) due to a traffic accident. Her hemodynamic state remained stable, and an enhanced CT scan obtained on admission showed no extravasation of contrast medium, pseudoaneurysm formation, or APF; therefore, NOM was selected. Although the patient’s physical condition was stable, an enhanced CT scan obtained 13 days after the injury showed APF in segment 8 of the liver. Although embolization was considered, the APF was not accompanied by portal dilatation suggestive of portal hypertension; hence, strict observation was selected. Consequently, follow-up CT performed on day 58 after the injury revealed spontaneous closure of the APF. 1. Introduction The most common cause of arterioportal fistula (APF) has been reported to be hepatic trauma (28%), followed by iatrogenic procedures (16%), congenital vascular malformation (15%), malignancy (15%), and rupture of splanchnic artery aneurysms (14%) [1]. As the indications for the nonoperative management (NOM) of hepatic trauma injury have expanded, with high reported success rates ranging from 83% to 100% [2–4], the incidence of complications, including APF, posttraumatic pseudoaneurysms, bile leakage, and hepatic abscesses, has increased [3, 5, 6]. APF is rare; however, it is considered to be clinically dangerous due to the possibility of portal hypertension and ultimate rupture of esophageal varices. Therefore, transarterial embolization is usually performed in APF patients with clinical signs, such as splenomegaly or ascites, that are suggestive of portal hypertension [7–9]. On the other hand, no indications for treatment have been established in APF patients without symptoms, as the natural history of posttraumatic APF is not well understood. We encountered a rare case of spontaneous closure of posttraumatic APF detected on follow-up enhanced computed tomography (CT) for blunt liver trauma. 2. Case Report A 35-year-old
References
[1]
J.-N. N. Vauthey, R. J. Tomczak, T. Helmberger et al., “The arterioportal fistula syndrome: clinicopathologic features, diagnosis, and therapy,” Gastroenterology, vol. 113, no. 4, pp. 1390–1401, 1997.
[2]
J. A. London, L. Parry, J. Galante, and F. Battistella, “Safety of early mobilization of patients with blunt solid organ injuries,” Archives of Surgery, vol. 143, no. 10, pp. 972–976, 2008.
[3]
G. C. Velmahos, K. Toutouzas, R. Radin et al., “High success with nonoperative management of blunt hepatic trauma: the liver is a sturdy organ,” Archives of Surgery, vol. 138, no. 5, pp. 475–481, 2003.
[4]
G. C. Velmahos, K. G. Toutouzas, R. Radin et al., “Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study,” Archives of Surgery, vol. 138, no. 8, pp. 844–851, 2003.
[5]
A. B. Christmas, A. K. Wilson, B. Manning et al., “Selective management of blunt hepatic injuries including nonoperative management is a safe and effective strategy,” Surgery, vol. 138, no. 4, pp. 606–611, 2005.
[6]
P. R. Miller, M. A. Croce, T. K. Bee et al., “Associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management,” Journal of Trauma, vol. 53, no. 2, pp. 238–244, 2002.
[7]
ò. Estrada, C.-A. Mestres, M.-A. López-Boado, J. A. Salmerón, J. Visa, and J.-C. García-Valdecasas, “Posttraumatic intrapancreatic aortosplenic fistula causing portal hypertension,” Asian Cardiovascular and Thoracic Annals, vol. 11, no. 3, pp. 272–274, 2003.
[8]
A. Kirchgatterer, C. Baldinger, F. Lenglinger et al., “Portal hypertension due to traumatic hepatic arterioportal fistula: report of successful embolization,” European Journal of Gastroenterology and Hepatology, vol. 10, no. 12, pp. 1057–1059, 1998.
[9]
B. J. Eastridge and J. P. Minei, “Intrahepatic arterioportal fistula after hepatic gunshot wound: a case report and review of the literature,” The Journal of Trauma, vol. 43, no. 3, pp. 523–526, 1997.
[10]
N. A. Stassen, I. Bhullar, J. D. Cheng, M. Crandall, R. Friese, O. Guillamondegui, et al., “Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline,” The Journal of Trauma and Acute Care Surgery, vol. 73, pp. S288–S293, 2012.
[11]
W. P. English, M. B. Johnson, K. R. Borman, and W. W. Turner Jr., “Mesenteric ischemia: an unusual presentation of traumatic intrahepatic arterioportal fistula,” American Surgeon, vol. 67, no. 9, pp. 865–867, 2001.
[12]
S. Kayser, B. Marincek, R. Schlumpf, M. Fried, and H. P. Wirth, “Rapidly progressive portal hypertension 23 years after post-traumatic arterioportal fistula of the liver,” American Journal of Gastroenterology, vol. 91, no. 7, pp. 1442–1446, 1996.
[13]
J. Lerut, N. Vauthey, J. Triller, P. Gertsch, and W. Schweizer, “Intrahepatic arterioportal fistula following conservative treatment of a traumatic liver rupture: case report,” Journal of Trauma, vol. 33, no. 5, pp. 760–764, 1992.
[14]
H. Tanaka, A. Iwai, H. Sugimoto, T. Yoshioka, and T. Sugimoto, “Intrahepatic arterioportal fistula after blunt hepatic trauma: case reports,” Journal of Trauma, vol. 31, no. 1, pp. 143–146, 1991.
[15]
E. A. Guzman, L. E. McCahill, and F. B. Rogers, “Arterioportal fistulas: introduction of a novel classification with therapeutic implications,” Journal of Gastrointestinal Surgery, vol. 10, no. 4, pp. 543–550, 2006.
