An unusual case of portal hypertension secondary to a traumatic arteriovenous fistula in a patient with an associated celiac artery aneurysm
Ulugbek Negmadjanov, Oscar A. Vazquez, Reagan L. Ross, Aidan D. Hamm, Jessica L. Buicko, Miguel A. Lopez-Viego
Department of Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL
BACKGROUND. Splenic arteriovenous fistulas (AVFs) represent a rare pathological entity that should be considered in cases of acute portal hypertension not related to chronic liver disease. The presentation of splenic AVFs may vary, and the patients may be either asymptomatic or present with a clinical picture of gastrointestinal bleeding, diarrhea, ascites, or heart failure due to a hyperdynamic blood flow state. We present a rare case of a splenic AVF causing portal hypertension in a 78-year-old female with a history of a remote gunshot wound to the abdomen.
METHODS. Institutional review of a single case with imaging
RESULTS. A 78-year-old female was admitted to the hospital with complaints of 1 month of ascites, diarrhea, abdominal cramping, increased abdominal girth, and melena. The patient's past medical history was notable for gout and a prior laparotomy and left nephrectomy for a gunshot wound 58 years ago at age 20. Her laboratory workup was notable for hemoglobin of 10.7, creatinine of 0.83, normal liver function tests, and an international normalized ratio of 1.1. She underwent a computed tomography (CT) of the abdomen and pelvis with findings of portal hypertension with a dilated splenic vein with aneurysmal changes measuring 7 cm (Fig 1A). The patient also had additional findings of a 3 cm celiac artery aneurysm. Shortly after admission, the patient developed anemia secondary to bleeding esophageal varices and underwent upper endoscopy with banding. The patient required several transfusions and developed acute kidney injury. Vascular surgery was consulted after an extensive workup that did not reveal the etiology of the portal hypertension. We performed a mesenteric angiogram that demonstrated a splenic arteriovenous fistula (Fig 1B). The splenic artery was ligated at its origin and at several distal areas with audible cessation of arterial flow in the splenic vein on doppler examination. The calcified, non-thrombosed celiac artery aneurysm was resected with primary closure of its origin using a lateral arteriorrhaphy. The liver and small bowel were well perfused after surgery with excellent flow in the common hepatic artery. The patient had an uncomplicated postoperative course, and a follow-up CT angiogram demonstrated an intact mesenteric aneurysm repair and absent arterial flow in the splenic vein.
CONCLUSIONS. Splenic AVFs are relatively rare in clinical practice. Associated risk factors for the development of splenic arteriovenous fistulas include pancreatitis, iatrogenic injuries, connective tissue disorders, congenital abnormalities, trauma, and infection. They are most commonly encountered among multiparous females. The diagnosis of a splenic AVF should be considered in the differential diagnosis of portal hypertension, especially in the absence of liver disease. Once the diagnosis is established, operative intervention is required to avoid the common sequelae of an arterialized portal circulation. Surgical ligation and aneurysmectomy was used in this case with a successful outcome. 
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