Endovascular treatment of a post-traumatic celiac trunk–portal vein fistula

Abstract

Post-traumatic splanchnic arteriovenous fistulas are uncommon vascular lesions that can result in significant hemodynamic disturbances. We report the case of a patient with a history of an abdominal gunshot wound who developed a high-flow celiac trunk–to–portal vein fistula, successfully treated using an endovascular occlusion device. Complete exclusion of the arteriovenous shunt was achieved without complications, suggesting that an endovascular approach can be a safe and effective treatment for patients with complex vascular anatomy.

Introduction

Acquired arteriovenous fistulas are uncommon vascular conditions, most frequently associated with penetrating trauma, surgical procedures, biopsies, or local inflammatory processes [1]. These fistulas are clinically important because high-flow arteriovenous shunting can lead to significant hemodynamic changes, with symptoms depending on the location and size of the shunt and potentially resulting in volume overload and high-output heart failure [2].

Celiac trunk–to–portal vein fistulas are rare. Diagnosis is often incidental or established in patients with nonspecific symptoms, typically through imaging studies such as contrast-enhanced computed tomography and angiography [[1], [3]]. Although surgery has traditionally been the main treatment, advances in endovascular techniques now provide less invasive options, with high success rates and lower morbidity and mortality [[2], [3]], especially in patients with a history of multiple abdominal surgeries.

Case report

A 19-year-old male patient with a history of an abdominal gunshot wound involving the left hemithorax and left hemiabdomen was admitted to the emergency department of an outside institution. On admission, a focused assessment with sonography for trauma (FAST) demonstrated free intraperitoneal fluid in all four quadrants and a left pleural effusion, prompting emergent surgical management.

The initial surgical intervention included left pleural drainage and exploratory laparotomy, requiring duodenal and gastric repair, portal vein suturing, and abdominal packing, with temporary abdominal closure. The patient showed favorable clinical evolution, and during a subsequent procedure, the pleural drain was removed and definitive abdominal wall closure was performed.

During the postoperative period, contrast-enhanced abdominal computed tomography revealed an incidental high-flow arteriovenous fistula between the celiac trunk and the portal vein. The fistulous tract originated from the right lateral wall of the celiac trunk and communicated with the left lateral wall of the portal vein trunk, forming a well-defined linear vascular channel consistent with a traumatic fistulous pathway. The fistula measured 21 mm in length and 11.4 mm in width (Fig. 1).

Fig. 1.

Contrast-enhanced abdominal computed tomography. Multiplanar reconstructions in coronal (A) and axial (B) planes demonstrating a high-flow arteriovenous fistula between the celiac trunk and the portal vein, associated to a fistulous tract (arrows). Early opacification of the portal venous system is observed, consisting in a significant arteriovenous shunt.

Due to its high-flow nature, contrast opacification of the distal branches of the celiac trunk—particularly the splenic and hepatic arteries—was markedly reduced. The abdominal aorta and iliac arteries showed preserved calibers, with no evidence of aneurysmal dilation or dissection (Fig. 2).

Fig. 2.

Three-dimensional contrast-enhanced computed tomography reconstruction. Volumetric rendering demonstrates the anatomical relationship between the celiac trunk, the fistulous tract, and the portal venous system, providing complementary information for spatial understanding and endovascular planning.

Diagnostic evaluation was completed with abdominal angiography, which confirmed the tomographic findings and identified the fistulous origin a few millimeters distal to the celiac trunk ostia and proximal to its bifurcation, with direct drainage into the portal vein, consistent with a high-flow arteriovenous fistula (Fig. 3).

Fig. 3.

Diagnostic celiac trunk angiography showing early opacification of the portal vein through the fistulous tract. Reduced visualization of the hepatic and splenic arteries, consisting in a high-flow arteriovenous shunt and hemodynamic steal phenomenon.

Based on these findings, an endovascular approach was selected for a definitive treatment.

Endovascular treatment

Image fusion of the tomographic and angiographic datasets were performed using a dedicated image-processing software (VesselNavigator, Philips Healthcare, Best, The Netherlands), providing detailed vascular mapping that facilitated procedural planning and guidance (Fig. 4).

Fig. 4.

Fusion imaging of CT volume data and angiography using an endovascular navigation software (VesselNavigator, Philips Healthcare, Best, The Netherlands), enabling detailed anatomical characterization.

The procedure was performed via right femoral arterial access, with placement of a 6-French introducer sheath. During the procedure 5000 UI of unfractionated heparin was administered.

Under fluoroscopic guidance, a 0.035-inch J-tip hydrophilic guidewire was advanced along with a 5-French Cobra diagnostic catheter, achieving selective catheterization of the fistula. The hydrophilic guidewire was then exchanged for a 0.035-inch super-stiff guidewire, and a 6-French Destination sheath (Terumo Corporation, Tokyo, Japan) was placed into the portal vein through the fistula.

After an adequate position and system stability was confirmed, arteriovenous shunt occlusion was performed by deploying a self-expanding vascular occlusion device AVP II 10 × 14 mm (Amplatzer, Abbott Vascular, Santa Clara, CA, USA). Final control angiography showed complete exclusion of the fistula with no residual shunt and excellent opacification of the common hepatic and splenic arteries (Fig. 5).

Fig. 5.

Final angiography after endovascular fistula occlusion. Distal celiac branches flow restoration is observed.

Outcome and follow-up

The patient had an uneventful immediate postoperative course, remained hemodynamically stable, and experienced no procedure-related complications. He was subsequently discharged.

At 30-day follow-up, contrast-enhanced computed tomography confirmed celiac trunk patency, a correct positioning of the occlusion device, and absence of residual shunt (Fig. 6).

Fig. 6.

Post-procedural follow-up computed tomography showing correct position of the occlusion device, patency of the celiac trunk, and absence of residual shunting.

Antiplatelet therapy with acetylsalicylic acid 100 mg daily was prescribed for three months.

Discussion

Treatment of acquired splanchnic arteriovenous fistulas remains challenging due to their low incidence and complex anatomy. Historically, surgical management was the predominant strategy; however, current literature demonstrates a clear trend toward endovascular approaches, with high technical success rates and lower morbidity and mortality compared with conventional surgery [1,3].

Surgical options include ligature of the afferent and/or efferent vessels, resection of the involved segment, and, depending on the vascular territory, procedures such as splenectomy or hepatic resection. These approaches may be limited by difficult access to deep visceral structures, increased bleeding risk, and higher morbidity, particularly in patients with distorted anatomy or multiple prior abdominal surgeries. In this context, endovascular therapy is often preferred, due to its minimally invasive nature [[2], [3], [4]].

Several endovascular embolization strategies have been described, including coils, liquid embolic agents, and stent-grafts [3,5,6]. In the present case, the use of liquid embolic agents was excluded due to the high-flow pattern of the fistula carrying an associated risk of non-target embolization. Coil embolization could be suboptimal because of the short fistulous neck, the increased risk of device migration [5,6], as well as the potential need for multiple coils to achieve complete occlusion.

The use of a covered stent was also ruled out due to the lesion’s proximity to the celiac trunk ostia and the absence of an adequate landing zone, where patency of distal branches could not be guaranteed.

In this setting, vascular occlusion devices provide relevant technical advantages, including precise deployment and controlled delivery, enabling repositioning prior to final release. These features have been shown to reduce distal embolization in high flow shunts and to be associated with favorable outcomes in splanchnic arteriovenous fistulas [[4], [7], [9]].

Finally, advanced imaging techniques, such as fusion of CT with real-time angiography, play a key role in understanding complex vascular anatomy, improving endovascular navigation, and optimizing procedural efficiency by reducing fluoroscopy time and contrast volumen [8].

Conclusion

Endovascular closure of a post-traumatic celiac trunk to portal vein fistula represents a safe, effective, and minimally invasive therapeutic strategy in selected patients. Adequate procedural planning based on multimodality imaging is essential for achieving technical and clinical success. Furthermore, interdisciplinary approach enables comprehensive decision-making and optimal patient management.

Patient consent

Written, informed consent was obtained from the patient for publication of this case.