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Postbiopsy Arterioportal Fistula in Patients with Hepatocellular Carcinoma: Clinical Significance in Transarterial Chemoembolization

Hong Suk Park1, Sang Hyun Lee1, Young Il Kim1, Jong Seok Lee2, Min Kyung Lim3, Joong-Won Park1, Joo Hyuk Lee2 and Chang-Min Kim1

1 Center for Liver Cancer, National Cancer Center, 809, Madu 1-dong, Ilsan-gu, Goyang-si, Gyeonggi-do 411-764, South Korea.
2 Department of Radiology, National Cancer Center, Gyeonggi-do 411-764, South Korea.
3 Division of Cancer Control and Epidemiology, National Cancer Center, Gyeonggi-do 411-764, South Korea.


Figure 1
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  		Fig. 1A —58-year-old man who underwent biopsy 4 days before transarterial chemoembolization. Arterial phase of celiac arteriography performed with digital subtraction angiography technique shows filling of portal vein branches (arrowheads) via arterioportal fistula. Because arterioportal fistula steals blood flow from tumor-feeding vessel, hepatocellular carcinoma is only faintly visualized (arrow).

 

Figure 2
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  		Fig. 1B —58-year-old man who underwent biopsy 4 days before transarterial chemoembolization. On arteriography after superselection of tumor-feeding vessel with microcatheter, tumor staining and portal vein (arrowheads) are more clearly visualized. Chemoembolization was performed at this level.

 

Figure 3
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  		Fig. 1C —58-year-old man who underwent biopsy 4 days before transarterial chemoembolization. Spot radiograph obtained immediately after chemoembolization shows retention of adjacent portal vein and tumor with iodized oil.

 

Figure 4
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  		Fig. 1D —58-year-old man who underwent biopsy 4 days before transarterial chemoembolization. Unenhanced CT scan obtained 1 month after transarterial chemoembolization shows complete retention of iodized oil in tumor.

 

Figure 5
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  		Fig. 2A —55-year-old man who had arterioportal fistula without biopsy. Arteriography after superselection of tumor-feeding vessel with microcatheter shows tumor staining and portal vein (arrowheads).

 

Figure 6
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  		Fig. 2B —55-year-old man who had arterioportal fistula without biopsy. Spot radiograph obtained after chemoembolization shows retention of adjacent portal vein and tumor with iodized oil.

 

Figure 7
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  		Fig. 2C —55-year-old man who had arterioportal fistula without biopsy. Enhanced liver CT scan obtained 1 month after transarterial chemoembolization shows complete retention of iodized oil in tumor.

 

Figure 8
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  		Fig. 3A —51-year-old man who had postbiopsy arterioportal fistula that required gelatin sponge embolization to occlude fistula tract before iodized oil infusion during transarterial chemoembolization. Arterial phase of CT scan obtained before biopsy shows ill-defined heterogeneously enhancing tumor without evidence of arterioportal shunt.

 

Figure 9
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  		Fig. 3B —51-year-old man who had postbiopsy arterioportal fistula that required gelatin sponge embolization to occlude fistula tract before iodized oil infusion during transarterial chemoembolization. In early arterial phase of selective arteriography 7 days after biopsy, portal vein (black arrows) is well visualized. Tumor is indistinct and outlined only by fine peritumoral arteries (white arrows).

 

Figure 10
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  		Fig. 3C —51-year-old man who had postbiopsy arterioportal fistula that required gelatin sponge embolization to occlude fistula tract before iodized oil infusion during transarterial chemoembolization. Because nearly all infusate passed into portal vein through arterioportal fistula, it was embolized with gelatin sponge first. Spot radiograph obtained after chemoembolization shows successful saturation of tumor with iodized oil and little retention in portal vein.

 

Figure 11
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  		Fig. 3D —51-year-old man who had postbiopsy arterioportal fistula that required gelatin sponge embolization to occlude fistula tract before iodized oil infusion during transarterial chemoembolization. One-month follow-up CT scan shows compact uptake of iodized oil in tumor.

 

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