Management of Superior Mesenteric Arteriovenous Fistula after Small Bowel Resection 20 Years Previously: Endovascular Treatment

A 59-year-old man was admitted to the West China Hospital (Sichuan, China) with recurrent abdominal pain and diarrhea. The patient had undergone a resection of the small bowel due to small intestinal bleeding caused by an ulcer 20 years previously and had no history of trauma. Physical examination revealed stable vital signs, but there was tenderness in the area of the epigastrium radiating to the back without muscle tension and rebound pain. Laboratory tests revealed hemoglobin, white blood cell, total bilirubin, prothrombin time, albumin and creatinine levels of 97 g/L, 18.65×109/L, 53 umol/L, 12.0 s, 34.1 g/L, 112 μmol/L, respectively. Computed tomography (CT) angiography of the abdomen and pelvis revealed marked enhancement of the superior mesenteric vein (3.1 cm in diameter) in the arterial phase, the fistula of the neck between the superior mesenteric artery and the superior mesenteric vein (0.9 cm in diameter), the engorgement of the intestinal walls and mesentery, and abdominal ascites (Figure 1). Endovascular treatment was implemented in the hybrid operating room. If unsuccessful, open surgery would immediately follow. Superior mesenteric angiography demonstrated a superior mesenteric arteriovenous fistula (SMAVF) in accord with CT (Figure 2). Embolization of the fistula was performed with multiple 8 mm, 10 mm and 12 mm coils deployed at the neck of the SMAVF, respectively. An additional angiogram showed no opacification of the SMAVF (Figure 3). After the procedure, the patient was monitored carefully for any evidence of bowel ischemia. During the next several days, the patient’s abdominal pain disappeared and the initial watery diarrhea gradually resolved. Confirmation of these findings was obtained by ultrasound with no evidence of portal hypertension. At the three-month follow-up, the patient was in satisfactory condition and had no symptoms of bowel ischemia.