Selective coil occlusion of a large arterioportal fistula in a liver graft

A woman, born in 1958, developed hepatitis B virus fulminant hepatic failure and underwent ABO blood group incompatible orthotopic liver transplantation in 1989 and was retransplanted with an ABO identical graft in 1992 for chronic rejection. Since her first liver transplantation she had received regular anti-hepatitis B surface antigen immunoglobulins. Hepatitis B virus antigenemia became positive in 1994. She received lamivudine therapy in 1997 and adefovir in 2004 for YMDD mutant reinfection. During this whole period she underwent regular liver biopsies aimed to evaluate the recurrent hepatitis B virus hepatitis. In 2003 an abdominal computed tomography did not show any vascular abnormalities in the liver graft and two percutaneous biopsies were performed at that time for follow-up of the graft. In June 2004 a murmur was detected in her abdomen. A liver graft duplex ultrasound demonstrated an arterioportal fistula that was confirmed by computed tomography (Fig. 1). At that time this fistula was asymptomatic. The patient had no sign of portal hypertension, no ascites, and no hemobilia. No varix was demonstrated at esophagogastroscopy. She was informed of her fistula but as it was asymptomatic, it was proposed that she be regularly followed by duplex ultrasound. Nine months later the patient was readmitted for edema of the lower limbs and upper right abdominal discomfort, attributed to the fistula. Percutaneous coil embolization was performed (Fig. 2 and Fig. 3). This procedure allowed selective closure of the fistula. The symptoms described by the patient disappeared as soon as she came back