Treatment of a mesenteric arteriovenous malformation via percutaneous transhepatic vascular embolization in a cirrhotic patient with alcohol-induced liver disease, resulting in lowered portal pressure - Case Study
A 66-year-old man, who had been experiencing fatigue and hepatic dysfunction, underwent a detailed examination. His medical history included fatty liver, hypertension, hyperuricemia, and chronic gastritis. On abdominal ultrasound, signs of cirrhosis and splenomegaly were observed, but no ascites were present.
Abdominal contrast-enhanced CT revealed an anastomosis of the ileal artery and ileal vein via a nidus within the mesentery, which led to the diagnosis of a mesenteric arteriovenous malformation (AVM). This condition was also confirmed based on other findings, such as a decrease in portal pressure following the embolization and the presence of blunting of the liver edge, splenomegaly, and signs of cirrhosis on the CT scan.
The man tested negative for hepatitis B, hepatitis C virus, and antinuclear and antimitochotondrial antibodies. He also had a history of regularly consuming approximately 100-180 g per day of alcohol.
Treatment options for decreasing portal pressure in mesenteric AVMs primarily involve interventional radiology techniques and surgery, with pharmacotherapy playing a limited role. Key treatment approaches include endovascular embolization, surgical resection, and the use of pharmacological agents.
Endovascular embolization, a minimally invasive interventional radiology procedure, was performed for the mesenteric AVM. The ileal vein, which was the dominant outflow vein, was embolized, and the blood flow in the arteriovenous malformation disappeared. This procedure is often first-line for symptomatic cases due to its targeted nature and lower morbidity.
In this case, the endovascular embolization was successful in reducing the portal pressure. The decrease in portal pressure was confirmed through laboratory test results, showing a 29% reduction following the embolization.
In summary, endovascular embolization is the preferred minimally invasive approach with reasonable success in reducing portal pressure in mesenteric AVMs, especially symptomatic ones. Surgery is reserved for refractory or extensive cases. Adjunctive use of pharmacological agents, such as nonselective beta-blockers, may be beneficial to manage overall portal hypertension, although specific evidence in AVM cases is limited.
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