Arterioportal fistulas may be acquired or congenital, and may have an intra- or extrahepatic location. Common causes of acquired arterioportal fistulas are cirrhosis and hepatic neoplasms, blunt or penetrating trauma, percutaneous liver biopsy, gastrectomy, transhepatic cholangiography, and biliary surgery (Fig. 34). In the case of congenital arterioportal fistulas, these are typically associated with hereditary hemorrhagic teleangectasia, biliary atresia, and Ehlers-Danlos Syndrome. Often asymptomatic within the first year of life, the first symptom of arterioportal fistula is usually portal hypertension associated with splenomegaly, hy-persplenism, variceal formation, and ascites .
US with color Doppler is the most useful imaging technique for making the diagnosis of arterio-portal fistula. At Doppler US, common features include enlargement of the hepatic artery and dilatation of the segment of the portal vein in which the fistula is located. In congenital arterioportal fistula, hepatofugal flow in the portal vein can be detected along with color speckling in the hepatic parenchyma adjacent to the fistula, which is due to vibration artifact .
Imaging features of arterioportal fistulas on dynamic CT and MR include marked enhancement of the main portal vein, segmental branches, or major tributaries, with attenuation or signal intensity approaching that of the aorta during the arterial phase. Perfusion anomalies of the surrounding liver parenchyma such as regional increases in arterial inflow as a response to inverted portal flow, and increased portal vein inflow due to the shunt itself, may also be observed [ 16].Angiog-raphy is often indicated for possible embolization.
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