Combined endovascular-surgical treatment for complex congenital intrahepatic arterioportal fistula: A case report and review of the literature

Figure 3 Angiographic images during the hybrid endovascular-surgical procedure of the congenital intrahepatic arterioportal fistula. A-D: The initial attempts of selective anterograde catheterisation of the vascular malformation failed due to the small size of the arterial branches, and thus a hybrid procedure was performed. It consisted of (1) retrograde venous catheterisation of the fistula through direct left portal vein puncture (white arrow) and embolisation of the shunt with coils; and (2) surgical exposure of the Rex and selective surgical ligation of the small dysplastic arteries feeding the fistula; E and F: Final angiographic images from the celiac trunk and the superior mesenteric artery, which revealed complete closure of the shunt without signs of revascularisation. c: Coils; gl: Glue; ha: Hepatic artery; ihas: Intrahepatic arteries; lga: Left gastric artery; lpa: Left phrenic artery; sma: Superior mesenteric artery; sa: Splenic artery; sc: Surgical clips; Dotted arrows: External internal biliary drainage.