HEPATIC ARTERIOPORTAL FISTULA FOLLOWING PENETRATING TRAUMA: CASE SERIES AND REVIEW OF THE LITERATURE

Objectives: Hepatic arterioportal fistula (HAPF) is an uncommon complication of hepatic trauma, which can manifest with abdominal pain and the sequelae of portal hypertension months to years after injury. The purpose of this study is to present cases of HAPF from our busy urban trauma center and make recommendations for management.

Methods: One hundred and twenty-seven patients with high-grade penetrating liver injuries (American Association for the Surgery of Trauma [AAST] - Grades IV-V) between January, 2019, and December, 2021, were retrospectively reviewed. Three patients were identified with an acute HAPF following penetrating abdominal trauma from our ACS-verified adult Level 1 trauma center. Institutional experience with overall surgical management is described and reviewed with the current literature.

Results: All three of our patients presented in hemorrhagic shock requiring emergent operative intervention. The first patient had postoperative angiography and coil embolization of the HAPF. The second and third patients underwent damage control laparotomy with temporary abdominal closure followed by postoperative transarterial embolization with gelatin sponge particles (Gelfoam) and combined Gelfoam/n-butyl cyanoacrylate, respectively. All three patients had resolution of HAPF on follow-up imaging with continued post management for traumatic injuries.

Conclusion: Hepatic arterioportal fistula can present as a complication of hepatic injury and manifest with significant hemodynamic aberrations. Although surgical intervention was required to achieve hemorrhage control in all cases, management of HAPF in the setting of high-grade liver injuries was achieved successfully with modern endovascular techniques. A multidisciplinary approach to such injuries is necessary to optimize care in the acute setting following traumatic injury.