Postbiopsy arterioportal fistula in patients with hepatocellular carcinoma: clinical significance in transarterial chemoembolization.

OBJECTIVE: The purpose of this study was to determine, retrospectively, the frequency of postbiopsy arterioportal fistula in hepatocellular carcinoma and its significance in transarterial chemoembolization (TACE). MATERIALS AND METHODS: Forty-one patients who underwent percutaneous liver biopsy for diagnosis of hepatocellular carcinoma were referred for TACE. The control population comprised 161 patients referred during the same period who underwent TACE without biopsy. We determined that an arterioportal fistula was present by opacification of the portal vein during the arterial phase of angiography or by opacification with iodized oil during TACE. We considered hepatocellular carcinoma to be responsive to TACE when the sum of iodized oil retention in the tumor and a low-attenuation area on CT was greater than 50% of tumor size. We compared the frequency of arterioportal fistula and the rate of tumor response to TACE in both groups and also evaluated possible factors associated with postbiopsy arterioportal fistula, such as age, sex, Child-Pugh score, tumor size, average number of needle passes, average distance that the needle traversed normal liver before reaching the mass, and average interval between biopsy and TACE. RESULTS: Twenty-three (56.1%) of 41 patients in the biopsy group and 19 (11.8%) of 161 patients in the control group had an arterioportal fistula (p < 0.001). The rate of tumor response to TACE was 87.8% (36/41) in the biopsy group and 87.0% (140/161) in the control group (p = 0.5932). Of the possible related factors, only tumor size correlated negatively with the occurrence of arterioportal fistula. CONCLUSION: Percutaneous liver biopsy in hepatocellular carcinoma patients apparently increases the rate of arterioportal fistula but does not seem to affect the rate of tumor response to TACE.

Segmental degradation of left ventricular wall motion after persistent coronary fistula in a posttransplantation patient: a case report and short review of literature.

A 50-year-old man received an orthotopic heart transplant because of severe coronary heart disease and congestive heart failure. Two years after the transplantation, a continuous murmur occurred at the left sternal edge after repeated endomyocardial biopsies. Echocardiography and coronary angiography revealed a dilated left anterior descending artery with a fistula to the right ventricle. The circumflex was large with an equally postero-lateral branch, and the right coronary artery was rather small with collaterals to the distal part of the left anterior descending branch. The patient had refused any intervention to close the fistula. The left ventricular levogram was normal. Two years later, in a follow-up angiogram, the left ventricular ejection fraction had decreased as a result of hypo- and akinesis of the apex and posterior wall. We suggest that this local wall motion disturbance derives from a steal phenomenon rather than being a sequela of rejection. The decrease in left ventricular ejection fraction was associated with shortness of breath upon moderate exercise. Standard heart failure medication relieved the patient's symptoms. The observation of local wall motion disturbances in this case, as well as conflicting views in the literature, raises the question whether postbiopsy coronary fistulas in transplant patients should be closed.