Fig. 1. SMA injection shows a proximal fistulous connection to a peripancreatic vein (arrow) leading to the portal vein (large arrow). The superior mesenteric vein is markedly enlarged (arrowheads). Case Reference No. CC-0498-02 A 22-year-old man who had sustained an abdominal gunshot wound 8 years earlier presented with upper and lower GI bleeding. A CT scan demonstrated a massively dilated portal vein which enhanced during the arterial phase, suggesting a fistula between the mesenteric arterial system and the portal vein. As the patient's bleeding continued, he became more and more coagulopathic and thrombocytopenic. Aortic and selective mesenteric arteriography revealed direct communication from the proximal superior mesenteric artery (SMA) to a massively enlarged superior mesenteric vein (SMV) and portal vein (Fig. 1). Celiac artery injection revealed enlargement of the pancreaticoduodenal arcade feeding the fistula (Fig. 2). In addition, there was retrograde flow via an arc of Riolan from the inferior mesenteric artery (IMA) supplying the fistula (Fig. 3). Attempts were made to occlude the fistula with two 8-mm detachable balloons deployed via the SMA. However, torrential flow through the fistula dislodged the balloons and propelled them into the distal left portal vein. Subsequently, a 9-mm balloon was inflated across the fistula, and helical coils were positioned behind it. These were also dislodged by the torrential flow through the fistula. Finally, a 9-mm nondetachable balloon was inflated across the origin of the fistula to control the massive GI hemorrhage until a covered stent was available or surgery could be safely performed (Fig. 4). Unfortunately, the patient expired shortly thereafter. Questions: 1) Would you have treated this patient with a covered stent initially? 2) Do you make your own covered stents and if so, what materials do you use? 3) If you use commercially available covered stents, which type do you prefer and do you keep some in stock at all times?

Fig. 2. Celiac artery injection shows enlargement of the pancreaticoduodenal arcade feeding the fistula. An old bullet fragment is also identified (arrow). Fig. 3. Flush abdominal aortogram shows retrograde flow through the arc of Riolan from the IMA to the SMA (arrow), and subsequently to the portal vein via the fistula. Fig. 4. A 9-mm balloon is placed across the origin of the fistula. Injection of the distal GDA shows tamponade of flow through the fistula. The previously placed balloons and coils, which had migrated into the portal system, are identified at the top of the image. The embolized balloons were subsequently ruptured percutaneously with a 22-gauge Chiba needle.