Laparoscopic ligation of a patent ductus venosus (Arantii Ductus) in an adult patient

The ductus venosus is an embryological portosystemic shunt that connects umbilical vein and inferior vena cava. During fetal life, oxygenated blood bypasses liver circulatory system through this duct which closes after birth with postpartum hemodynamic changes. Persistent patency can be a congenital or acquired condition. We present a case of a 34 year-old male who came complaining abdominal pain and exertional dyspnea. Abdominal CT-scan and MRI documented the presence of a portosystemic shunt from a patent ductus venosus (PDV), associated with stenosis of the celiac tripod. Trans-esophageal contrast ultrasound excluded intracardiac shunt. The portal phase during arteriography revealed a high-flow portacaval shunt consistent with a large Arantius' duct. An hemodynamic percutaneous approach was excluded by multidisciplinary assessment due to the large size of the duct (23 mm), hence a laparoscopic surgical approach was performed. Intraoperative hemodynamic variations of pulmonary and hepatic blood flow were ruled out by clamping test of the duct through invasive monitoring, thus the PDV was divided with a linear vascular stapler. Post-operative course was uneventful and the patient was discharged in POD 5. Serum ammonia and liver test were normal at 1-month follow-up. After 2 months, echocardiography confirmed the absence of pulmonary hypertension on exertion. At 6-months follow up, abdominal complaints recurred. The diagnosis and management of PDV in adult patient remains controversial. In our experience surgical management is safe and effective in larger PVD after multidisciplinary hemodynamic evaluation. Mini-invasive approach is feasible in case of extra-parenchymal PDV.