[Chronic back pain, hepatomegaly and dyspnea]

A 57-year-old male had suffered from back pain for years. Three years before the presenting symptoms he had had a lumbar disc operation during which he had bled markedly. Current symptoms of tiredness and dyspnea were new to this otherwise healthy and active man. Initial examinations revealed an enlarged liver, some ascites and signs of heart failure. A liver biopsy showed well-preserved structures with minor signs of inflammation. Cardiac cathetrization revealed increased pulmonary pressures and thus portopulmonary hypertension was suspected. A clinical examination, however, revealed a thrill and a strong systodiastolic murmur in the lower abdomen. CT-angiography confirmed the suspicion of an arteriovenous fistula. The fistula was successfully treated with a covered stent placed in the common iliac artery.