to Interventional Radiology with a plan to embolize the fistulas. Within days of the planned endovascular intervention, the patient presented to an outside hospital with hematemesis and hematochezia. She was medically stabilized and underwent an upper endoscopy that revealed large esoph- ageal and fundic varices, with sub- sequent banding of the esophageal varices. She was transferred to our hospital and underwent embolization in Interventional Radiology. Angio- grams were performed and a large right hepatic APF was visualized with 1 large feeding by the right hepatic artery and an additional smaller more superior feeding artery. Detachable coils (Interlock; Boston Scientific, Natick, MA) were placed into 2 hep- atic artery feeding vessels, incompletely occluding blood flow into the portal vein after 30 minutes. The Onyx-34 liquid embolic system (Covidien, Mansfield, MA) was used as an adjunctive technique to fill the inter- stices of the coil mass to impede flow from the high flow fistula into the portal vein. The coil mass acted as a “scaffold” to prevent nontarget embo- lization of the liquid into the portal circulation. (Onyx-34 is approved in the United States for use in brain arteriovenous malformations and is considered off-label for this purpose.) Postembolization angiograms demon- strated occlusion of the fistula with no opacification of the portal vein. The patient tolerated the procedure well without any complications and had complete resolution of her symptoms. Magnetic resonance angiography and venography 1 and 6 months later showed successful occlusion of the APF, without evidence of persistent fistulous connection. Although APFs are a rare etio- logy of portal hypertension, they are important to consider in the differ- ential diagnosis of portal hypertension. The largest case series of hepatic APFs included 88 patients over 16 years, many of which were attributed to trauma or iatrogenic procedures. 1 APFs are not unexpected consequences of a liver biopsy, but those that occur are typically microscopic, thrombose, and self resolve without any symptom. 2 Clinically significant APFs after liver biopsy commonly present with gastro- intestinal bleeds (47%) followed by ascites (33%). Why certain individuals have APFs that progress to clinical significance remains unknown. It is important to be aware that many years may elapse between biopsy and clinical presentation with a range from 1 hour to 43 years reported. 3 For any patient with new onset portal hypertension, elicitation of a prior history of liver biopsy should prompt consideration of APF, even if this history is remote. Further research is necessary to exam- ine whether biopsy technique and ultrasound guidance play a role in the development of large APFs. For- tunately, while clinically significant APFs are rare, minimally invasive endovascular embolization provides definitive therapy in the majority of cases. Kimberly Bloom-Feshbach, MD* Aaron Fischman, MDw Jennifer Leong, MDz Department of *Medical Education zMedicine wInterventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY REFERENCES 1. Vauthey JN, Tomczak RJ, Helmberger T, et al. The arterioportal fistula syn- drome: clinicopathologic features, diag- nosis, and therapy. Gastroenterology. 1997;113:1390–1401. 2. Okuda K, Musha H, Nakajima Y, et al. Frequency of intrahepatic arteriovenous fistula as a sequela to percutaneous needle puncture of the liver. Gastroenter- ology. 1978;74:1204–1207. 3. Iwaki T, Miyatani H, Yoshida Y, et al. Gastric variceal bleeding caused by an intrahepatic arterioportal fistula that formed after liver biopsy: a case report and review of the literature. Clin J Gastroenterol. 2012;5:101–107. Esophageal Perforation After Pneumatic Dilation for Achalasia: Successful Closure With an Over-the-Scope Clip To the Editor: A 65-year-old woman with end- stage achalasia had persistent dysphagia, regurgitation, and weight loss despite serial botulinum toxin injections into the lower esophageal sphincter. Therefore, she had a percu- taneous endoscopic gastrostomy tube placed for maintenance of nutrition and was referred to our center for further management. Pneumatic dila- tion with a 30-mm diameter Rigiflex balloon (Boston Scientific, MA) was performed under endoscopic and fluo- roscopic guidance. Endoscopic inspec- tion immediately after dilation showed a 1.5-cm-long linear esophageal full- thickness perforation just proximal to the gastroesophageal junction. An Over-the-Scope Clip (Ovesco Endo- scopy, Tu¨bingen, Germany) was then deployed to close the esophageal per- foration. Chest x-ray revealed pneu- momediastinum and subcutaneous emphysema in the neck. The patient was kept nil per oral and was started on intravenous piperacillin and fluco- nazole. The patient developed lower chest pain, transient low-grade fever (T max of 101.61F, normal <98.6), and leukocytosis (WBC count 16,710 k/mL; normal range, 3700 to 11,000 k/mL), which resolved within 2 days. A gas- trograffin swallow study performed after 2 days did not show any esoph- ageal leak. The patient was then started on a clear liquid diet along with gastrostomy tube feedings. She tol- erated them well and was discharged home after 2 days. At 1-month follow- up, the patient reported improvement in dysphagia and was tolerating a soft diet without regurgitation or chest pain. Pneumatic dilation is an effective, safe, nonsurgical treatment option for patients with achalasia. Esophageal perforation is the most serious com- plication of pneumatic dilation with an overall rate of about 2% (range, 1% to 16%) when performed by experienced operators. 1 Management of perfo- rations varies: conservative manage- ment for small perforations with anti- biotics and total parenteral nutrition for weeks and surgical repair through thoracotomy for larger perforations with extensive soilage of the media- stinum. 2 An overall 50% of esophageal perforations may require surgical intervention. Early placement of a fully covered esophageal stent and leaving it in for 2 weeks was reported to be suc- cessful for closure of an esophageal perforation after pneumatic dilation. 3 To our knowledge, ours will be the first published case of successful treatment of an esophageal perforation after pneumatic dilation by placement of an M.R.S.: concept and design, acquisition of data, and drafting of the manuscript. S.R.: acquisition of data and critical revision of the manuscript. P.N.T.: concept and design and critical revision of the manuscript.The authors declare that they have nothing to disclose. Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved. J Clin Gastroenterol  Volume 50, Number 3, March 2016 Letters to the Editor Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved. www.jcge.com | 267