A case of portal hypertension associated with a giant hepatic arterioportal fistula successfully treated with partial hepatic arterial embolization.

Adult-onset symptomatic hepatic arterioportal fistula (HAPF) is a rare vascular abnormality for which optimal treatment strategies have not been established. We report a case of a symptomatic giant HAPF successfully treated with interventional radiology. A woman in her 60 s presented with massive ascites. Imaging studies revealed an intrahepatic HAPF with multiple abnormal communications between the posterior segmental branch of the portal vein and arterial inflow from the right hepatic artery and the right inferior phrenic artery, leading to a diagnosis of portal hypertension associated with HAPF. Due to the high surgical risk associated with massive ascites, partial transcatheter arterial embolization targeting the major hepatic arterial inflow was performed instead of using a portal venous approach. Although complete shunt occlusion was not achieved, the disappearance of early portal venous enhancement was used as the procedural endpoint, suggesting a marked reduction in hepatofugal portal flow. Following treatment, ascites resolved, serum albumin levels improved, and liver volume increased on follow-up imaging. The patient has remained recurrence-free for two years after treatment. Partial hepatic arterial embolization aimed at flow reduction, rather than complete shunt obliteration, may be an effective and less invasive therapeutic strategy for complex HAPF.