Abstract
BackgroundIntrahepatic arterioportal fistula (IAPF) is a rare cause of portal hypertension. Interventional radiology (IVR) is generally selected as the first-line therapeutic option. Surgical treatment for IAPF is required in refractory cases of IVR. As the treatment success rate with IVR is high, cases requiring surgical treatment are extremely rare.Case presentationA 54-year-old man was admitted to another hospital complaining of hematemesis due to rupture of the esophageal varices. A computed tomography revealed ascites and arterioportal fistula in the left lobe of the liver. Transcatheter arterial embolization (TAE) was performed to occlude the fistula; however, it could not reach complete occlusion. Thereafter, there were a total of four hematemeses, and six endoscopic variceal ligations were required. The second TAE also failed to reach complete occlusion. He was transferred to our hospital for further treatment. Because liver function was low due to frequent hematemeses and there was also uncontrollable ascites, it was confirmed that hepatectomy could not be performed safely at this time. Therefore, we ligated the left portal branch and ligated and dissected the left gastric vein to decrease portal vein pressure. However, on the 5th day after surgery, the esophageal varices reruptured. As the disappearance of ascites was observed in the postoperative course and the general condition also improved, left hepatectomy was performed to remove IAPF. There was no recurrence of portal hypertension for 1 year and 3 months since hepatectomy.ConclusionsThis case was difficult to treat with IVR and required surgical treatment. Our experience in the present case suggests that hepatectomy to remove arterioportal fistula was considered effective for improving portal hypertension due to IAPF. However, careful treatment selection according to the patient’s overall condition and clinical course is necessary for IAPF presenting with severe portal hypertension.
Highlights
Intrahepatic arterioportal fistula (IAPF) is a rare cause of portal hypertension
Our experience in the present case suggests that hepatectomy to remove arterioportal fistula was considered effective for improving portal hypertension due to IAPF
We describe the case of a patient with IAPF who required left hepatectomy after ligation of the left portal vein and ligation and dissection of the left gastric vein
Summary
We encountered a case of IAPF with portal hypertension that was difficult to treat with IVR because of diffuse fistulas. TAE is the first-line treatment for all IAPF cases with severe portal hypertension. Surgical treatment should be chosen for cases refractory to TAE. In IAPF cases, portal pressure is predicted to be high owing to the anastomosis between the artery and the portal vein. Embolizing the branch of the portal vein with the IVR technique to reduce the portal vein pressure may cause embolic material to be swept away, and we think that the risk is high in IAPF cases. Surgical treatment should be selected for refractory cases of TAE. It may be difficult to decide which type of surgery is preferred in cases of poor general condition or liver reserve, it is necessary to select an adequate treatment according to the patient’s condition
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