Spontaneous hepatic arterioportal fistula in extrahepatic portal vein obstruction: Combined endovascular and surgical management

Ananya Panda; Durgadevi Narayanan; Arjunlokesh Netaji; Vaibhav Kumar Varshney; Lokesh Agarwal; Pawan Kumar Garg

doi:10.14701/ahbps.22-126

Ann Hepatobiliary Pancreat Surg

Published online March 22, 2023; https://doi.org/10.14701/ahbps.22-126

Ananya Panda¹, Durgadevi Narayanan¹, Arjunlokesh Netaji¹, Vaibhav Kumar Varshney², Lokesh Agarwal², Pawan Kumar Garg¹

¹Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India,
²Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Correspondence to: Ananya Panda, MD, DNB, FRCR
Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Marudhar Industrial Area, 2nd Phase, M.I.A 1st Phase, Basni, Jodhpur, Rajasthan 342001, India
Tel: +91-9013283425, E-mail: drananyapanda@gmail.com
ORCID: https://orcid.org/0000-0003-0862-0741

Received December 2, 2022; Revised January 7, 2023; Accepted January 16, 2023.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract: Hepatic arterioportal fistulae are abnormal communications between the hepatic artery and portal vein. They are reported to be congenital or acquired secondary to trauma, iatrogenic procedures, hepatic cirrhosis, and hepatocellular carcinoma, but less likely to occur spontaneously. Extrahepatic portal venous obstruction (EHPVO) can lead to pre-hepatic portal hypertension. A spontaneous superimposed hepatic arterioportal fistula can lead to pre-sinusoidal portal hypertension, further exacerbating its physiology. This report describes a young woman with long-standing EHPVO presenting with repeated upper gastrointestinal variceal bleeding and symptomatic hypersplenism. Computed tomography scan demonstrated a cavernous transformation of the portal vein and a macroscopic hepatic arterioportal fistula between the left hepatic artery and portal vein collateral in the central liver. The hepatic arterioportal fistula was associated with a flow-related left hepatic artery aneurysm and a portal venous collateral aneurysm proximal and distal to the fistula, respectively. Endovascular coiling was performed for the hepatic arterioportal fistula, followed by proximal splenorenal shunt procedure. This case illustrates an uncommon association of a spontaneous hepatic arterioportal fistula with EHPVO and the utility of a combined endovascular and surgical approach for managing multifactorial non-cirrhotic portal hypertension in such patients.; Keywords : Arterioportal fistulas; Extrahepatic portal venous obstruction; Embolization; Endovascular; Portal hypertension