Hepatic arterioportal fistula.

Hepatic arterioportal fistula (HAPF) is uncommon, arising largely from either a ruptured hepatic artery aneurysm or from penetrating trauma. It is being encountered increasingly, secondary to rising numbers of percutaneous transhepatic procedures. We will describe five cases of HAPF seen at Emory University Hospital over the last 5 years and conclude with a review of the current status of treatment of this condition. HAPF occurred secondary to ruptured hepatic artery aneurysm in two patients, operative injury in two patients, and after trauma in one patient. The predominant clinical manifestation in these patients were complications of portal hypertension, most commonly gastrointestinal bleeding. Angiography remains the definitive diagnostic procedure and it was used to accurately diagnose HAPF in all cases. However, duplex ultrasonography is rapidly becoming a useful screening tool and was the initial imaging modality in the most recent case. Several factors determine the therapeutic approach including the location of the HAPF and associated comorbidity. Due to the development of portal hypertension even asymptomatic fistulas should be treated. In general, surgery is the procedure of choice for extrahepatic fistula, while embolization is optimal for intrahepatic fistulas. Embolization is also useful for patients in whom associated comorbidity prohibits surgical treatment. The goal of surgery is to interrupt the fistula, to maintain hepatic arterial flow, and to close the defect in the portal vein.