Arterioportal Fistula Embolization

Background and indications

Arterioportal fistula (APF) is an abnormal communication between a hepatic artery branch and a portal vein branch, causing an arterioportal shunt. APFs can be congenital (rare) or acquired (post-traumatic, post-liver biopsy, or tumor-associated — particularly HCC). They cause segmental or diffuse portal hypertension, potentially worsening pre-existing cirrhosis (ascites, esophageal varices).

Embolization is indicated for symptomatic (portal hypertension) or hemodynamically significant APFs, and for APFs associated with HCC in preparation for chemoembolization or radioembolization (arterioportal shunt prevents effective tumor targeting).

Pre-procedure assessment

Assessment includes multiphasic hepatic CT angiography (arterioportal shunt visualization: early portal enhancement during arterial phase), hepatic Doppler ultrasound (portal flow reversal), and portal hypertension workup if applicable.

Procedure

Under local anesthesia and sedation, a catheter is introduced through the femoral artery. Under fluoroscopic guidance, the hepatic arterial branch originating the fistula is identified by selective arteriography and super-selectively catheterized. Embolization is performed with calibrated particles, coils, or acrylic glue depending on fistula size and flow. The procedure takes 1 to 2 hours.

Results and scientific evidence

APF embolization offers 85-95% technical success rate and secondary portal hypertension resolution in most cases. For post-biopsy APFs, cure rate is 90-95%. For tumor-related APFs, embolization enables TACE or radioembolization to be performed.

Risks and complications

Segmental hepatic infarction (5-10%), abdominal pain (20-30%), non-target embolization (< 2%). Major complications are rare (< 3%). Recurrence risk exists mainly for tumor-related APFs.

Recovery

1-2 night hospitalization. Control Doppler ultrasound at 1-3 months to verify fistula closure.

Practical information

The procedure is performed as a short inpatient stay. It is performed by an interventional radiologist, in coordination with the hepatologist.