CASE REPORT Open Access Endovascular treatment of hepatic arterioportal fistula complicated with giant portal vein aneurysm via percutaneous transhepatic US guided hepatic artery access: a case report and review of the literature Umut Oguslu * , Sadik Ahmet Uyanik and Burçak Gümüş Abstract Background: Hepatic arterioportal fistulas are rare, abnormal, direct communications between hepatic artery and portal venous system. Treatment options shifted from surgery to endovascular interventions. Catheterization may be challenging. We report a case of a hepatic arterioportal fistula treated successfuly with Amplatzer Vascular Plug II via percutaneous transhepatic hepatic artery access after failed transfemoral approach. Case presentation: 58 year old woman presented with right heart failure, kidney insufficiency and massive ascites related to portal hypertension caused by hepatic arterioportal fistula. She had a history of previous abdominal surgery. Colour Doppler ultrasound and computed tomography revealed a giant portal vein aneurysm related to large hepatic areterioportal fistula. Endovascular treatment was planned. Catheterization of the hepatic artery could not be realized due to severe tortuosity and angulation of the celiac artery and its branches. Access to the hepatic artery was obtained directly via percutaneous transhepatic route and fistula site was embolized with Amplatzer Vascular Plug II and coils. Immediate thrombosis of the aneurysm sac and draining portal vein was observed. Patients clinical status improved dramatically. Conclusion: Transcatheter embolization is the first choice of the treatment of hepatic arterioportal fistulas but the type of the therapy should be tailored to the patient and interventional radiologist should decide the access site depending on his own experience if the routine endovascular access can not be obtained. Keywords: Hepatic arterioportal fistula, Percutaneous transhepatic access, Amplatzer vascular plug Background Arterioportal fistulas (APFs) are rare vascular anomalies that consist of direct connection between mesenteric ar- terial structures to the portal veins. Majority of the APFs are asymptomatic. They may manifest with gastrointes- tinal bleeding, ascites, high – output heart failure, diar- rhea. Portal hypertension and hepatic cirrhosis (Vauthey et al. 1997). The interval between fistula formation and its detection has a range between hours to decades (Ryan and Lorber 1968). Open partial hepatic resection or surgical ligation of the feeding artery for treatment is the surgical option but has high risk of morbidity and long hospital stay in this patient with severe comorbidities. Recently endovas- cular treatment has become the first choice of treatment because of its less invasive nature and higher success rate in selected cases (Hirakawa et al. 2013). Target vessel anatomy may preclude safe access to APF localization via transfemoral approach. In these © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. * Correspondence: umutoguslu@gmail.com Department of Radiology, Okan University Hospital, Aydinli Cad. No: 2 Okan Universitesi Hastanesi Icmeler, Tuzla, Istanbul, Turkey CVIR Endovascular Oguslu et al. CVIR Endovascular (2019) 2:39 https://doi.org/10.1186/s42155-019-0084-y