Surgical Management of Hepatocellular Carcinoma Complicated by Severe Portal Hypertension Secondary to an Arterioportal Shunt: A Case Report.

Abstract

Introduction: Arterioportal (AP) shunts are a recognized vascular complication of hepatocellular carcinoma (HCC). Severe AP shunts can cause portal hypertension, which can lead to complications such as variceal bleeding and refractory ascites. However, optimal management of HCC complicated by severe AP shunts remains challenging, particularly in patients with advanced disease.

Case presentation: A 73-year-old woman presented with melena and massive hematemesis due to esophageal varices. Contrast-enhanced computed tomography revealed multifocal HCC confined to the right hepatic lobe, Vp3 portal vein tumor thrombosis, and a high-flow AP shunt with hepatofugal portal flow. Despite treatment with diuretics, progressive portal hypertension resulted in rapidly worsening refractory ascites. Although the disease corresponded to Barcelona Clinic Liver Cancer stage C, hepatic functional reserve was relatively preserved, with no extrahepatic metastases having been identified. Angiography revealed a severe AP shunt with persistent opacification of the portal venous system even under balloon-assisted angiography, suggesting exceptionally high shunt flow. Given that the severe portal hypertension was primarily attributed to the AP shunt, right hepatectomy was performed with the dual aim of curative tumor resection and AP shunt elimination. Histopathological examination revealed HCC with portal vein tumor thrombosis and a vessel-encapsulating tumor cluster pattern. Postoperatively, portal venous flow normalized, refractory ascites resolved completely, and tumor marker levels markedly decreased.

Conclusion: In carefully selected patients with HCC complicated by a severe AP shunt, hepatectomy may represent a potential treatment option for simultaneously achieving tumor control and alleviating AP shunt-related portal hypertension. Treatment decisions should consider hemodynamic abnormalities in addition to conventional tumor staging and require careful multidisciplinary evaluation.