Left hepatectomy for chronic biopsy-induced intrahepatic arterioportal fistula with aneurysmal degeneration

Arterioportal fistula (APF) is a rare complication of percutaneous liver biopsy. While most biopsy-induced shunts are asymptomatic and resolve on their own, persistent high-flow lesions can lead to progressive vascular remodeling, creating significant management challenges. A 49-year-old woman presented 17 years after undergoing a percutaneous liver biopsy, complaining of a pulsatile epigastric mass. Computed tomography revealed a large aneurysmal intrahepatic APF involving the middle hepatic artery and left portal vein. Due to the complexity of the anatomy and concerns about portal perfusion, endovascular embolization was not pursued. Instead, the patient underwent a formal left hepatectomy, which effectively controlled the fistulous area. Histopathological examination confirmed chronic arterialization of portal venous structures, accompanied by fibromyxoid intimal thickening, consistent with long-standing high-flow shunting. This case illustrates the delayed progression of biopsy-induced APF and emphasizes that hepatic resection is a definitive and safe option for anatomically complex lesions when embolization is not feasible. Careful preoperative mapping of arterial inflow and portal venous outflow is essential for effective operative planning and safe resection in complex APFs.