Background <p>Hepatic arteriovenous fistula refers to the direct abnormal communication between the hepatic artery and the portal vein or hepatic vein. Clinical symptoms of hepatic arteriovenous fistula primarily depend on the blood flow volume, location, and duration of the fistula. Symptoms may include liver fibrosis, portal hypertension, enlarged heart, and ultimately heart failure. Congenital hepatic artery-portal fistula is a rare condition, predominantly observed in children or infants. Although interventional hepatic artery embolization is typically the initial treatment choice, it may not always be effective.</p> <p>Case presentation.</p> <p>We present a case of a 22-year-old Chinese male patient with hepatic arteriovenous fistula who underwent multiple interventional therapies. The patient was diagnosed with “hepatic artery-portal fistula, viral hepatitis B, and ascites” at Shengjing Hospital in August 2018, following complaints of abdominal distension. Hepatic artery embolization and diuretic treatment were administered, resulting in symptom relief. However, after discharge, the patient experienced recurrent abdominal distension, hematemesis, and melena. Consequently, hepatic artery embolization was performed periodically in May 2020, November 2020, January 2021, May 2021, and August 2021 to manage these conditions. During the hepatic artery embolization procedure, the contrast agent was monitored entering the portal vein directly from the hepatic artery. In the present case, interventional therapy was unable to completely block the fistula, providing only temporary relief. Consequently, liver transplantation is considered the ultimate treatment option for complex and diffuse intrahepatic vascular fistulas following hepatic artery embolization. The patient has currently been approved and registered for liver transplantation.</p> Conclusions <p>Patients with diffuse hepatic arteriovenous fistula are prone to symptoms of portal hypertension, such as gastrointestinal bleeding caused by esophageal-gastric varices and ascites resulting from poor venous return, which significantly impact patient safety and quality of life. Arterial embolization provides only temporary symptom control. In cases where diffuse hepatic arteriovenous fistula is suspected or when interventional treatment fails, prompt liver transplantation should be considered. Therefore, this case report aims to enhance the understanding of the timing and selection of hepatic arteriovenous fistula treatment, along with providing a review of previous studies.</p>