Endovascular stent grafting for superior mesenteric vein erosion in necrotizing pancreatitis: A lifesaving intervention in a rare complication

Abstract

Vascular complications, though rare, significantly increase the morbidity and mortality associated with necrotizing pancreatitis (NP). While arterial pseudoaneurysms are well-documented, major venous injuries, particularly superior mesenteric vein (SMV) erosion, are exceedingly uncommon, with only 2 cases previously reported in the literature. We describe a 41-year-old male with severe necrotizing pancreatitis complicated by abdominal compartment syndrome, who developed acute, life-threatening hemorrhage due to pancreatic enzyme erosion of the SMV. Surgical attempts to control the bleeding were unsuccessful, and the hemorrhage was ultimately managed with endovascular stent grafting of the SMV. This case underscores the complexity of vascular injuries in pancreatitis and highlights the potential role of endovascular interventions, such as venous stent grafting, as life-saving procedures when conventional surgical techniques fail. Our case adds to the limited but growing body of evidence supporting the use of venous stenting for mesenteric venous injuries in NP.

Keywords: Endovascular stent grafting; Hemorrhagic pancreatitis; Necrotizing pancreatitis; Superior mesenteric vein erosion; Vascular complications.

Fig. 1

A 41-year-old male diagnosed with pancreatitis. Contrast enhanced CT scan of the abdomen and the pelvis with axial (A) and coronal (B) images showing significant enlargement and edema of the pancreas with multiple areas of decreased enhancement concerning for acute necrotizing pancreatitis with peripancreatic fluid and stranding.

Fig. 2

A 41-year-old male diagnosed with necrotizing pancreatitis. (A) CT angiogram showing interval increase in size of the peripancreatic collection with mass effect and a focus of arterial hyperenhancement concerning for pseudoaneurysm (arrow). (B) Digital subtraction angiogram of the celiac artery shows dorsal pancreatic artery arising directly from the celiac trunk with a distal pseudoaneurysm (arrow). (C) A more selective DSA of the dorsal pancreatic artery showing the pseudoaneurysm. (D) Postglue embolization DSA of the celiac artery showing complete embolization of the dorsal pancreatic artery.

Fig. 3

A 41-year-old male diagnosed with necrotizing pancreatitis. (A) Axial and coronal (B) CT venogram showing a large hemorrhagic peripancreatic collection with evidence of surgical packing. The portal vein is degenerative but patent. The proximal SMV is not clearly visualized (arrow). Hematoma anterior to the IVC at the portacaval region (*).

Fig. 4

A 41-year-old male diagnosed with necrotizing pancreatitis and hemorrhage. (A) Transhepatic portal venogram showing abrupt termination of the central segment of the SMV (arrow) including inflow into the portal vein with delayed and faint opacification the portal vein (*) and a compressed central area. (B) Post stenting venogram showing a patent SMV and portal vein (arrow) and re-established portal flow (*). (C) Post transhepatic tract closure venogram using a vascular plug (arrow) and glue.

Fig. 5

A 41-year-old male diagnosed with necrotizing pancreatitis and hemorrhage from the SMV status post endovascular stent grafting of the SMV. Intraoperative observation of an exposed 0.5 cm segment of the stent off an SMV wall defect (arrows), without active bleeding.

Fig. 6

A 41-year-old male diagnosed with necrotizing pancreatitis and hemorrhage status post-SMV stent grafting. (A,B) Axial and (C) Coronal reconstruction images of a contrast enhanced CT scan demonstrating a patent stent within the portal vein (*) extending into the SMV in a tapered fashion (arrow).