Usefulness of A Portal Vein Stent for Sinistral Portal Hypertension: A Case Report

Abstract

Introduction: Portal vein (PV) and splenic vein (SV) stenosis are known complications of pancreatoduodenectomy (PD) and often lead to portal hypertension. PV stenosis extending to the SV confluence can result in sinistral portal hypertension (SPH), characterized by gastrointestinal varices and splenomegaly in the presence of normal liver function. There is no standardized treatment strategy for SPH following PD.

Case presentation: A 42-year-old female underwent robot-assisted PD for a pancreatic neuroendocrine tumor without immediate PV complications. Postoperatively, the patient experienced fluid retention; however, this did not pose a problem, and no therapeutic intervention was necessary. Two months later, imaging revealed PV stenosis and SV obstruction. Eleven months after surgery, the patient presented with melena, and imaging confirmed the presence of gastroesophageal varices with severe PV stenosis and complete SV obstruction. Endoscopic variceal ligation was performed, and the hemodynamic status of the portal system was assessed using computed tomography during arterial portography (CTAP). CTAP showed communication between the superior mesenteric vein and the SV via the middle colic vein. Therefore, we decided to perform PV stenting. The stent was successfully placed, resulting in a significant improvement in the esophageal varices. The patient was discharged on postoperative day 4, receiving anticoagulant therapy, with no further complications.

Conclusions: This case demonstrates the efficacy of PV stenting after careful hemodynamic assessment in a patient who developed SPH due to PV stenosis and SV obstruction following PD.

Keywords: pancreatoduodenectomy; portal vein stenosis; portal vein stent; sinistral portal hypertension; splenic vein stenosis.

Fig. 1. Photograph of the PV immediately after resection. The LGV, MCV, SV, and IMV were preserved.

IMV, inferior mesenteric vein; LGV, left gastric vein; MCV, middle colic vein; PV, portal vein; SV, splenic vein

Fig. 2. (A, B) Enhanced CT at 1 week after surgery. Enhanced CT showed fluid accumulation around the PV and SV (arrows). There was mild stenosis but no obvious blood flow obstruction in the PV or SV (arrowhead). (C–E) Enhanced CT at 2 months after surgery. (C, D) Inflammatory changes around the PV and obstruction of the SV were observed (arrowheads). (E) No development of esophageal varices (arrow).

PV, portal vein; SV, splenic vein

Fig. 3. Enhanced CT at the time of hemorrhage. (A, B) Inflammatory changes were observed around the PV, along with severe stenosis of the PV and obstruction of the SV (arrowheads). (C) The development of esophageal varices was noted (arrow).

PV, portal vein; SV, splenic vein

Fig. 4. (A) Upper gastrointestinal endoscopy at the time of bleeding. Well-developed varices were observed in a circumferential fashion from the incisor 30 cm to the esophagogastric junction. (B) Upper gastrointestinal endoscopy 2 days after portal vein stenting. The esophageal varices had nearly disappeared, leaving only scars from endoscopic variceal ligation.

Fig. 5. CT during arterial portography. (A, C) Splenic arteriography revealed obstruction of the SV. Furthermore, the collateral veins around the esophagus and stomach were similarly enhanced, and the left PV was contrasted via the collateral vein around the pancreaticojejunal anastomosis. (B, D) SMA angiography showed that a portion of the SV, as well as the esophageal and perigastric collateral veins, were contrasted from the MCV via the omental vein and the transverse colonic marginal vein.

IMV, inferior mesenteric vein; MCV, middle colic vein; PV, portal vein; SMA, superior mesenteric artery; SMV, superior mesenteric vein; SV, splenic vein

Fig. 6. The patient underwent PV stenting via the ileocecal approach. (A) Portography before stenting. The left branch of the PV was not contrasted at all, and the MCV was contrasted. (B) Portography after stenting. The left branch of the PV was slightly contrasted, and the MCV was no longer contrasted. (C) Enhanced CT performed 2 years after PV stenting showed no stent migration or occlusion (arrow) and no recurrence of esophageal varices.

MCV, middle colic vein; PV, portal vein