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Extrahepatic Portal Vein Aneurysm
Case Report Extrahepatic Portal Vein Aneurysm Giovanni Battista Levi Sandri, Laurent Sulpice, Michel Rayar, Elise Bosquet, Karim Boudjema, and Bernard Meunier, Rennes, France
Portal vein aneurysms (PVAs) are usually incidental on imaging and asymptomatic. If it is symptomatic or associated with a pathologic finding, a treatment is recommended. We report a case of a 75-year-old Caucasian man presenting with symptomatic and size-increasing portosplenomesenteric aneurysms. Interventional radiology was not indicated because of the large size. A surgical approach was chosen for the patient. Surgical technique consists of an aneurysmorrhaphy in the first time and in the second time, a Goretex prosthesis placement involving the vein. Early complication was treated with a radiologic approach. Six months after surgery, patient had no more symptoms. PVA management remains a surgical challenge for surgeon, for timing and type of treatment.
Portal vein aneurysms (PVAs) are usually incidental on imaging and asymptomatic. The aneurysms are acquired, and many causes are known as secondary to advanced hepatocellular disease with portal hypertension, pancreatitis, trauma, after liver transplantation, and less commonly PVAs have been described in the pediatric population without underlying liver disease or portal hypertension.1 A few number of PVAs are congenital, they are a result of an underlying congenital weakness of the portal vein wall.2 If PVA is symptomatic or associated with a pathologic finding, a treatment is recommended. Medical management includes anticoagulation, and surgical management includes aneurysmorrhaphy, portocaval, and mesocaval shunt. We report a case of a 75-year-old Caucasian man presenting with symptomatic and size-increasing
Service de Chirurgie Hepatobiliaire et Digestive, Centre Hospitalier Universitaire de Rennes, Universite de Rennes 1, Rennes, France. Correspondence to: Bernard Meunier, MD, PhD, Service de Chirurgie Hepatobiliaire et Digestive, Centre Hospitalier Universitaire de Rennes, Universite de Rennes 1, Rennes, France; E-mail: bernard. [email protected] Ann Vasc Surg 2014; -: 1–3 http://dx.doi.org/10.1016/j.avsg.2013.11.018 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: November 16, 2013; manuscript accepted: November 20, 2013; published online: ---.
portosplenomesenteric aneurysms. Past medical history included hypertension, dyslipidemia, arrhythmias, hypothyroidism, benign prostatic hypertrophy, appendectomy, and cholecystectomy. Diagnosis of PVA has been done in 2004 after an ultrasound examination. Until November 2011, no evolution or symptom has been described since diffuse abdominal pain. A computed tomography (CT) was performed showing an increasing size of the PVA, from 4 cm to 8 cm (Fig. 1). Interventional radiology was not indicated because of the large size. A surgical approach was chosen for the patient. A laparotomy was performed, and the first exploration of abdominal cavity was done. After anticoagulation, both sides of the aneurysm were clamped, and a longitudinal incision of the vein at the level of the aneurysm was performed. Then, excision of excess aneurysm wall was done. A continuous suture was performed to restore a normal vein diameter. Finally, the wall of the vein was enhanced by a Goretex prosthesis (Fig. 2). Ultrasound Doppler was performed, and portal vein velocity was calculated (15 mm Hg). The clamping time was 15 min. No blood transfusion was needed. Tight stenosis of the prosthesis was observed at the first CT scan control, and a radiologic stent was placed. Six months after surgery, patient had no more symptoms. The CT scan shows a functioning 1
2 Case Report
Annals of Vascular Surgery
Fig. 1. Computed tomography before surgery.
Fig. 3. Computed tomography control 6 month after surgery.
Fig. 2. Intraoperative picture of the prosthesis.
prosthesis, and portal vein stent is permeable (Fig. 3).
DISCUSSION PVA is unusual.3 It is defined by a focal length of the vein beyond the normal expansion. Etiology remains controversial,4e6 in our case, we considered a congenital etiology. To prevent potential serious complications in a patient with low surgical risk, a surgical treatment of the aneurysm is recommended.3,7 Surgical
option should be considered if the aneurysm causes symptoms, if size increases with high risk of thrombosis or rupture.3,8 Otherwise, a conservative attitude seems reasonable if the aneurysm is surgically inaccessible.9 Patients with portal hypertension and portal vein thrombosis are usually candidates for surgical bypass: portocaval or mesocaval shunts to reduce portal pressure may prevent progressive dilation of the portal aneurysm. If thrombosis is present into the superior mesenteric and splenic veins, a thrombectomy is recommended.10 In patients without portal hypertension, an aneurysmorrhaphy procedure could be performed to preserve the portal circulation and restores a laminar flow in the portal vein. In our case, the patient had a giant saccular aneurysm of the splenic-mesenteric confluence, and we opted for a new approach. This technique reduces the risk of thrombosis preserving the intima of the vein and restores a laminar flow. The consolidation of the vein wall was made using a Goretex prosthesis around the vein. However, the risk of stenosis becomes more important. PVA management remains a surgical challenge for surgeon, for timing and type of treatment. It is,
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2014
in our opinion, a serious alternative to aneurysmorrhaphy procedure described in the literature. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. REFERENCES 1. Fulcher A, Turner M. Aneurysms of the portal vein and superior mesenteric vein. Abdom Imaging 1997;22:287e92. 2. Gallagher DM, Leiman S, Hux CH. In utero diagnosis of a portal vein aneurysm. J Clin Ultrasound 1993;21:147e51. 3. Barzilai R, Kleckner MS. Hemocholecyst following ruptured aneurysm of portal vein ; report of a case. Arch Surg 1956;72:725e7. 4. Giavroglou C, Xinou E, Fotiadis N. Congenital extrahepatic portal vein aneurysm. Abdom Imaging 2006;31:241e4.
Case Report 3
5. Lee HC, Yang YC, Shih SL, Chiang HJ. Aneurysmal dilatation of the portal vein. J Pediatr Gastroenterol Nutr 1989;8:387e9. 6. Novelo P, Derghal K, Lambert A, Labadie H, Dyan S, Licht H. Aneurysmal malformation of the extrahepatic portal vein. Gastroenterol Clin Biol 1994;18:81e3. 7. Calligaro KD, Ahmad S, Dandora R, et al. Venous aneurysms, surgical indications and review of the literature. Surgery 1995;117:1e6. 8. Thomas TV. Aneurysm of the portal vein: report of two cases, one resulting in thrombosis and spontaneous rupture. Surgery 1967;61:550e5. 9. Rafiq SA, Sitrin MD. Portal vein aneurysm: case report and review of the literature. Gastroenterol Hepatol (N Y) 2007;3: 296e8. 10. Glazer S, Gaspar RM, Esposito V, Harrison L. Extrahepatic portal vein aneurysm: report of a case treated by thrombectomy and aneurysmorrhaphy. Ann Vasc Surg 1992;6: 338e43.
Portal vein aneurysms (PVAs) are usually incidental on imaging and asymptomatic. If it is symptomatic or associated with a pathologic finding, a treatment is recommended. We report a case of a 75-year-old Caucasian man presenting with symptomatic and size-increasing portosplenomesenteric aneurysms. Interventional radiology was not indicated because of the large size. A surgical approach was chosen for the patient. Surgical technique consists of an aneurysmorrhaphy in the first time and in the second time, a Goretex prosthesis placement involving the vein. Early complication was treated with a radiologic approach. Six months after surgery, patient had no more symptoms. PVA management remains a surgical challenge for surgeon, for timing and type of treatment.
Portal vein aneurysms (PVAs) are usually incidental on imaging and asymptomatic. The aneurysms are acquired, and many causes are known as secondary to advanced hepatocellular disease with portal hypertension, pancreatitis, trauma, after liver transplantation, and less commonly PVAs have been described in the pediatric population without underlying liver disease or portal hypertension.1 A few number of PVAs are congenital, they are a result of an underlying congenital weakness of the portal vein wall.2 If PVA is symptomatic or associated with a pathologic finding, a treatment is recommended. Medical management includes anticoagulation, and surgical management includes aneurysmorrhaphy, portocaval, and mesocaval shunt. We report a case of a 75-year-old Caucasian man presenting with symptomatic and size-increasing
Service de Chirurgie Hepatobiliaire et Digestive, Centre Hospitalier Universitaire de Rennes, Universite de Rennes 1, Rennes, France. Correspondence to: Bernard Meunier, MD, PhD, Service de Chirurgie Hepatobiliaire et Digestive, Centre Hospitalier Universitaire de Rennes, Universite de Rennes 1, Rennes, France; E-mail: bernard. [email protected] Ann Vasc Surg 2014; -: 1–3 http://dx.doi.org/10.1016/j.avsg.2013.11.018 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: November 16, 2013; manuscript accepted: November 20, 2013; published online: ---.
portosplenomesenteric aneurysms. Past medical history included hypertension, dyslipidemia, arrhythmias, hypothyroidism, benign prostatic hypertrophy, appendectomy, and cholecystectomy. Diagnosis of PVA has been done in 2004 after an ultrasound examination. Until November 2011, no evolution or symptom has been described since diffuse abdominal pain. A computed tomography (CT) was performed showing an increasing size of the PVA, from 4 cm to 8 cm (Fig. 1). Interventional radiology was not indicated because of the large size. A surgical approach was chosen for the patient. A laparotomy was performed, and the first exploration of abdominal cavity was done. After anticoagulation, both sides of the aneurysm were clamped, and a longitudinal incision of the vein at the level of the aneurysm was performed. Then, excision of excess aneurysm wall was done. A continuous suture was performed to restore a normal vein diameter. Finally, the wall of the vein was enhanced by a Goretex prosthesis (Fig. 2). Ultrasound Doppler was performed, and portal vein velocity was calculated (15 mm Hg). The clamping time was 15 min. No blood transfusion was needed. Tight stenosis of the prosthesis was observed at the first CT scan control, and a radiologic stent was placed. Six months after surgery, patient had no more symptoms. The CT scan shows a functioning 1
2 Case Report
Annals of Vascular Surgery
Fig. 1. Computed tomography before surgery.
Fig. 3. Computed tomography control 6 month after surgery.
Fig. 2. Intraoperative picture of the prosthesis.
prosthesis, and portal vein stent is permeable (Fig. 3).
DISCUSSION PVA is unusual.3 It is defined by a focal length of the vein beyond the normal expansion. Etiology remains controversial,4e6 in our case, we considered a congenital etiology. To prevent potential serious complications in a patient with low surgical risk, a surgical treatment of the aneurysm is recommended.3,7 Surgical
option should be considered if the aneurysm causes symptoms, if size increases with high risk of thrombosis or rupture.3,8 Otherwise, a conservative attitude seems reasonable if the aneurysm is surgically inaccessible.9 Patients with portal hypertension and portal vein thrombosis are usually candidates for surgical bypass: portocaval or mesocaval shunts to reduce portal pressure may prevent progressive dilation of the portal aneurysm. If thrombosis is present into the superior mesenteric and splenic veins, a thrombectomy is recommended.10 In patients without portal hypertension, an aneurysmorrhaphy procedure could be performed to preserve the portal circulation and restores a laminar flow in the portal vein. In our case, the patient had a giant saccular aneurysm of the splenic-mesenteric confluence, and we opted for a new approach. This technique reduces the risk of thrombosis preserving the intima of the vein and restores a laminar flow. The consolidation of the vein wall was made using a Goretex prosthesis around the vein. However, the risk of stenosis becomes more important. PVA management remains a surgical challenge for surgeon, for timing and type of treatment. It is,
Vol.
-,
No.
-, -
2014
in our opinion, a serious alternative to aneurysmorrhaphy procedure described in the literature. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. REFERENCES 1. Fulcher A, Turner M. Aneurysms of the portal vein and superior mesenteric vein. Abdom Imaging 1997;22:287e92. 2. Gallagher DM, Leiman S, Hux CH. In utero diagnosis of a portal vein aneurysm. J Clin Ultrasound 1993;21:147e51. 3. Barzilai R, Kleckner MS. Hemocholecyst following ruptured aneurysm of portal vein ; report of a case. Arch Surg 1956;72:725e7. 4. Giavroglou C, Xinou E, Fotiadis N. Congenital extrahepatic portal vein aneurysm. Abdom Imaging 2006;31:241e4.
Case Report 3
5. Lee HC, Yang YC, Shih SL, Chiang HJ. Aneurysmal dilatation of the portal vein. J Pediatr Gastroenterol Nutr 1989;8:387e9. 6. Novelo P, Derghal K, Lambert A, Labadie H, Dyan S, Licht H. Aneurysmal malformation of the extrahepatic portal vein. Gastroenterol Clin Biol 1994;18:81e3. 7. Calligaro KD, Ahmad S, Dandora R, et al. Venous aneurysms, surgical indications and review of the literature. Surgery 1995;117:1e6. 8. Thomas TV. Aneurysm of the portal vein: report of two cases, one resulting in thrombosis and spontaneous rupture. Surgery 1967;61:550e5. 9. Rafiq SA, Sitrin MD. Portal vein aneurysm: case report and review of the literature. Gastroenterol Hepatol (N Y) 2007;3: 296e8. 10. Glazer S, Gaspar RM, Esposito V, Harrison L. Extrahepatic portal vein aneurysm: report of a case treated by thrombectomy and aneurysmorrhaphy. Ann Vasc Surg 1992;6: 338e43.