Saving Life through Endovascular Stent Grafting in Extreme Cases of Pancreatitis: Uncommon Superior Mesenteric Vein Erosion Intervention
In a recent medical case, a 41-year-old male with a medical history of hypertension and hyperlipidemia presented with acute pancreatitis and acute kidney injury. The patient's condition rapidly deteriorated, leading to severe necrotizing pancreatitis, a rare but life-threatening complication.
The superior mesenteric vein (SMV), a critical structure in mesenteric circulation, became involved in the patient's condition. Although SMV involvement in pancreatitis is rare, it can happen, as thrombosis and vascular complications such as splenic vein thrombosis and SMV thrombosis are documented in pancreatitis. In this case, the SMV eroded due to the inflammation and tissue necrosis, leading to hemorrhage.
Faced with this challenging situation, the medical team turned to endovascular stent grafting as a treatment modality. While specific case reports on SMV erosion treated by stent grafting are uncommon, the use of endovascular techniques to manage vascular erosions, pseudoaneurysms, or bleeding in pancreatitis-related vessels is increasingly recognised as a minimally invasive alternative to open surgery. The aim of this intervention is to exclude the damaged vessel segment, control bleeding, and preserve venous flow.
The patient underwent prompt diagnosis with imaging (usually CT angiography) to identify the site and extent of venous injury or erosion. Subsequently, endovascular intervention with stent-graft placement was performed to seal the venous defect and prevent hemorrhage while maintaining patency of the vessel. Supportive management, including control of pancreatitis and necrosis through medical and possibly surgical means, was also provided.
This case adds to the limited but growing body of evidence supporting the use of venous stenting for mesenteric venous injuries in necrotizing pancreatitis. The patient's successful treatment underscores the potential role of endovascular interventions, such as venous stenting, as life-saving procedures when conventional surgical techniques fail.
However, it is important to note that current evidence for this specific scenario remains scarce and mainly anecdotal. Treatment involves imaging diagnosis followed by endovascular repair or surgery depending on severity and patient stability. Broader reviews or case series in specialized vascular or pancreatic surgery literature would have more detailed evidence.
This case also highlights the complexity of vascular injuries in pancreatitis. The SMV is a complex structure, located near other vital structures, and the lack of established management guidelines makes injuries in this area especially challenging to treat.
The patient experienced hemodynamic collapse with severe hypotension and copious hemorrhagic output from his abdominal drains. Frank bloody output from his Jackson-Pratt (JP) drain prompted an urgent computed tomography angiography (CTA). Postoperative CTA and CT venogram showed left hepatic and splenic infarctions, a compressed mid-SMV with patent distal segments, and a hyperdense hematoma near the inferior vena cava (IVC).
Endoscopic retrograde cholangiopancreatography (ERCP) confirmed the absence of gallstones. The patient underwent decompressive laparotomies and necrosectomies due to worsening necrosis, pseudocyst formation, and nontraumatic abdominal compartment syndrome leading to end organ damage.
In conclusion, superior mesenteric vein erosion in necrotizing pancreatitis is an extremely rare but severe complication associated with vascular injury. Endovascular stent grafting has emerged as a viable therapeutic option for venous injury, particularly in high-risk cases where surgical repair is not feasible. The IR team was consulted for possible SMV repair, and the patient's hemorrhage was successfully managed with endovascular stent grafting of the SMV, a procedure not previously reported in the context of necrotizing pancreatitis. This case underscores the importance of continued research and the development of specialized treatment guidelines for managing such rare but life-threatening complications.
[1] Thrombosis and vascular complications in pancreatitis. UpToDate. Accessed on March 16, 2023. https://www.uptodate.com/contents/thrombosis-and-vascular-complications-in-pancreatitis
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