Lifesaving Intervention of Endovascular Stent Grafting for Erosion of Superior Mesenteric Vein in Necrotizing Pancreatitis - A Remarkable Solution to a Rare Condition
A 41-year-old male, with a medical history of hypertension and hyperlipidemia, presented with acute pancreatitis and acute kidney injury. The case, described in this article, is complicated by abdominal compartment syndrome and refractory hemorrhage from Superior Mesenteric Vein (SMV) erosion.
Necrotizing pancreatitis (NP) can lead to severe vascular complications, and the SMV is no exception. This rarity and lack of established management guidelines make SMV injuries particularly challenging. In this case, the patient experienced hemodynamic collapse with severe hypotension and copious hemorrhagic output from his abdominal drains.
Computed tomography (CT) of the abdomen revealed acute interstitial pancreatitis. The bleeding was promptly investigated with an urgent computed tomography angiography (CTA), which revealed an arterial source of bleeding from a branch of the celiac artery. Frank bloody output from his Jackson-Pratt (JP) drain further emphasized the urgency of the situation.
Interventional radiology (IR) embolized a 12 mm dorsal pancreatic artery pseudoaneurysm (Figure 2). However, the bleeding persisted, and the CTA showed that the source of the bleeding was from the SMV. In this complex case, SMV stenting was the life-saving procedure that successfully controlled the bleeding.
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) (Figure 3). The stent was confirmed within the disrupted venous wall during subsequent surgical confirmation.
Necrotizing pancreatitis significantly increases morbidity and mortality in approximately 25% of patients. To the authors' knowledge, this is the first reported case of SMV erosion treated with endovascular stent grafting in the context of NP. Endovascular stenting has emerged as a viable therapeutic option for venous injury, particularly in high-risk cases where surgical repair is not feasible.
Endoscopic retrograde cholangiopancreatography (ERCP) confirmed the absence of gallstones, ruling out gallstone pancreatitis as the cause. The patient's condition required mechanical ventilation for hypoxic respiratory failure.
Rare cases of SMV erosion in necrotizing pancreatitis can occur due to direct enzymatic vascular wall damage from pancreatic enzymes, perivascular inflammation, or external compression. Endovascular stent grafting has been used as a management strategy to repair the damaged vein and prevent hemorrhagic complications.
In conclusion, superior mesenteric vein erosion in necrotizing pancreatitis results from pancreatic enzyme injury and inflammation. Endovascular stent grafting offers a valuable treatment option to manage this rare but serious vascular complication by sealing the defect and preserving venous circulation. Early diagnosis and prompt endovascular treatment can reduce morbidity by controlling hemorrhage and maintaining venous flow.
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