Surgical procedure using endovascular stent grafting for addressing erosion in the superior mesenteric vein in patients with necrotizing pancreatitis; a critical treatment option for an uncommon complication
A 41-year-old male, with a medical history of hypertension and hyperlipidemia, presented with acute pancreatitis and acute kidney injury. Computed tomography (CT) of the abdomen revealed acute interstitial pancreatitis (Fig. 1). As the condition worsened, the patient developed severe necrotizing pancreatitis complicated by abdominal compartment syndrome.
The hemorrhage, caused by pancreatic enzyme erosion of the superior mesenteric vein (SMV), was life-threatening. Surgical attempts to control the bleeding were unsuccessful. The CTA revealed an arterial source of bleeding from a branch of the celiac artery.
In a bid to manage the hemorrhage, the IR team was consulted for possible SMV repair. Interventional radiology (IR) embolized a 12 mm dorsal pancreatic artery pseudoaneurysm (Fig. 2). However, the hemorrhage ultimately required endovascular stent grafting of the SMV.
The case adds to the limited but growing body of evidence supporting the use of venous stenting for mesenteric venous injuries in necrotizing pancreatitis (NP). Venous injuries in NP are particularly challenging due to their rarity and the lack of established management guidelines.
Endoscopic retrograde cholangiopancreatography (ERCP) confirmed the absence of gallstones. The patient required mechanical ventilation for hypoxic respiratory failure. Due to worsening necrosis, pseudocyst formation, and nontraumatic abdominal compartment syndrome leading to end organ damage, the patient underwent decompressive laparotomies and necrosectomies.
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) (Fig. 3).
It is worth noting that, based on typical scientific literature knowledge, superior mesenteric vein erosion due to necrotizing pancreatitis is an extremely rare but serious complication. Published cases are exceedingly few and appear sporadic rather than accumulated in large series. To the best of the authors' knowledge, no prior cases of SMV erosion treated with endovascular stent grafting in the context of NP have been reported.
This case highlights the potential role of endovascular interventions, such as venous stent grafting, as life-saving procedures when conventional surgical techniques fail. If you require the precise number from peer-reviewed literature, a dedicated systematic review or a search through specialized medical databases (e.g., PubMed, Embase) focusing on case reports or series of "superior mesenteric vein erosion," "necrotizing pancreatitis," and "endovascular stent grafting" may be needed.
- Interventional radiology (IR) played a crucial role in managing the life-threatening hemorrhage caused by pancreatic enzyme erosion of the superior mesenteric vein (SMV), employing therapies such as embolization and endovascular stent grafting.
- In the field of medical-conditions like chronic diseases, such as necrotizing pancreatitis (NP), the scientific investigation into effective therapies and treatments continues to grow, with evidence supporting the use of venous stenting for mesenteric venous injuries in NP.
- The treatment of type-2 diabetes, hypertension, and other health-and-wellness concerns is essential for managing underlying medical-conditions, and in this case, the patient's history of hypertension and hyperlipidemia could have contributed to the development of acute pancreatitis.
