016 - Case Report: Use of Stent Grafts for Portal Vein and Superior Mesenteric Artery Injuries
John Rexroth, B.S. – Medical Student, Wayne University School of Medicine; P. Joe Massa, MD – Interventional Radiologist, Henry Ford Hospital; David McVinnie, MD – Interventional Radiologist, Henry Ford Hospital
Purpose: Portal venous and superior mesenteric artery injuries are rare pathologies with iatrogenic, traumatic, infectious/inflammatory, and neoplastic etiologies. Treatment possibilities include embolization and stenting. Here we report a case of sequential stenting of the portal vein (PV) and superior mesenteric artery (SMA) for biliary stent related vascular injuries.
Material and Methods: 67-year-old male Jehovah’s witness with unresectable pancreatic adenocarcinoma status post chemo and radiation who presented with bright red blood per rectum and drop in hemoglobin from 9.5 to 5.3 g/dL. Multiphasic CT did not initially identify bleeding source. At endoscopy, clot was seen in the stomach and duodenum without active hemorrhage. Repeat endoscopy one day later confirmed hemobilia with manipulation of the existing metallic biliary stent. IR review of the prior CT identified a PV pseudoaneurysm communicating directly with the stented common bile duct. Transhepatic portography confirmed PV pseudoaneurysm which was then excluded using a stent graft (Gore Viabahn VBX). The patient’s hemoglobin stabilized and he was discharged.
Results: Two months later the patient re-presented with recurrent bright red blood per rectum. Multiphasic CT demonstrated occlusion of the stented PV with new fistula between proximal SMA and the previously excluded PV pseudoaneurysm; arteriography confirmed the finding. A small branch arising from the proximal SMA opposite the fistulous connection was coil embolized (to prevent endoleak) and a stent graft (Gore Viabahn VBX) was placed across the fistula. Completion angiography confirmed occlusion of the arteriovenous fistula. The patient was subsequently discharged without further bleeding. He expired 5 months later due to other causes.
Conclusions: Patients with pancreatic tumors and common bile duct stents have a small risk of visceral arterial and venous injuries. Overall understanding of the risk factors and outcomes are lacking due to the paucity of reported cases. We present a case where these injuries were effectively treated with the use of stent grafting.