Repeated Plastic Stentings of Common Hepatic Duct for Portal Vein Aneurysm Compression in a Patient Unsuitable for Surgery

Abstract

Portal vein aneurysms are rare vascular malformations with unclear etiologies and optimal treatment guidelines. Although Doppler ultrasonography is the most commonly used diagnostic tool, there is no gold standard imaging modality. Despite recommendations of surgical treatment for symptomatic aneurysms, there are limited options in the management of portal vein aneurysm-related complications in patients unfit for surgical intervention. We describe an 85-year-old man who presented with abdominal pain and low-grade fever with clinical signs consistent with cholangitis. Endoscopic retrograde cholangiopancreatography revealed a common hepatic duct stricture and concomitant intraductal ultrasonography identified adjacent aneurysmal portal vein dilatation. The final diagnosis of portal vein aneurysm was made using contrast computerized tomography scan. The patient was considered unsuitable for surgery due to his advanced age and multiple comorbidities. Instead, an endoscopic biliary plastic stent was inserted as a therapeutic alternative, which successfully achieved complete resolution of symptoms 3 days after the procedure. The patient was regularly followed at the outpatient clinic with repeated stent replacements every 3 to 4 months. After a follow-up of over 3.5 years, the patient remained symptom-free without signs of portal vein aneurysm compression. The result suggests that repeated stent replacements may be a therapeutic option for biliary compression by portal vein aneurysm in patients contraindicated for surgical intervention.

A large asymptomatic portal vein aneurysm in an old man

“…This case still represents one of the largest currently reported PVA. In addition, before the present case, only eight newly diagnosed PVAs have been described in patients aged 80 years or older and, among them, only four with no mention of cirrhosis or liver cancer 6,17‐19 . According to our knowledge, no paper aiming to compare PVA in patients with and without cirrhosis is available in the English literature.…”

“…In addition, before the present case, only eight newly diagnosed PVAs have been described in patients aged 80 years or older and, among them, only four with no mention of cirrhosis or liver cancer. 6,[17][18][19] According to our knowledge, no paper aiming to compare PVA in patients with and without cirrhosis is available in the English literature. A large majority of PVA are associated with cirrhosis and portal hypertension, 9 suggesting that portal hypertension is one of the most important conditions behind PVAs development.…”

Portal Vein Aneurysm Complicated by Thrombosis

“…Portal vein aneurysms are defi ned as having a portal vein diameter of > 1.9 cm in patients with cirrhosis and > 1.5 cm in healthy patients, or a portal vein extrahepatic diameter of > 2 cm and an intrahepatic diameter of > 0.9 cm [3][4][5][6]9] . Our patient had a portal vein diameter of 5.6 cm.…”

“…P ortal vein aneurysm (PVA) was fi rst described by Barzilai and Kleckner Jr [1] in 1956 and since then only 190 cases have been reported in the literature [2][3][4] . Portal vein aneurysm accounts for 3% [3][4][5][6][7] of all visceral aneurysms, with an incidence of 0.06% [5,7] , which has increased to 0.43% in recent years [3,4,6,8] with improved imaging procedures and incidental fi ndings. Portal vein aneurysms usually remain stable in size and do not progress [6] , 63% of them being extrahepatic.…”

“…Portal vein aneurysm accounts for 3% [3][4][5][6][7] of all visceral aneurysms, with an incidence of 0.06% [5,7] , which has increased to 0.43% in recent years [3,4,6,8] with improved imaging procedures and incidental fi ndings. Portal vein aneurysms usually remain stable in size and do not progress [6] , 63% of them being extrahepatic. Portal vein aneurysms of > 5 cm are extremely rare [9] .…”