Abstract
Extrahepatic portal vein aneurysm is a relatively uncommon entity. We reported the case of a 51-year-old man, who was incidentally diagnosed with an asymptomatic 52 × 65 mm portal vein aneurysm, which was located at the main trunk of the portal vein, just before its bifurcation. The patient was treated with partial clamping of the portal vein aneurysm and aneurysmorrhaphy. Postoperative course was uneventful. Surgical intervention should be considered for patients with large, symptomatic or expanding portal vein aneurysms.
Introduction
Extrahepatic portal vein aneurysm (PVA) is a relatively uncommon entity characterized by dilatation of the portal vein (PV), and it is often an incidental, asymptomatic finding. Since it was first described in 1956, less than 200 cases have been reported in the literature.1,2 The prevalence of PVAs is 0.43%, 72% of which are asymptomatic at presentation. 3 Although it has been identified more frequently in the recent years, the etiology and optimal management still remain a challenge. Herein, we presented the case of 51-year-old man, who was incidentally diagnosed with a large asymptomatic PVA and we described the surgical treatment.
Case report
A 51-year-old man, with no medical history, underwent an annual abdominal ultrasound check-up, which revealed a marked dilatation of the main PV. His abdomen was soft and non-tender, with no palpable abdominal mass. Subsequently, computed tomography angiography (CTA) showed a large PVA measuring 52 × 65 mm in maximal diameter (Figure 1) without evidence of thrombus. In order to prevent the complications of aneurysm such as rupture or thrombosis, an open surgical intervention was performed. We used a Satinsky to partially clamp the PV, allowing the blood flow and dividing the body of the PVA into two parts. The aneurysmal wall was laterally sutured, leaving it normal in size and contour. Postoperative course was uneventful, and follow-up with CTA detected no stricture or dilation of the PV.
Preoperative computed tomography angiography (CTA) showing a large portal vein aneurysm (PVA) measuring 52 × 65 mm in maximal diameter located at the main trunk of the portal vein.
Discussion
Extrahepatic PVA is an uncommon vascular abnormality, and the literature is confined to case reports and small series. The exact etiology of PVAs still remains controversial, although they appeared to be congenital or acquired. The most common location of the aneurysm is at the main PV trunk in 52.4% of the cases, followed by 44.3% at the confluence of the superior mesenteric vein and the splenic vein and 3.3% at the extrahepatic right or left PV. 3 Clinical symptoms of PVAs are proportionally related to size and small aneurysms are often asymptomatic. The most common presentation of PVA is abdominal pain, followed by incidental detection of asymptomatic patients on CTA or ultrasound, whereas the minority of patients may present with gastrointestinal bleeding. Complications of PVA include thrombosis, aneurysmal rupture, complete occlusion of the PV, portal-systemic shunt, and pressure effects on adjacent viscera. The natural history of PVA is not fully understood. As a result, there is no consensus for their optimal management so far. Most of the PVAs are managed conservatively.4,5 On the other hand, many asymptomatic PVA patients who were left undiagnosed or untreated have been presented with several severe complications and have high mortality rates due to rupture, local compression, or portal hypertension.6–8 We propose that surgical intervention should be considered once symptoms arise or the aneurysm expands, particularly when the diameter of the aneurysm exceeds 5 cm. The target is to relieve compression symptoms and to prevent potential complications, including rupture and thrombosis. Various procedures have been proposed, including reconstruction with aneurysmorrhaphy, 9 mesocaval or portocaval shunts, 7 polytetrafluoroethylene bypass, 10 or vein graft. However, there has been no consensus on a single best treatment. The type of the operation depends on the shape and the location of the aneurysm, the presence of complications, and the associated comorbidities such as liver cirrhosis and portal hypertension.11,12
Conclusions
Extrahepatic PVAs are a relatively rare clinical entity. They are often associated with cirrhosis and portal hypertension, although they may be discovered incidentally. Surgical intervention should be considered for patients with large or expanding, or symptomatic PVAs, in order to prevent potentially fatal complications. The management of PVA should be on a case-by-case basis, depending on symptoms, size, and anatomy of PVA.
Footnotes
Conflict of interest
None declared.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Ethical approval
This study was approved by the Institutional Review Board of the hospital.