Gastrointestinal Hemorrhage from Portal Vein Pseudoaneurysm after Pancreaticojejunostomy in Chronic Calcific Pancreatitis: A Stent Graft Rescue

Abstract

Pseudoaneurysms of the portal vein are rare vascular abnormalities resulting from causes, including trauma, pancreatitis, or pancreaticobiliary surgery. They can be asymptomatic, but can present with significant gastrointestinal bleed, despite low pressure gradient in venous systems. We describe a rare case of symptomatic portal vein pseudoaneurysm following pancreaticojejunostomy surgery, presenting with massive gastrointestinal hemorrhage, which was subsequently managed with a percutaneous transhepatic portal stent graft.

Keywords

pseudoaneurysm - chronic pancreatitis - pancreaticojejunostomy

Case Report

A 32-year-old man, a known case of chronic calcific pancreatitis with recurrent abdominal pain, underwent a lateral pancreatojejunostomy. The postoperative period was uneventful, and he was discharged on fifth postoperative day. Two weeks later, the patient presented to the emergency department with abdominal pain following a severe episode of hematemesis. He also reported two episodes of melena on the previous day. Patient's blood pressure was 90/50 mm Hg, and he had tachycardia (110/min), with serum hemoglobin of 6 g%. After initial stabilization with intravenous fluids and blood products, an upper gastrointestinal endoscopy was performed, which revealed fresh blood clots in the duodenum and the proximal jejunum.

An emergency computed tomography (CT) angiography was subsequently performed, which revealed blood clots at the pancreatojejunostomy site and a 5 × 4 mm size saccular portal vein pseudoaneurysm arising from the main portal vein, projecting into the pancreaticojejunal anastomotic site ([Fig. 1A–C]). Adjacent portal vein focal narrowing and a mural-based, nonocclusive thrombus along the anterior wall of the portal vein were also noted ([Fig. 1B]). Chronic pancreatic parenchymal calcification was noted in the pancreatic head region ([Fig. 1B]). After multidisciplinary team discussion, it was decided to do an emergency percutaneous transhepatic portal vein covered stenting, to exclude the aneurysm.

Fig. 1 (A) Axial computed tomography (CT) abdomen (portal venous phase) image showing small portal vein pseudoaneurysm projecting into pancreaticojejunostomy site (black arrow). (B) Oblique sagittal reconstructed CT abdomen (portal venous phase) maximum intensity projection (MIP) image showing portal pseudoaneurysm (thick white arrow), mural-based portal vein nonocclusive thrombus (white arrow), and pancreatic parenchymal calcification (dotted white arrow). (C) Coronal volumetric rendered reconstructed image showing portal vein pseudoaneurysm (arrow).

Ultrasound-guided puncture of the right anterior branch of the portal vein was performed using a micropuncture set (Cook Medical, Bloomington, United States), followed by the placement of a 10 Fr sheath (Performer; Cook Medical). The area of portal vein narrowing and the pseudoaneurysmal site was successfully negotiated using a hydrophilic guidewire (Glidewire; Terumo, Tokyo, Japan) and a multipurpose catheter. Digital subtraction angiography revealed a saccular pseudoaneurysm of the main distal portal vein, just 1 cm proximal to splenomesenteric vein confluence, with active contrast extravasation seen on delayed images on high-pressure injection ([Fig. 2A, B]). The hydrophilic guidewire was then exchanged for an Amplatz SuperStiff guidewire. A 12 mm × 60 mm FLUENCY Plus Vascular Stent Graft (Bard Peripheral Vascular, Tempe, Arizona, United States) was deployed across the pseudoaneurysm, with the distal tip positioned just at the portomesenteric confluence. Poststent deployment venography demonstrated complete exclusion of the aneurysm, with patent intrahepatic and extrahepatic portal veins, as well as the superior mesenteric vein ([Fig. 3A, B]). The thrombus within portal vein was partially removed with mechanical thrombectomy with the AngioJet Thrombectomy System. The hepatic parenchymal tract was embolized using 8 mm × 5 mm pushable coils (Nester; Cook Medical) and a slurry of gelatin sponge (Gelfoam; Pfizer Inc.). During the procedure, 5000 IU of heparin were administered.

Fig. 2 (A) Digital subtraction angiographic image showing portal vein pseudoaneurysm (black arrow) and filling defect in main portal vein representing mural thrombus (thick black arrow). (B) Digital subtraction angiographic image showing active contrast extravasation from portal pseudoaneurysm.

Fig. 3 (A) Digital subtraction angiographic image showing portal vein stent graft with wall-to-wall flow and exclusion of aneurysm (arrow). (B) Fluoroscopic spot image showing patent stent graft (arrow), with patent superior mesenteric vein and intrahepatic portal vein branches.

The patient was discharged 2 days later on oral anticoagulation therapy with tablet Eliquis 5 mg twice daily, with no further episodes of melena. Follow-up Doppler ultrasound at 1 month confirmed a patent portal vein stent.

Discussion

Portal vein aneurysms are rare vascular anomalies, comprising less than 3% of all venous aneurysms.[1] They can occur along the entire length of the portal vein, with the extrahepatic portal vein trunk and the splenoportal confluence being the most common sites. Chronic liver disease, pancreatitis, traumatic injuries, and Budd–Chiari syndrome are notable acquired causes, alongside congenital etiologies.[1]

Portal vein pseudoaneurysm formation in the context of acute pancreatitis occurs secondary to the leakage of pancreatic enzymes, leading to localized inflammation and weakening or dehiscence of the portal vein wall.[2] Locoregional malignancies involving the pancreas or stomach can also infiltrate the portal venous wall. Portal vein injuries due to blunt trauma or pancreatic surgery are additional significant causes ([Table 1]). While portal pseudoaneurysms may remain asymptomatic, they can also present with massive, life-threatening gastrointestinal hemorrhage, as seen in our case.

Table 1 Portal vein pseudoaneurysm reported cases and management

Author	Etiology of portal pseudoaneurysm	Treatment
Pescatori et al (2020)[6]	Pancreatic surgery	Portal vein stent
Walton et al (2018)[5]	Pancreatic lymphoma with biliary stenting(traumatic)	Portal vein stent
Lerardi et al (2016)[4]	Blunt trauma	Portal vein stent
Weber et al (2016)[7]	Seat belt injury	Portal vein stent
Javadrasshid et al (2012)[a]	Spontaneous	Surgery
Walis et al (2010)[a]	Blunt trauma	Conservative

^a Javarashid et al. and Walis et al. are described in Walton et al.[5]

CT angiography is the preferred imaging modality for evaluating nontraumatic, emergent abdominal vascular complications following pancreatic surgeries.[2] Vascular complications after pancreatic surgery are not uncommon, with arterial injuries—especially involving the gastroduodenal and pancreaticoduodenal arcades—being frequently observed. However, only a few isolated cases of portal vein aneurysms have been reported postpancreatic surgery. One case described a portal vein aneurysm with a portoenteric fistula following pancreaticoduodenectomy.[3] To our knowledge, no prior reports exist in the literature of a portal vein pseudoaneurysm occurring after lateral pancreatojejunostomy for chronic calcific pancreatitis.

Asymptomatic posttraumatic portal vein pseudoaneurysms can be managed conservatively with serial imaging to monitor for changes in size or intraluminal thrombosis. However, symptomatic or bleeding pseudoaneurysms require urgent intervention through either open surgical or endovascular approaches.[4] Open surgical procedures such as aneurysmectomy or aneurysmorrhaphy carry high morbidity and mortality in these patients. Endovascular management options include coiling and stent grafting. Since the aneurysm had a wide neck and was close to the splenomesenteric confluence, stent graft placement was deemed the most suitable treatment option. Conversely, endovascular placement of a portal vein stent graft via a transhepatic approach offers a viable, minimally invasive treatment option for such challenging cases.[4] A review of the literature reveals four previously reported cases where portal vein stent grafts were used: two in traumatic settings, one in a patient with pancreatic lymphoma and biliary stenting, and one after pancreaticoduodenectomy ([Table 1]). Polytetrafluoroethylene-covered stent grafts are best suited for such cases with 1 year stent patency reported in most of cases.[5] However, recent advances in stent materials, such as the addition of biocompatible polymers like polyurethane and the use of biodegradable material, have improved stent biocompatibility and help prevent restenosis and thrombosis. Long-term anticoagulation is essential in patients undergoing portal vein stent graft placement to maintain stent patency. Regular follow-up is recommended, ideally using Doppler ultrasound—initially at 3-month intervals during the first year, and annually thereafter.

However, limitations of this approach include limited long-term follow-up data and unknown long-term effects of proteolytic enzymes on the structural integrity of the stent graft fabric.

Conclusion

Portal vein pseudoaneurysms, though rare, can lead to catastrophic gastrointestinal hemorrhage, especially following pancreatic pathology or intervention. Early recognition through imaging and prompt management is essential. While open surgery carries significant risk, percutaneous endovascular stent graft placement offers a promising, minimally invasive alternative. However, long-term outcomes and durability of stent grafts in the proteolytic environment of pancreatitis remain areas for further research.

Conflict of Interest

None declared.

Note

Institutional review board (IRB) approval was not required for the image presentation (IRB- 2025/027/EXP/011).

• References

• 1 Kurtcehajic A, Zerem E, Alibegovic E, Kunosic S, Hujdurovic A, Fejzic JA. Portal vein aneurysm-etiology, multimodal imaging and current management. World J Clin Cases 2023; 11 (04) 725-737
• 2 Laurenzi A, Ettorre GM, Lionetti R, Meniconi RL, Colasanti M, Vennarecci G. Portal vein aneurysm: what to know. Dig Liver Dis 2015; 47 (11) 918-923
• 3 Burke CT, Park J. Portal vein pseudoaneurysm with portoenteric fistula: an unusual cause for massive gastrointestinal hemorrhage. Semin Intervent Radiol 2007; 24 (03) 341-345
• 4 Ierardi AM, Berselli M, Cuffari S, Castelli P, Cocozza E, Carrafiello G. Uncommon case of a post-traumatic portal vein pseudoaneurysm treated with percutaneous transhepatic stent grafting. Cardiovasc Intervent Radiol 2016; 39 (10) 1506-1509
• 5 Walton H, Yu D, Imber C, Webster G. Portal vein pseudoaneurysm secondary to pancreatic lymphoma and biliary stent insertion: a rare cause of haemobilia. CVIR Endovasc 2018; 1 (01) 5
• 6 Pescatori LC, Kobeiter H, Zaarour Y. et al. Transhepatic endovascular repair for portal vein haemorrhage. CVIR Endovasc 2020; 3 (56)
• 7 Weber D, Pardhan A, Rao S, Pachter H. Hemobilia due to a portal vein to common bile duct fistula from a seatbelt injury. J Trauma Acute Care Surg 2016; 81 (01) 802-804

Publication History

Article published online:
29 October 2025