CASE 2177 Published on 30.07.2003

Splenic vein stenosis complicating chronic pancreatitis, recanalization with endoprosthesis prior to pancreatic surgery

Section

Interventional radiology

Case Type

Clinical Cases

Authors

Bastarrika G, Bilbao JI, Martínez-Cuesta A, Elorz M, Vivas I

Patient

37 years, male

Categories
No Area of Interest ; Imaging Technique CT, CT
Clinical History
Alcoholic patient referring a past history of acute hemorrhagic pancreatitis. Secondary to this inflammatory process the patient developed splenic vein stenosis and severe collaterals. Follow-up abdominal CT exams revealed a pancreatic pseudocyst in the tail of the pancreas. The patient was admitted to our hospital for pancreatic surgery.
Imaging Findings
The patient was admitted to our hospital for pancreatic surgery. The patient referred a past history seven years before of acute hemorrhagic pancreatitis that had required an internal-external biliary drainage for the management of a secondary stenosis of the common bile duct. As a consequence of this inflammatory process the patient developed splenic vein stenosis and severe collateral pathways including gastric and gastroesophageal varices. Follow-up demonstrated the appearance of splenomegaly and insulin-dependent diabetes mellitus related with chronic pancreatitis. Upper gastrointestinal endoscopy was performed periodically to observe the presence and extent of the varices, showing no significant modifications.
Abdominal computed tomography (CT) revealed a pancreatic pseudocyst in the tail of the pancreas, associated with extensive venous collaterals in the anterior surface of the stomach and along the greater curvature (Fig. 1a, 1b).
Excision of the pancreatic pseudocyst was recommended in another institution. Past history and clinical manifestations led to a visceral angiography for surgical planning. The preoperative angiography showed severe gastric and gastroesophageal varices, splenorenal shunt, and splenic vein stenosis. Flow in the splenic vein was hepatopetal. Superior mesenteric and portal veins were patent (Fig. 2a).
In order to prevent bleeding during surgery secondary to variceal rupture, a percutaneous treatment was decided. A transcatheter embolization of collaterals with coils followed by recanalization of splenic vein stenosis with two endovascular prostheses (Wallstent, Boston Scientific, Natick, MA, USA) allowed decompression of the collateral pathways, reducing left-sided hypertension (Fig. 3a, 3b). The transhepatic access tract was embolized with coils. One month later, contrast-enhanced abdominal CT scan and angiography were performed. CT images did not demonstrate complications related with the percutaneous procedure (Fig. 4a). Angiography demonstrated permeability of the splenic vein endoprostheses. Flow through splenic vein as well as through superior mesenteric and portal vein was hepatopetal. No collateral pathways were demonstrated (Fig. 5a). Finally, the patient refused further surgical intervention. No episodes of variceal bleeding have been documented during a sixteen months follow-up.
Discussion
Chronic pancreatic inflammatory disease (chronic pancreatitis) is the most frequent cause of isolated splenic vein stenosis and thrombosis [1]. Splenic vein stenosis and thrombosis occurs approximately in 10-40% of patients with chronic pancreatitis. Other causes of splenic vein stenosis and thrombosis include pancreatic cancer or iatrogenic causes (surgery), transplantation of the pancreas, penetrating gastric ulcers, and retroperitoneal fibrosis. In cases of chronic pancreatitis splenic vein stenosis and thrombosis may happen secondary to the inflammatory changes of the pancreatic process itself, as the vein may be involved by surrounding edema. As a consequence, collateral pathways are developed in order to drain this abnormal outlet of venous blood [2].
Splenic vein stenosis and thrombosis causes a localized form of portal hypertension known as left-sided hypertension and as a consequence, splenic vein stenosis and thrombosis may be complicated by the formation of varices, with the potential of massive upper gastrointestinal bleeding.
Splenic vein stenosis and thrombosis may be either asymptomatic or symptomatic. Even more, there might not be clinical evidence of chronic pancreatitis. The most common clinical manifestation of splenic vein stenosis and thrombosis is variceal haemorrhage and massive upper gastrointestinal bleeding. Palpation demonstrates splenomegaly in almost all patients.
Abdominal CT is the preferred technique for the evaluation of patients with chronic pancreatitis and its complications. Several CT findings suggest splenic vein thrombosis, such as a vein with a non-enhancing lower attenuation centre, and irregular enhancing vessels around the splenic vein, corresponding to collateral veins.
Endoscopy is indicated in symptomatic (to ascertain the point of bleeding), and asymptomatic patients, as it may demonstrate the presence, location, and extend of varices.
Other non-invasive diagnostic tools in the evaluation of patients with suspected splenic vein stenosis and thrombosis include ultrasonography, magnetic resonance imaging, and more recently, endoscopic ultrasonography.
Nevertheless, the diagnostic gold standard is angiography [3]. A venous phase may demonstrate patency of the portal vein and filling of collateral pathways with focal or complete absence of opacification of the splenic vein. Angiography may also be very useful as this diagnostic technique may detect the source of bleeding in cases endoscopy fails to demonstrate it.
There are diverse therapeutic options for patients suffering of splenic vein stenosis and thrombosis. Close observation should be the attitude in asymptomatic subjects, as they might develop gastric or gastroesophageal varices that may never bleed. Classically, in symptomatic patients, splenectomy with or without pancreatic surgery has been considered the treatment of choice as it decreases the venous outflow through the collaterals [1]. Consequently, splenectomy prevents further haemorrhage. Besides splenectomy in these challenging patients pancreatic surgery is often indicated for the treatment of the underlying pancreatic inflammatory disease [4].
Controversy remains with the role of prophylactic splenectomy in patients with splenic vein stenosis and thrombosis that undergo pancreatic surgery.
Percutaneous splenic artery embolization itself as a way of non-operative splenectomy may also be considered an alternative to conventional splenectomy. Nevertheless, percutaneous non-operative splenectomy itself is not exempt of complications. Nowadays patients usually undergo a transcatheter splenic embolization before the surgical splenectomy in order to reduce the collateral pathways. The goal of preoperative collateral embolization is to reduce intraoperative complications related left-sided hypertension, such as variceal bleeding [5]. In our opinion, a percutaneous transhepatic approach offers advantages as it ascertains the diagnosis of splenic vein stenosis and thrombosis, and allows demonstration of anatomic variants and collaterals. Furthermore, a transhepatic percutaneous approach allows embolization of bleeding vessels in cases it becomes necessary and recanalization of the affected vessels with endovascular stent-graft placement in order to ensure a safe venous outflow.
In conclusion, endovascular stent-grafts provide an innovative approach in selected patients. Recanalization of splenic vein stenosis and thrombosis prior to pancreatic surgery in patients with chronic pancreatitis decompresses the gastric and gastroesophageal varices, reducing left-sided hypertension. As a consequence, severe complications secondary to bleeding during surgery are considerably reduced and elective pancreatic surgery may be done more safely. Percutaneous recanalization of splenic vein stenosis seems to be cost-effective. This procedure may minimize surgical and postoperative complications reducing the morbidity and mortality related to the invasive procedures. The percutaneous approach would lead to a reduction of costs not only of those derived from surgical complications themselves but also costs due to unnecessary days of hospitalization.
Differential Diagnosis List
Splenic vein stenosis complicating chronic pancreatitis, recanalization with endoprosthesis prior to pancreatic surgery
Final Diagnosis
Splenic vein stenosis complicating chronic pancreatitis, recanalization with endoprosthesis prior to pancreatic surgery
Case information
URL: https://www.eurorad.org/case/2177
DOI: 10.1594/EURORAD/CASE.2177
ISSN: 1563-4086