Giant Intrahepatic Portal Vein Aneurysm: Leave it or Treat it?

Portal vein aneurysm-etiology, multimodal imaging and current management

Portal vein aneurysm (PVA) is a rare vascular abnormality, representing 3% of all venous aneurysms in the human body, and is not well understood. It can be congenital or acquired, located mainly at the level of confluence, main trunk, branches and bifurcation. A PVA as an abnormality of the portal venous system was first reported in 1956 by Barzilai and Kleckner. A review from 2015 entitled “Portal vein aneurysm: What to know” considered fewer than 200 cases. In the last seven years, there has been an increase in the number of PVAs diagnosed thanks to routine abdominal imaging. The aim of this review is to provide a comprehensive update of PVA, including aetiology, epidemiology, and clinical assessment, along with an evaluation of advanced multimodal imaging features of aneurysm and management approaches.

Thrombosis of the inferior vena cava secondary to incidental portal vein aneurysm

Aneurysm of the portal vein is a rare type of visceral aneurysm that is largely asymptomatic although some patients may develop symptoms or secondary complications. In this report, we present the first case in the literature of inferior vena cava (IVC) thrombosis arising as a consequence of portal vein aneurysm. A 95-year-old male with past medical history significant for hypertension, hypercholesterolemia, type II diabetes mellitus, benign prostatic hyperplasia, and gastroesophageal reflux presented to the emergency department with several days of altered mental status, disorganized behavior, visual hallucinations, and weight loss. Contrast-enhanced computed tomography of the patient's abdomen and pelvis was performed to assess for infection or malignancy. The study revealed a large saccular aneurysm of the proximal portal vein arising near the portal confluence. Compression of the adjacent IVC was also seen which contained a hypoattenuating filling defect, probably representing thrombus. Incidental large hepatic cysts were seen, and a 6 mm pancreatic cyst was also identified which likely represented an intra-ductal papillary mucinous neoplasm . He was determined not to be a surgical candidate due to age, comorbidities, and absence secondary symptoms. The patient was discharged on quetiapine and enoxaparin for management of agitation and IVC thrombosis, respectively. This case demonstrates the increasing rates of detection of portal vein aneurysm and the range of complications that may arise as a result.

A rare pediatric case of portal vein aneurysm thrombosis

Portal vein aneurysm (PVA) is rarely encountered, and published papers describing this etiology in adults and children typically include only case reports or small case series. We present a clinical case of PVA in a child associated with severe complications, including diffuse thrombosis of the portal venous system. A 10-year-old boy presented with abdominal pain and vomiting, resulting in an initial diagnosis of pancreatic head tumor based on suspicious images on abdominal grayscale ultrasound. Contrast-enhanced computed tomography confirmed a diagnosis of occlusive PVA thrombosis (36 × 37 × 95 mm). Lacking drastic symptoms, the patient was treated with conservative anticoagulant therapy. On follow-up, the thrombosis appeared to shrink gradually and disappeared at 6 months based on Doppler ultrasound imaging. The PVA was reduced in size, and hepatopetal flow was restored. Surgeons and radiologists should be aware of this rare entity to ensure that a precise diagnosis can be established and to provide suitable treatment.

A new classification of congenital abnormalities of UPVS: sonographic appearances, screening strategy and clinical significance

The umbilical–portal venous system (UPVS) plays an important role in embryonic development, as well as a significant blood circulation system to ensure the normal blood supply of fetal heart and brain and other vital organs. Congenital anomalies of UPVS contain many subtypes with a broad spectrum of manifestations and prognoses. Furthermore, because of fetal small lumen of UPVS, the sonographic evaluation remains difficult in utero. Appreciation of normal embryology and anatomy of UPVS is essential to an understanding of sonographic characteristics of anomalies of UPVS and fetal sequential changes. Through reviewing previous references and our experience with congenital abnormalities of UPVS, a new comprehensive classification is proposed. The new classification identifies three types of congenital abnormalities of UPVS based on morphological abnormalities and shunts. The embryology and etiology, sonographic, clinical and prognostic characteristics of each subtype of the new classification are described in detail. Knowledge of congenital abnormalities of UPVS can give sonographers a clue and aid prenatal sonographic diagnosis. The purpose of this article is to help the sonographers to understand the new classification of congenital abnormalities of UPVS, master the sonographic characteristics of each subtype and prenatal ultrasonographic screening strategy, and guide subsequent appropriate counseling and management.

Asymptomatic portal vein aneurysm: Three case reports

BACKGROUND

Portal vein aneurysm (PVA) is an uncommon vascular dilatation, showing no clear trend in sex or age predominance. Due to the low number of published cases and the lack of management guidelines, treatment of this condition remains a clinical challenge.

CASE SUMMARY

We present three cases of asymptomatic PVA; the first and second involve an extrahepatic manifestation, of 48 mm and 42.3 mm diameter respectively, and the third involves an intrahepatic PVA of 27 mm. All were diagnosed incidentally during routine check-up, upon ultrasonography scan. Since all patients were asymptomatic, a conservative treatment strategy was chosen. Follow-up imaging demonstrated no progression in the aneurysm dimension for any case.

CONCLUSION

As PVA remains asymptomatic in many cases, recognition of its imaging features is key to favourable outcomes.

Rupture of portal vein pseudoaneurysm caused by impinging infected walled off pancreatic necrosis (WOPN): a rare complication

We report a case of walled off pancreatic necrosis in a patient with alcoholic pancreatitis who underwent endoscopic ultrasound-guided multiple pigtail catheter drainage. 10 days later patient presented with massive haemorrhage likely due to erosion of portal vein pseudoaneurysm caused by decubitus of pigtails. Patient required emergent portal venorrhaphy to arrest haemorrhage.

A large asymptomatic portal vein aneurysm in an old man

Ultrasound (US) is a useful tool in diagnosis and follow-up of portal vein aneurysms (PVA). In the absence of international surgical guidelines on PVAs, US can be effectively used in follow-up of asymptomatic patients not suitable for surgery.

Portal vein aneurysm with complete spontaneous regression after 10 years using conservative treatment

Portal vein aneurysms are rare vascular findings for which there are no optimal treatment guidelines. The scarce knowledge about their etiology, natural history, and management mean that there are limited treatment options. Here, we describe the case of a 69-year-old woman who presented with a 35-mm hypoechoic area in the hilar region of the liver that was accidentally detected by ultrasonography. Color Doppler ultrasonography demonstrated a mass with internal flow contiguous with portal vein, which was confirmed to be a portal vein aneurysm by computed tomography. Given that she experienced no symptoms of impending rupture or thrombosed aneurysms, we adopted a conservative treatment. Follow-up imaging demonstrated slow progression of the aneurysm diameter, from 35 to 43 mm at 3 years, and to 48 mm at 6 years; subsequent imaging after 6 years did not show any change in the diameter from 48 mm. However, the portal vein aneurysm completely regressed with no complications at a follow-up of over 10 years. This case suggests that long-term observation with periodic imaging may be an acceptable therapeutic option for asymptomatic portal vein aneurysms that show no short-term improvement. This case report contributes to a better understanding of how to treat this rare disease.

Thrombosis of a portal vein aneurysm: a case report with literature review

OBJECTIVES

Portal vein aneurysm is an unusual vascular dilatation of the portal vein. The etiology, diagnosis and management are ill-defined.

METHODS

A case of a portal vein aneurysm complicated with complete thrombosis is presented with a literature review providing an overview of the etiology, clinical presentation and management.

RESULTS

Portal venous aneurysms represent approximately 3% of all venous aneurysms with a reported prevalence of 0.06%. The reported incidence is on the rise with increasing use of modern imaging techniques in clinical practice. Usually, portal vein aneurysms are incidental findings and patients are asymptomatic. They can be congenital or acquired and portal hypertension represents the most frequent cause of the acquired version. Various complications such as biliary tract compression, portal vein thrombosis, and rupture can occur. Treatment options are conservative management or surgery. Surgical treatment is currently reserved for symptomatic patients with severe abdominal pain, symptoms of pressure effect or with expanding aneurysms, and/or complications such as thrombosis or rupture.

CONCLUSION

Conservative management seems the best option in the majority of patients. A multidisciplinary approach discussing the best option on a case-by-case base in light of their individual underlying risk and symptoms is advised.

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

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.