CT demonstration of portal vein aneurysm

Portal vein aneurysm: What to know

Portal vein aneurysm is an unusual vascular dilatation of the portal vein, which was first described by Barzilai and Kleckner in 1956 and since then less than 200 cases have been reported. The aim of this article is to provide an overview of the international literature to better clarify various aspects of this rare nosological entity and provide clear evidence-based summary, when available, of the clinical and surgical management. A systematic literature search of the Pubmed database was performed for all articles related to portal vein aneurysm. All articles published from 1956 to 2014 were examined for a total of 96 reports, including 190 patients. Portal vein aneurysm is defined as a portal vein diameter exceeding 1.9 cm in cirrhotic patients and 1.5 cm in normal livers. It can be congenital or acquired and portal hypertension represents the main cause of the acquired version. Surgical indication is considered in case of rupture, thrombosis or symptomatic aneurysms. Aneurysmectomy and aneurysmorrhaphy are considered in patients with normal liver, while shunt procedures or liver transplantation are the treatment of choice in case of portal hypertension. Being such a rare vascular entity its management should be reserved to high-volume tertiary hepato-biliary centres.

A case report of extrahepatic portal vein aneurysm with thrombosis

Extrahepatic portal vein aneurysm (PVA) is very rare with only 17 previously reported cases. Methods of treatment include resection, thrombectomy, and portal venous decompression. We report herein the first case of large PVA with thrombosis which has been managed without surgical treatment over a long period. A PVA was detected in a 78-year-old woman by abdominal ultrasonography. Computed tomography revealed an aneurysm of 6 cm in a diameter in the porta hepatis. Portal venography showed obstruction of the portal vein and developed collateral vessels around the aneurysm. Since the patient had no symptoms of portal hypertension, we decided to carefully manage her clinical course without surgical treatment. At present, this patient is healthy and has developed no complications over the 5 years since leaving our hospital. This case suggests that surgical treatment is not required for PVA without portal hypertension.

Ultrasonography and 3D-CT Follow-Up of Extrahepatic Portal Vein Aneurysm: A Case Report

Extrahepatic portal vein aneurysm is a rare disorder. From 1956 to 2008, we found only 43 published English-language reports, including 67 cases, using Pub Med. We report a case of a 77-year-old woman who had complaints of lower abdominal fullness and residual urine. We performed ultrasonography (US), which demonstrated a congenital extrahepatic portal vein aneurysm. She had no obvious symptoms of the extrahepatic portal vein aneurysm. She had undergone gastrectomy without blood transfusion for gastric ulcer more than 20 years ago. Physical examination revealed no abnormal findings. US revealed a 2.2 × 1.8 cm, round shaped hypoechogenic lesion at the hepatic hilum. Color Doppler US showed bidirectional colors due to circular flow within this lesion. 3D-CT and CT angiography demonstrated that the saccular aneurysm at the hepatic hilum was 3.0 cm in diameter and was enhanced equal to that of portal vein.Twenty-six months after the diagnosis, the aneurysm had not grown in size. Since our patient had no serious complaints or liver disease, surgical procedures had not been employed. US and 3D-CT are noninvasive diagnostic techniques and are helpful in the diagnosis and follow-up of extrahepatic portal vein aneurysms.

Visceral venous aneurysms: clinical presentation, natural history and their management: a systematic review

AIM

Aneurysms of the visceral veins are considered rare clinical entities. The aim is to assess their clinical presentation, natural history and management.

METHODS

An electronic search of the pertinent English and French literature was undertaken. All studies reporting on aneurysms of visceral veins were considered. Cases describing patients with arterial-venous fistulae and extrahepatic or intra-hepatic portosystemic venous shunts were excluded.

RESULTS

Ninety-three reports were identified, including 176 patients with 198 visceral venous aneurysms. Patients' age ranges from 0 to 87 years, and there is no apparent male/female preponderance. The commonest location of visceral venous aneurysms is the portal venous system (87 of 93 reports, 170 of 176 patients, 191 of 198 aneurysms). Aneurysms of the renal veins and inferior mesenteric vein are also described. Portal system venous aneurysms were present with abdominal pain in 44.7% of the patients, gastrointestinal bleeding in 7.3%, and are asymptomatic in 38.2%. Portal hypertension is reported in 30.8% and liver cirrhosis in 28.3%. Thrombosis occurred in 13.6% and rupture in 2.2% of the patients. Adjacent organ compression is reported in 2.2% (organs compressed: common bile duct, duodenum, inferior vena cava). The management ranged from watchful waiting to intervention. In 94% of the cases, aneurysm diameter remained stable and no complications occurred during follow-up. In most of the cases, indications for operation were symptoms and complications. Six cases of renal vein aneurysm are reported; three of them were asymptomatic. Three of these patients were treated surgically.

CONCLUSION

The most frequent location of visceral venous aneurysms is the portal venous system. They are often associated with cirrhosis and portal hypertension. They may be asymptomatic or present with abdominal pain and other symptoms. Watchful waiting is an appropriate treatment, except when complications occur. Most common complications are aneurysm thrombosis and rupture. Other visceral venous aneurysms are extremely rare.

Extrahepatic portal vein aneurysm--report of six patients and review of the literature

Extrahepatic portal vein aneurysm is a rare condition. We report six patients with extrahepatic portal vein aneurysm, four of whom were surgically treated. In addition, a review of the literature was performed to examine natural history, management, and outcomes regarding portal vein aneurysm. Patients seen at our institution with extrahepatic portal vein aneurysm greater than 1.9 cm in diameter were reviewed (1998 to 2006). There were five females and one male; median age was 66.5 (30-77). Computed tomography (CT) scan was utilized for diagnosis in all cases. The median diameter of the aneurysm was 4.7 cm (2.7-6.0). Indications for surgery included gallstone pancreatitis, mass effect on the adjacent duodenum, a peripancreatic mass, and liver cirrhosis. Three patients underwent aneurysm resection, and one patient had an orthotropic liver transplant. Two patients were managed with observation. The median follow-up from first presentation and surgery was 50 months (9-181) and 5 months (2-73), respectively. At last follow-up, five patients were alive with radiologically proven portal vein patency. One patient died 2 months after liver transplantation. There was no case of aneurysmal rupture. One patient had intramural thrombus at presentation that resolved with conservative treatment. This report suggests that symptomatic aneurysms can be safely resected with excellent patency.

Congenital extrahepatic portal vein aneurysm

Portal vein aneurysm is a rare clinical entity, with only 41 published cases in the English-language literature. Twenty-five of them were congenital. We present the case of a 50-year-old woman who was incidentally diagnosed with a congenital extrahepatic portal vein aneurysm during an investigation for dyspepsia. Ultrasonographic features are described with correlation of computed tomographic and magnetic resonance findings. Etiology, clinical significance, and management strategies for these lesions are discussed and a review of the literature regarding this entity is presented.

Extrahepatic portal vein aneurysm: Two case reports of surgical intervention

We report two cases of extrahepatic portal vein aneurysm, and both of them underwent surgical intervention. The first case had a mild pain in right upper quadrant of the abdomen; the second had no obvious symptoms. Physical examination revealed nothing abnormal. Both of them were diagnosed by magnetic resonance imaging angiography (MRA). One of the aneurysms was located at the main portal vein, the other, at the confluence of the superior mesenteric vein and the splenic vein, and these two places are exactly the most common locations of the extrahepatic portal vein aneurysm reported in the literature (30.7% each site). The first case underwent aneurysmorrhaphy and the second case, aneurysm resection with splene-ctomy. Both of them recovered soon after the operation, and the symptom of the first case was greatly alleviated. During the follow-up of half a year, no complication and adverse effect of surgical intervention was found and the color Doppler ultrasonography revealed no recurrence of the aneurysmal dilation. We suggest that surgical interv-ention can alleviate the symptom of the extrahepatic portal vein aneurysm and prevent its complications effectively and safely for low risk patients.

Ileocolic Arteriovenous Fistula with Superior Mesenteric Vein Aneurism: Endovascular Treatment

We report a case of a venous aneurysm secondary to an acquired ileocolic arteriovenous fistula in a 64-year-old woman with recurrent abdominal pain and history of appendectomy. The aneurysm was diagnosed by ultrasound and computed tomography. Angiography showed an arteriovenous fistula between ileocolic branches of the superior mesenteric artery and vein. This vascular abnormality was successfully treated with coil embolization.

CT findings of portal vein aneurysm caused by gastric adenocarcinoma invading the portal vein

The known causes of acquired origin portal vein aneurysm are portal hypertension, pancreatitis and trauma. We describe the CT findings of an additional cause of acquired origin portal vein aneurysm, namely gastric adenocarcinoma invading the portal venous system.

Biliary fistulae and haemorrhage

Percutaneous biliary drainage is the most common aetiology of haemobilia. Bile duct fistulae can also arise from the hepatic or portal vein, most commonly as a result of trauma. Percutaneous methods for treating haemobilia from all these sources are discussed in detail.

Superior mesenteric venous aneurysm

The case of a 50-year-old woman with an extremely rare venous malformation of the portal venous system is reported. The patient presented with a true aneurysm of the superior mesenteric vein, which has thus far been reported in no more than eight cases worldwide. This malformation may be congenital or acquired. Secondary aneurysms are thought to be due to liver disease, portal hypertension, trauma, or inflammation. Aneurysms of the portomesenteric venous system may be asymptomatic or give rise to severe, often dramatic conditions such as crampy abdominal pain, jaundice, and upper gastrointestinal hemorrhage secondary to portal hypertension. The diagnosis is usually made by ultrasound (B-mode or color flow Doppler), CT scan, and MRI. Invasive procedures such as venous phase mesenteric arteriography or splenoportography may be helpful in confirming it. In our opinion aneurysms of the portal venous system, even if they are congenital and (still) asymptomatic, require early surgical control because the prognosis for patients with these aneurysms is unpredictable and potential complications (e.g., portal hypertension, fistula, contained perforation, or rupture) may be fatal. In the case presented the mesenteric venous aneurysm was resected and the confluent veins were reconstructed.

Venous aneurysms: surgical indications and review of the literature

BACKGROUND

During the last 20 years we diagnosed five cases of venous aneurysm of the jugular (n = 4) and basilic (n = 1) veins. The purpose of this report was to determine the natural history and indications for surgery of venous aneurysms.

METHODS

Our five cases were included in an English-language literature review performed through August 1993.

RESULTS

In our series two aneurysms (one external jugular vein, one basilic vein) were excised for cosmetic reasons. Three internal jugular vein aneurysms were followed up for up to 4 years without complications with serial color duplex ultrasonography. Of 32 patients with abdominal venous aneurysms (18 portal, seven inferior vena cava, four superior mesenteric, two splenic, one internal iliac), 13 (41%) had major complications including five deaths. Of 31 patients with deep venous aneurysms of the extremity (29 popliteal, two common femoral), 22 (71%) had deep vein thrombosis or pulmonary embolism and in 17 recurrent deep vein thrombosis or pulmonary embolism developed when patients were treated with anticoagulation alone.

CONCLUSIONS

Prophylactic surgery is cautiously recommended for low-risk patients with venous aneurysms of the abdomen and strongly recommended for most patients with lower extremity deep venous aneurysms. Other venous aneurysms should be excised only if they are symptomatic, enlarging, or disfiguring.

Portal vein aneurysm in the liver associated with multiple vascular malformations

Portal vein aneurysm (PVA) includes focal dilatation of the portal vein, and was formerly thought to be a rare disease. We report a 46-year-old man with chronic aggressive hepatitis and intrahepatic portal vein aneurysm communicating with the hepatic vein. Hemangiomas in the liver and intracranial arteriovenous malformation (AVM) were also found. To our knowledge, this is the first report of a case of PVA in a patient with congenital intracranial AVM. As the PVA in this patient communicated with the hepatic vein, and as hemangiomas in the liver and intracranial AVM were also present, the pathogenesis in this patient seems to have been congenital anomaly of the vasculature.

Case report: splenic vein aneurysm--report of a lesion that progressively expanded

A case of splenic vein aneurysm is reported. The patient was diagnosed as having a cirrhotic liver with portal hypertension. Computed tomography and angiography demonstrated a splenic vein aneurysm with saccular dilatation. The splenic vein aneurysm increased in size as the hepatic cirrhosis deteriorated; however, there were no complications such as rupture or thrombosis. To our knowledge this is the first report describing the development of a portal system aneurysm.

Extrahepatic portal vein aneurysm: report of a case treated by thrombectomy and aneurysmorrhaphy

Extrahepatic portal vein aneurysm is a rare condition with only 15 cases before ours being reported in the English literature. The etiology is thought to be congenital, secondary to portal hypertension or associated with abnormal weakness of the vein wall. It often presents in conjunction with major gastrointestinal bleeding, but may occur with minimal or no symptoms. Diagnosis is made with color duplex ultrasound, computed tomographic scan, venous phase mesenteric angiography, magnetic resonance imaging, or splenoportography. Thrombosis, rupture, and pressure effects are the major complications of portal vein aneurysm. Shunting procedures are recommended in cases with portal hypertension secondary to liver disease. We report the first case treated by thrombectomy and aneurysmorrhaphy with a successful 10 year follow-up. This procedure should be considered to preserve portal vein flow when portal hypertension is absent or is secondary to the aneurysm itself.

Splenic vein aneurysm: MR appearance--a case report

A presumed pancreatic head mass by non-contrast CT examination, was proven to be a splenic vein aneurysm by enhanced CT, MRI, sonography and arteriography. Dangerous percutaneous aspiration was avoided.

Extrahepatic portal vein aneurysm associated with a tortuous portal vein

Portal vein aneurysm is rare and its etiology is controversial. A case of extrahepatic portal vein aneurysm associated with an unusually tortuous portal vein is described. Real-time ultrasonography showed anechoic masslike lesions at the porta hepatis communicating with the superior mesenteric vein and intrahepatic portal branches. This suggested the presence of two saccular portal vein aneurysms, 27 x 21 mm and 21 x 13 mm in size. Magnetic resonance imaging and portal venography confirmed the portal vein aneurysms and an unusually tortuous portal vein curving caudally between them. The liver was histologically normal and there was no evidence of portal hypertension. It is speculated that these portal vein aneurysms may have been congenital and that the associated tortuous portal vein might have been secondary to hemodynamic changes in the portal venous system.