Intervention of endovascular stent grafting for the erosion of the superior mesenteric vein in necrotizing pancreatitis: A critical method to save life in a scarcely occurring complication
A 41-year-old male, with a medical history of hypertension and hyperlipidemia, recently experienced a rare and serious complication of necrotizing pancreatitis - superior mesenteric vein (SMV) erosion. This case adds to the limited but growing body of evidence supporting the use of venous stenting for mesenteric venous injuries in necrotizing pancreatitis.
The patient's condition deteriorated, requiring mechanical ventilation for hypoxic respiratory failure. Computed tomography (CT) of the abdomen revealed acute interstitial pancreatitis. An urgent computed tomography angiography (CTA) revealed an arterial source of bleeding from a branch of the celiac artery. Vascular complications in necrotizing pancreatitis can manifest as pseudoaneurysm formation, thrombosis, stenosis, or complete venous disruption. In this case, an arterial source of bleeding led to SMV erosion.
Endoscopic retrograde cholangiopancreatography (ERCP) confirmed the absence of gallstones. However, the absence of established management guidelines for venous injuries in necrotizing pancreatitis made the case particularly challenging. The IR team was consulted for possible SMV repair due to significant bleeding from a large venous vessel and near-complete pancreatic necrosis.
Endovascular stenting has emerged as a viable therapeutic option for venous injury, particularly in high-risk cases where surgical repair is not feasible. In this case, the hemorrhage was successfully controlled with SMV stenting. Superior mesenteric vein erosion caused by necrotizing pancreatitis is an extremely rare and serious complication. Treatment with endovascular stent grafting has been reported but is not well documented in large cohorts due to its rarity.
The 12 mm dorsal pancreatic artery pseudoaneurysm was embolized by interventional radiology, but the patient's critical condition persisted. Postoperative CTA and CT venogram showed left hepatic and splenic infarctions, a compressed mid-SMV with patent distal segments, and a hyperdense hematoma near the inferior vena cava.
Endovascular stent grafting is an emerging minimally invasive therapeutic option for managing such vascular complications. This technique involves placing a covered stent within the damaged vein segment to restore vessel integrity and prevent bleeding without open surgery. While widely used for arterial injury, its application to the SMV in pancreatitis-related erosion is rare but has shown promising outcomes in reported case studies or small series, helping control hemorrhage with less morbidity than open surgical repair.
However, the procedure requires specialized expertise in interventional radiology and careful patient selection due to the complex anatomy and risk of post-procedural thrombosis or infection. Current guidelines and reviews on necrotizing pancreatitis mainly focus on infection control, necrosectomy, and drainage, with limited discussion on vascular erosion management because such cases are so rare.
In summary, endovascular stent grafting offers a promising, minimally invasive treatment for rare SMV erosions in necrotizing pancreatitis, but evidence is limited to isolated cases and expert opinion rather than large trials. Clinical decision-making relies on multidisciplinary evaluation, balancing risks of hemorrhage against procedure-related complications. If your interest is clinical or research-oriented, current literature searches emphasize the need for more data on this rare complication's incidence, treatment strategies, and outcomes to inform standardized management protocols.
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