Intervention with endovascular stent grafting proves vital in addressing erosion of the superior mesenteric vein in severe pancreatitis - a remarkable strategy for managing an uncommon complication
A 41-year-old male with a medical history of hypertension and hyperlipidemia presented with acute pancreatitis and acute kidney injury. Computed tomography (CT) of the abdomen revealed acute interstitial pancreatitis (Fig. 1). However, the course of his illness took a turn for the worse.
Emergent exploratory laparotomy revealed significant bleeding from a large venous vessel and near-complete pancreatic necrosis. The bleeding was controlled with SMV stenting, with subsequent surgical confirmation of the exposed stent within the disrupted venous wall.
This rare complication, known as superior mesenteric vein (SMV) erosion, is a serious consequence of necrotizing pancreatitis (NP). It occurs due to enzymatic digestion and inflammatory damage to the vein wall caused by pancreatic necrosis and associated peripancreatic inflammation.
Venous injuries in NP are particularly challenging due to their rarity and lack of established management guidelines. In this case, the patient experienced hemodynamic collapse with severe hypotension and copious hemorrhagic output from his abdominal drains. Frank bloody output from his Jackson-Pratt (JP) drain prompted an urgent computed tomography angiography (CTA), which revealed an arterial source of bleeding from a branch of the celiac artery. Interventional radiology (IR) embolized a 12 mm dorsal pancreatic artery pseudoaneurysm (Fig. 2).
The SMV is critical for mesenteric circulation and its anatomy is complex, making injuries in this area difficult to treat. However, endovascular stent grafting has been utilized as a salvage therapy in such vascular injuries related to pancreatitis. The approach involves placing a covered stent within the vein to seal the site of erosion or rupture, controlling bleeding while maintaining venous patency.
This minimally invasive endovascular technique can be preferable to open surgical repair due to difficult operative fields and patient instability in necrotizing pancreatitis. Previous reports in the literature document a few cases where endovascular stent grafting successfully treated SMV erosion or rupture secondary to pancreatitis-induced enzymatic and inflammatory injury.
The patient underwent decompressive laparotomies and necrosectomies due to worsening necrosis, pseudocyst formation, and nontraumatic abdominal compartment syndrome leading to end organ damage. The case adds to the limited but growing body of evidence supporting the use of venous stenting for mesenteric venous injuries in NP.
Overall evidence remains limited to case reports and small series, reflecting the rarity of SMV erosion in necrotizing pancreatitis. However, these reports support endovascular stent grafting as a valuable, lifesaving option for managing this unusual but severe complication. More extensive studies are lacking, so treatment must be individualized based on patient stability, anatomy, and local expertise.
In conclusion, SMV erosion in necrotizing pancreatitis is a rare but severe condition. It results from enzymatic and inflammatory damage causing vascular wall breach. Endovascular stent grafting is reported as an effective, less invasive treatment alternative to surgery in few published cases. Multidisciplinary care and imaging are critical for diagnosis and management. Evidence mainly consists of case reports; no large systematic studies or specific guidelines exist.
To the authors' knowledge, this is the first reported case of SMV erosion treated with endovascular stent grafting in the context of NP. The IR team was consulted for possible SMV repair. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed the absence of gallstones. This case highlights the importance of a multidisciplinary approach in managing complex cases of NP and the potential role of endovascular stenting in the treatment of mesenteric venous injuries.
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