Necrotizing Pancreatitis and Endovascular Stenting of the Portal and Superior Mesenteric Vein: A Case Report

Introduction: Venous and arterial thrombosis are severe (vascular) complications of acute pancreatitis. They are commonly associated with necrotizing pancreatitis and are a major cause of mortality. Venous thrombosis, most frequently involving the splenic, portal or superior mesenteric veins (SMVs), occurs due to local inflammation, compression, or endothelial injury. Case Presentation: We present the case of a 35-year-old male that was admitted to the intensive care unit of our academic hospital due to severe acute pancreatitis. The patient developed a retroperitoneal acute necrotic collection (ANC), which was retroperitoneally drained and finally debrided with a video-assisted retroperitoneal debridement (VARD). Besides development of the ANC, thrombosis of the portal vein (PV) and the superior mesenteric vein (SMV) developed. Post VARD procedure extensive venous bleedings occurred in the retroperitoneal cavity necessitating angiography which showed extensive venous collaterals due to the occlusion of the PV and SMV. Stenting of the SMV and PV was performed, after this procedure venous return was restored and the retroperitoneal bleeding stopped. Nearly 2 years after placement an occlusion of the stents was noted, and again variceal hemorrhage occurred necessitating relining of the stents. Conclusion: Treatment of diffuse venous collateral bleeding in the setting of acute pancreatitis associated with PV and SMV obstruction due to stenosis and/or thrombosis is complex and potentially lethal. This case illustrates that endovascular stenting of the portomesenteric veins can be an effective salvage strategy to decompress venous collaterals, restore venous outflow, and arrest life-threatening bleeding. Given the rarity and severity of this complication, robust data on indications, timing, long-term patency, rebleeding risk, and overall survival after portomesenteric stenting in acute pancreatitis are lacking, underscoring the need for systematic reporting and prospective studies to guide clinical decision-making in this high-risk population.