Successful endovascular treatment of an obstruction following the surgical repair of a traumatic portal vein injury: a case report

Abstract

Traumatic portal vein injury is rare, but the associated mortality rate ranges from 50% to 70%. The management of this injury is difficult and remains controversial. In this case report, we describe the successful endovascular treatment of an obstruction that developed following the surgical repair of a traumatic portal vein injury. A man in his mid-40s who had been injured in a car accident presented to our trauma center with abdominal pain, abdominal distension, and open wounds over both knees. Emergency laparotomy revealed a longitudinal rupture from the upper border of the pancreas to the mid-portion of the portal vein; his hemorrhage was successfully controlled surgically. However, postoperative abdominal computed tomography imaging revealed portal vein obstruction. One week after admission to the intensive care unit, an endovascular stent was successfully inserted into the patient’s portal vein via a percutaneous transhepatic approach. The associated injuries, including the distal common bile duct obstruction, were successfully managed by choledochojejunostomy. The patient’s postoperative recovery was uneventful. Thus, endovascular stent placement is an effective and safe means of treating an obstruction following the surgical repair of a traumatic portal vein injury.

Background

Traumatic portal vein injury is rare, but it is associated with a mortality rate of 50% to 70%. ¹ Venorrhaphy comprises the isolation, exposure, and subsequent repair of a vein. However, this is a time-consuming and impractical procedure in patients with other injuries. ² and intraoperative exsanguination is the primary cause of death. ¹ Portal vein ligation was experimentally studied as an alternative by Child and Zuidema, ³ who estimated that 80% of patients may be able to tolerate this procedure. However, in 1975, Mattox et al. ⁴ reported that portal vein ligation is associated with a mortality rate of up to 100%. In 1982, Stone et al. ⁵ achieved a 65% survival rate for patients undergoing portal vein ligation, but in 1995, Jurkovich et al. ⁶ reported that only 1 out of 10 patients survived. Finally, a recent study of data in the National Trauma Data Bank, which was established by the American College of Surgeons, obtain similar perioperative survival rates for the ligation or surgical repair of the portal vein, with a trend toward superior survival in patients that had undergone repair. ²

The management of portal vein injuries by venorrhaphy or ligation is difficult and the choice of procedure remains controversial.^7–9 Endovascular stent placement is another option for the management of portal vein injury, but guidelines for this procedure have yet to be established. In this case report, we describe the successful endovascular treatment of a patient who experienced obstruction following the surgical repair of a traumatic portal vein injury.

Case presentation and methods

A man in his mid-40 s who had been injured in a car accident presented to our trauma center with abdominal pain, abdominal distension, and open wounds over both knees. The patient was hemodynamically unstable, with a systolic blood pressure of 70 mmHg, heart rate of 78 beats/minute, and respiratory rate of 22 breaths/minute. His medical and family histories were unremarkable. The Focused Assessment with Sonography for Trauma was positive for fluid accumulation in the hepato-renal recess and the peri-splenic compartment of the abdominal cavity. After resuscitation with 1 L of crystalloid fluid, followed by transfusion with two units each of packed red blood cell and fresh frozen plasma, and then three further units of each, his systolic blood pressure recovered to 150 mmHg. Thereafter, computed tomography (CT) imaging was performed, which revealed focal disruption of the proximal main portal vein with surrounding hemorrhage; liver laceration; and left acetabular, femoral head, and patellar fractures (Figure 1). Laboratory testing revealed mild acidosis (pH 7.34) with a high lactate concentration (4.1 mmol/L) and evidence of liver damage (aspartate aminotransferase and alanine aminotransferase activities of 539 IU and 416 IU, respectively; Supplementary tables 1–3).

Figure 1.

Initial computed tomography (CT) images. (a) Axial abdominal CT image revealing a focal outpouching and an enhancing nodular lesion associated with the proximal main portal vein (red arrow). (b) Coronal abdominal CT image revealing a focal disruption of the proximal main portal vein and surrounding hemorrhagic fluid (red arrows). (c) Fracture and posterior dislocation of the left femoral head and (d) Open comminuted fracture and displacement of the left patella.

Emergency laparotomy revealed longitudinal rupture of the portal vein from the upper border of the pancreas to the mid-portion of the vein, pancreatic head injury, gastroduodenal arterial hemorrhage, and laceration of segments 5 and 6 of the liver. Although the large volume of blood that accumulated in the surgical field caused hypotension and coagulopathy, we successfully controlled the bleeding through the primary repair of the portal vein using a single continuous suture (5-0 polypropylene, half-circle around the needle) and compression of the liver laceration using gauze; and an open abdominal management technique was pursued from the conclusion of the surgery. The portal vein injury was large (approximately 4 cm long); therefore, it was difficult to dissect the proximal and distal ends of the undamaged portion of the portal vein to ligate it.

The immediate postoperative abdominal CT examination revealed narrowing of the portal vein to 6 mm in diameter, with total obstruction by thrombus (Figure 2a and 2b). After resuscitation in the intensive care unit, further surgery was performed the following day, which revealed no evidence of bowel edema or bowel or liver ischemia. Therefore, we decided to close the abdomen. Orthopedic surgery was performed concomitantly.

Figure 2.

Follow-up computed tomography images obtained 1 day (a, b) and 3 days (c, d) post-injury. (a) Narrowing and obstruction of the portal vein by thrombosis (red arrow). (b) Poor opacification and obstruction of the main portal vein following surgery (red arrow). (c) Minimal fluid collection around the liver (red arrowheads) and residual portal vein obstruction (red arrow) and (d) Minimal fluid collection and a drainage tube placed in the liver bed (red arrowheads). Poor opacification of the main portal vein owing to the thrombus (red arrow).

Postoperatively, mild bile leakage (240 mL/day) occurred from the drain in the liver bed, and an abdominal CT examination performed on the second day postoperatively revealed a small amount of fluid collection (Figure 2c, 2d). One week after the patient’s admission to the intensive care unit, a self-expanding, metal vascular stent (Hercules vascular stent, 16 mm ×60 mm) was successfully inserted into his portal vein via a percutaneous transhepatic approach (Figure 3a and 3b). Following the advice of a vascular surgeon, the patient was administered rivaroxaban 20 mg (a non-vitamin K antagonist oral anticoagulant) after the insertion of the vascular stent. However, his bile leakage persisted and increased to 1090 mL/day in the area with the liver laceration in the week following the procedure. Furthermore, near-complete obstruction of his distal common bile duct was observed on endoscopic retrograde cholangiopancreatography (ERCP) (Figure 3c). Although the bile leakage decreased to approximately 200 mL/day following percutaneous transhepatic bile drainage (PTBD) (Figure 3d), stent insertion failed, owing to complete obstruction of the distal common bile duct. Therefore, during the patient’s fourth week of hospitalization, we performed loop choledochojejunostomy to manage the obstruction of the distal common bile duct. Following this, his postoperative recovery was uneventful.

Figure 3.

Images of the transhepatic portal vein stent insertion (a, b) and of the percutaneous transhepatic bile drainage (PTBD) insertion; and the endoscopic retrograde cholangiopancreatography (ERCP) findings (c, d). (a) Disruption of the proximal portal vein. (b) Severe stenosis of the proximal-to-mid portion of the portal vein following surgery and successful stent insertion. (c) ERCP image showing near-complete obstruction of the distal common bile duct and (d) Bile leakage from the liver and PTBD insertion.

The reporting of this study conforms to the CARE guidelines. ¹⁰

Discussion

The portal vein drains the gastrointestinal, splenic, and pancreatic circulation to the liver. It is the principal vessel of the portal venous system, contributing approximately 75% to the total blood flow. ¹¹ The pressure in the portal vein is approximately 10 mmHg, and injury to this vein can be lethal, because of the high blood flow rate, which averages 1 L/minute. ¹ In the present patient, the portal vein injury was approximately 4 cm long, stretching from the upper border of the pancreas to the middle of the extrahepatic portal vein. In addition, he had injuries including a liver laceration and pancreatic head injury. Owing to their anatomic proximity, portal vein injuries are frequently accompanied by hepatic artery injury and/or extrahepatic bile duct injury.^1,6,12 The initial surgical findings confirmed an injury to the pancreatic head, but there was no suspicion or confirmation of common bile duct (CBD) injury. After stent insertion failure, ERCP, and PTBD, the patient experienced distal CBD obstruction and underwent loop choledochojejunostomy during his fourth week of hospitalization. However, intraoperatively, we were unable to identify any distal CBD injury, owing to the presence of severe post-inflammatory adhesions.

Owing to the massive blood loss associated with such injuries, the survival rates of patients are 38% when only the portal vein is injured, and 8% when other structures in the portal triad are injured. ⁶ A study comparing the outcomes of patients undergoing ligation or repair following traumatic portal vein injury ² revealed mortality rates of 49% overall, 47% in patients undergoing repair, and 59% in patients undergoing ligation. There were no statistically significant differences between the mortality rates associated with surgical ligation and repair of the portal vein, although there was a trend toward superior survival in those who underwent repair and reconstruction instead of ligation. ² The portal vein can be surgically repaired by venorrhaphy in hemodynamically stable patients and can be ligated in hemodynamically unstable patients. However, guidelines for this choice have yet to be established. Vascular stent placement is another option for the management of portal vein injury; however, only a single case report of the use of this technique has been published, reporting its use to treat a patient with a post-traumatic portal vein pseudoaneurysm. ¹³ In the present patient, the portal vein injury was quite large; therefore, it was difficult to free the proximal and distal ends of the undamaged portion of the portal vein for ligation. Therefore, the damaged portal vein was closed using a continuous simple suture, and therefore the vessel was narrowed and blockage occurred.

The treatment of portal vein stenosis or occlusion can cause the resolution of the symptoms and prevent the related complications. ¹⁴ The reported technical success rate of 93.3% and clinical success rate of 86.7% imply that portal vein stent placement is an effective and safe treatment. ¹⁴ In early reports of portal vein stent-graft use, various complications were identified.^15,16 However, with further development of this technique, acceptable clinical courses and outcomes have been reported.^14,17 The patency of the stents has been reported to be over 70% and they have been reported to last approximately 8.1 months. ¹⁴ However, these results were obtained in patients with portal vein stenosis following general surgical procedures, such as pancreaticoduodenectomy, and there have been no reports of endovascular stent insertion into the portal vein to manage postoperative occlusion following blunt trauma. Because the present patient had no symptoms of bowel edema, compartment syndrome, or liver failure, we had enough time to discuss and carefully select the most appropriate treatment for his portal vein obstruction, and the procedure was performed as the patient’s condition improved.

Conclusion

In this report, we have described a rare case of successful endovascular stent insertion into the extrahepatic portal vein of a patient to manage postoperative occlusion following blunt trauma. Portal vein injury is a rare condition with a high mortality rate. This condition must be treated rapidly, on the basis of the patient’s hemodynamic condition. Furthermore, trauma surgeons should have a high index of suspicion for associated injuries. If postoperative portal vein narrowing and obstruction occurs, this can be treated by endovascular stent insertion.

Supplemental Material

sj-pdf-1-imr-10.1177_03000605231218954 - Supplemental material for Successful endovascular treatment of an obstruction following the surgical repair of a traumatic portal vein injury: a case report

Supplemental material, sj-pdf-1-imr-10.1177_03000605231218954 for Successful endovascular treatment of an obstruction following the surgical repair of a traumatic portal vein injury: a case report by Jin Suk Lee, Jin Young Lee, Younghoon Sul, Se Heon Kim, Jin Bong Ye, Su Young Yoon, Junepill Seok, Jonghee Han, Jung Hee Choi, Hong Rye Kim and Yook Kim in Journal of International Medical Research