Portal venous system aneurysms: imaging, clinical findings, and a possible new etiologic factor. AJR Am J Roentgenol. 2007;189:1023-1030. [PMID: 17954635 DOI: 10.2214/ajr.07.2121]

The natural history of portal venous system aneurysms

BACKGROUND

Portal venous system aneurysms (PVAs) are increasingly diagnosed on cross-sectional computed tomography imaging. However, the natural history of these aneurysms is poorly understood, and reports are limited to small case series.

METHODS

Terms relevant to PVAs were searched in radiology reports (2010-2022), with PVA presence confirmed by manual review. PVA were defined as a diameter greater than 1.5 cm in patients without cirrhosis and 1.9 cm in those with cirrhosis. Aneurysm growth was defined as greater than 20% increase in size, whereas aneurysm regression was defined as greater than 20% decrease in size. Patient demographics, comorbid conditions, and PVA outcomes were abstracted. Univariate statistics were used to compare groups.

RESULTS

Thirty-eight aneurysms with radiographic follow up were identified in 35 patients, involving the portal vein (n = 18; 47.4%), splenic vein (n = 10; 26.3%), superior mesenteric vein (n = 3; 7.9%), and portal confluence (n = 7; 18.4%). Although 12 (31.6%) were idiopathic, the remaining 26 (68.4%) were associated with portal hypertension (n = 20; 52.6%) and prior liver transplant (n = 4; 10.5%). The median growth was 0.2 cm (range, -2.6 to 2.4 cm) over median follow up over 5.0 years (range, 0.3-16.6 years). Five PVAs (13.2%) regressed and were largely idiopathic (80.0%; P = .03). Thirteen PVAs (34.2%) grew and were associated with portal hypertension (n = 11; 84.6%; P = .003) and thrombosis (n = 6; 46.2%; P = .05). Nine PVAs (23.7%) thrombosed, predominantly in males (n =7; 77.8%). The median growth was 1.0 cm (range, -0.7 to 1.9 cm). Three patients (33.3%) were symptomatic from PVA thrombosis including abdominal pain (n = 2; 22.2%), intestinal ischemia (n = 1; 11.1%), and variceal bleeding (n = 2; 22.2%). Four patients (44.4%) were treated with anticoagulation. No aneurysms ruptured. Of the 58 PVAs initially identified with and without radiographic follow up, five (8.6%) underwent intervention with a median diameter of 4.0 cm (range, 3.4-5 cm). Intervention included vein ligation (n = 1; 20.0%), aneurysmorrhaphy (n = 1; 20.0%), and aneurysmectomy (n = 3; 60.0%). There was one case of aneurysm recurrence 20 years following resection and one postoperative mortality.

CONCLUSIONS

Two-thirds of PVAa, including those with size greater than 3 cm, remain stable on surveillance. Although annual surveillance is initially recommended to confirm PVA stability, interval imaging can be subsequently extended given low growth rates. Over 20% of PVAs thrombosed, but none ruptured. Although we did not observe any cases of rupture, the devastating consequences of rupture necessitate consideration of surgical intervention for large symptomatic PVAs.

Resection of a retroperitoneal lumbar vein aneurysm: A case report

We present a rare case involving a 54-year-old man with a history of pancreatitis who developed a retroperitoneal lumbar vein aneurysm that was initially misidentified as a pancreatic pseudocyst. Subsequent imaging revealed an enlarged mass and retroperitoneal perforation. Despite initial hesitation, the patient eventually underwent radical surgery that enabled the successful removal of the mass, which was near the inferior vena cava. Pathological examination confirmed varicose veins, and the final diagnosis was lumbar vein aneurysm in the retroperitoneum. The patient's postoperative recovery was uneventful, with no symptoms or recurrence observed on 6-month follow-up imaging. We investigated a potential link between pancreatitis and recurrent bleeding due to weakened venous walls. The findings from this case underscore the rarity of venous aneurysms and the diagnostic and treatment challenges due to the limited number of cases; furthermore, they emphasize that surgery should be carefully considered based on the lesion location and associated risks.

Imaging of Visceral Vessels

The visceral vasculature is inextricably intertwined with abdominopelvic disease staging, spread, and management in routine and emergent cases. Comprehensive evaluation requires specialized imaging techniques for abnormality detection and characterization. Vascular pathology is often encountered on nondedicated routine imaging examinations, which may obscure, mimic, or confound many vascular diagnoses. This review highlights normal arterial, portal venous, and systemic venous anatomy and clinically relevant variants; diagnostic pitfalls related to image-acquisition technique and disease mimics; and characteristics of common and rare vascular diseases to empower radiologists to confidently interpret the vascular findings and avoid misdiagnosis.

Multimodality ultrasound assessment of the spleen: Normal appearances and emergency abnormalities

This paper summarizes the main splenic emergencies and their ultrasonographic findings to orient appropriate patient management. US requires minimal preparation time and allows to examine the parenchyma and to detect intraperitoneal fluid collections, which may be indirect evidence of solid organ injuries. In this paper, we analyze the role of B-mode, Doppler and Contrast-Enhanced Ultrasound in the diagnosis of splenic emergencies, with a particular focus on splenic infarction, infection, traumatic injuries and vascular splenic anomalies.

Portal vein aneurysm-etiology, multimodal imaging and current management

Portal vein aneurysm (PVA) is a rare vascular abnormality, representing 3% of all venous aneurysms in the human body, and is not well understood. It can be congenital or acquired, located mainly at the level of confluence, main trunk, branches and bifurcation. A PVA as an abnormality of the portal venous system was first reported in 1956 by Barzilai and Kleckner. A review from 2015 entitled “Portal vein aneurysm: What to know” considered fewer than 200 cases. In the last seven years, there has been an increase in the number of PVAs diagnosed thanks to routine abdominal imaging. The aim of this review is to provide a comprehensive update of PVA, including aetiology, epidemiology, and clinical assessment, along with an evaluation of advanced multimodal imaging features of aneurysm and management approaches.

Portal vein aneurysm, a pathological entity or an innocent bystander? A review of six cases

Portal venous aneurysms (PVAs) are a rare venous aneurysms. The mean diameter of a healthy portal vein varies considerably, with maximum diameter of 15 mm in healthy subjects and 19 mm in cirrhotic patients. The presentation varies; they could come with abdominal pain or more often as an incident imaging finding. Although risk factors like portal hypertension and liver cirrhosis have been highlighted, the aetiology remains to be clarified. PVA may be associated with various complications: thrombosis, aneurysmal rupture, inferior vena cava obstruction or duodenal compression. A conservative treatment showed satisfying clinical and radiological response, however, surgical and endovascular options can be considered. The aetiology and the mechanism of formation of PVA remain ill-defined. We aimed to use the small cohort of cases to define the distribution and radiological features of PVA and not for determining its prevalence or details of management. We retrospectively reviewed six cases from our institution (King Faisal Specialist Hospital and Research Centre, Jeddah) with variable presentations, complications and outcomes. Our review revealed that portal venous system aneurysms were mostly incidental, single, not gender- or age-specific and were frequently (66%) intrahepatic. Main portal vein was involved in three cases and splenic vein in only one case. Most of the portal venous system aneurysms were fusiform in configuration. Although PVAs are rare, more cases are detected through imaging. Hepatobiliary surgeons, gastroenterologists and radiologists should be aware of this entity, as it can have a wide variety of clinical spectrum. Our review and the limited evidence in published literature suggest that an individualised multidisciplinary team approach should be adopted to decide the best management and outcomes for each patient.

Radiological evaluation of extrahepatic and intrahepatic portal vein aneurysms: A report of two cases

Portal vein aneurysm (PVA) is a rare vascular entity. Here, we describe cases of 2 separate patients who presented with congenital and acquired causes of PVA respectively. The first patient presented with vague abdominal pain and was incidentally diagnosed with PVA, whereas the cause in the second patient was iatrogenic. With a limited number of cases published to date, there is little data on the natural history of the disease. Herein, we will discuss the radiological findings aiding us in reaching our diagnosis and also the probable mimickers of the disease, with a brief overview of its possible causes, complications, and the currently available management options.

A rare presentation of spontaneous rupture of splenic vein aneurysm as cardiac arrest: A case report

Splenic vein aneurysm (SVA) is a rare condition associated primarily with portal hypertension. This case highlights a potentially fatal, rare SVA complication in a young patient who presented in cardiac arrest, creating a diagnostic enigma in the emergency department until a POCUS revealed a possible underlying etiology.

Intrahepatic Portal Vein Aneurysm: A Case Report of an Uncanny Late Complication of Liver Transplantation

BACKGROUND

Whereas chronic rejection, opportunistic infections, post-transplant lymphoproliferative disorder, hemophagocytic lymphohistiocytosis, biliary tract issues, and cardiovascular side effects of immunosuppressive drugs are frequently reported as late complications in liver transplanted patients, intrahepatic portal venous aneurysm following liver transplantation remains exceptional and unusual.

CASE REPORT

We report the case of a 25-year-old man who underwent a liver transplantation in 1997 because he had glycogen storage disease type 4. The patient developed a late postoperative complication, an intrahepatic portal aneurysm, and 2 episodes of acute cholangitis.

DISCUSSION

By reviewing and scoping the literature, we tried to spotlight the best therapeutic attitude concerning the management of this rare complication.

Thrombosis of the inferior vena cava secondary to incidental portal vein aneurysm

Aneurysm of the portal vein is a rare type of visceral aneurysm that is largely asymptomatic although some patients may develop symptoms or secondary complications. In this report, we present the first case in the literature of inferior vena cava (IVC) thrombosis arising as a consequence of portal vein aneurysm. A 95-year-old male with past medical history significant for hypertension, hypercholesterolemia, type II diabetes mellitus, benign prostatic hyperplasia, and gastroesophageal reflux presented to the emergency department with several days of altered mental status, disorganized behavior, visual hallucinations, and weight loss. Contrast-enhanced computed tomography of the patient's abdomen and pelvis was performed to assess for infection or malignancy. The study revealed a large saccular aneurysm of the proximal portal vein arising near the portal confluence. Compression of the adjacent IVC was also seen which contained a hypoattenuating filling defect, probably representing thrombus. Incidental large hepatic cysts were seen, and a 6 mm pancreatic cyst was also identified which likely represented an intra-ductal papillary mucinous neoplasm . He was determined not to be a surgical candidate due to age, comorbidities, and absence secondary symptoms. The patient was discharged on quetiapine and enoxaparin for management of agitation and IVC thrombosis, respectively. This case demonstrates the increasing rates of detection of portal vein aneurysm and the range of complications that may arise as a result.

Large thrombosed portomesenteric venous aneurysm treated with pharmacomechanical thrombolysis combined with TIPS placement

Background

Aneurysms are rare anomalies of the portomesenteric venous system. Thrombotic complications of these lesions can lead to mesenteric venous ischemia and bowel infarction, potentially requiring surgical intervention. Herein we describe a case of mesenteric ischemia due to a large thrombosed portomesenteric aneurysm treated with endovascular techniques.

Case presentation

A 37-year-old previously healthy male who presented with abdominal pain to his local emergency department was found to have a thrombosed 12.0 × 5.1 cm portomesenteric venous aneurysm with evidence of mesenteric ischemia on CT. When conservative management with anticoagulation failed, transhepatic pharmacomechanical thrombolysis was initially performed. This was followed by TIPS placement with additional trans-TIPS thrombectomy to improve sluggish portal outflow and prevent re-thrombosis. The patient’s symptoms and imaging findings of ischemia resolved after endovascular therapy. No surgical intervention was required, and the patient was discharged on enoxaparin before being transitioned to apixaban. The TIPS remained patent at 2-year follow-up, with no change in the size of the aneurysm or re-thrombosis noted. The patient’s synthetic liver function was preserved with no evidence of hepatic encephalopathy during the follow-up period.

Conclusions

Endovascular therapies may be used to manage thrombotic complications of portomesenteric venous aneurysms, obviating the need for surgical intervention in selected patients.

Asymptomatic saccular portal vein aneurysm: a case report and review of the literature

Portal vein aneurysms are rare abnormal dilations of the portal vein and represent less than 3% of all visceral aneurysms. They may be congenital or acquired, symptomatic or asymptomatic, complicated or uncomplicated. Portal vein aneurysms may be fusiform or saccular and this last one has a low prevalence. Due to the small number of cases reported in the medical literature and the lack of specific guidelines, the management and treatment of this condition is still undefined. In this review, we report a case of saccular portal vein aneurysm in a 73-year old man with liver cirrhosis and discuss all cases of portal vein aneurysms reported in literature.

A rare pediatric case of portal vein aneurysm thrombosis

Portal vein aneurysm (PVA) is rarely encountered, and published papers describing this etiology in adults and children typically include only case reports or small case series. We present a clinical case of PVA in a child associated with severe complications, including diffuse thrombosis of the portal venous system. A 10-year-old boy presented with abdominal pain and vomiting, resulting in an initial diagnosis of pancreatic head tumor based on suspicious images on abdominal grayscale ultrasound. Contrast-enhanced computed tomography confirmed a diagnosis of occlusive PVA thrombosis (36 × 37 × 95 mm). Lacking drastic symptoms, the patient was treated with conservative anticoagulant therapy. On follow-up, the thrombosis appeared to shrink gradually and disappeared at 6 months based on Doppler ultrasound imaging. The PVA was reduced in size, and hepatopetal flow was restored. Surgeons and radiologists should be aware of this rare entity to ensure that a precise diagnosis can be established and to provide suitable treatment.

A rare case of congenital aneurysm of the portal system at level of spleno-porto-mesenteric confluence complicated by massive thrombosis

Portal venous aneurysm is a rare and potential dangerous vascular pathology, which can result in thrombosis or rupture. It may be congenital or acquired. Acquired form can be related mainly to portal hypertension, chronic hepatic disease, and trauma. We present a peculiar case of a congenital aneurysm involving the hepatic portal system in nearly all its extra-hepatic components: the main portal trunk, the spleno-porto-mesenteric confluence and the distal segment of splenic, superior, and inferior mesenteric veins, in a 20-year-old male patient. The aneurysm was complicated by massive thrombosis in absence of further predisposing factors.

A new classification of congenital abnormalities of UPVS: sonographic appearances, screening strategy and clinical significance

The umbilical–portal venous system (UPVS) plays an important role in embryonic development, as well as a significant blood circulation system to ensure the normal blood supply of fetal heart and brain and other vital organs. Congenital anomalies of UPVS contain many subtypes with a broad spectrum of manifestations and prognoses. Furthermore, because of fetal small lumen of UPVS, the sonographic evaluation remains difficult in utero. Appreciation of normal embryology and anatomy of UPVS is essential to an understanding of sonographic characteristics of anomalies of UPVS and fetal sequential changes. Through reviewing previous references and our experience with congenital abnormalities of UPVS, a new comprehensive classification is proposed. The new classification identifies three types of congenital abnormalities of UPVS based on morphological abnormalities and shunts. The embryology and etiology, sonographic, clinical and prognostic characteristics of each subtype of the new classification are described in detail. Knowledge of congenital abnormalities of UPVS can give sonographers a clue and aid prenatal sonographic diagnosis. The purpose of this article is to help the sonographers to understand the new classification of congenital abnormalities of UPVS, master the sonographic characteristics of each subtype and prenatal ultrasonographic screening strategy, and guide subsequent appropriate counseling and management.

A case of venous aneurysm of a splenorenal shunt

A 66-year-old man presented with liver cirrhosis due to non-alcoholic steatohepatitis and hyperammonemia. Contrast-enhanced CT showed a dilated and tortuous splenorenal shunt and a large venous aneurysm in the shunt. The venous aneurysm showed gradual enlargement over 10 years and worsening hyperammonemia, so balloon-occluded retrograde transvenous obliteration was performed. Under balloon occlusion, 5% ethanolamine oleate was injected from a microcatheter into the venous aneurysm, which was subsequently embolized with microcoils. Contrast-enhanced CT after the procedure showed complete thrombosis of the venous aneurysm. 10 months later, the venous aneurysm reduced in size, and hyperammonemia had improved.

The First Case of Coil Embolization for Left Gastric Vein Aneurysm with Liver Cirrhosis: A Case Report and Review of the Literature

We herein report the first case of interventional radiology for a left gastric vein aneurysm with a gastrorenal shunt. The etiology of the aneurysm was considered secondary to portal hypertension and liver cirrhosis due to hepatitis B virus infection. As the aneurysm was asymptomatic but had a tendency to expand, we successfully performed coil embolization for the aneurysm through a gastrorenal shunt.

Asymptomatic portal vein aneurysm: Three case reports

BACKGROUND

Portal vein aneurysm (PVA) is an uncommon vascular dilatation, showing no clear trend in sex or age predominance. Due to the low number of published cases and the lack of management guidelines, treatment of this condition remains a clinical challenge.

CASE SUMMARY

We present three cases of asymptomatic PVA; the first and second involve an extrahepatic manifestation, of 48 mm and 42.3 mm diameter respectively, and the third involves an intrahepatic PVA of 27 mm. All were diagnosed incidentally during routine check-up, upon ultrasonography scan. Since all patients were asymptomatic, a conservative treatment strategy was chosen. Follow-up imaging demonstrated no progression in the aneurysm dimension for any case.

CONCLUSION

As PVA remains asymptomatic in many cases, recognition of its imaging features is key to favourable outcomes.

Comparative anatomo-radiological study of intrahepatic venous vascularization in the Spain

BACKGROUND

Anatomic variations in the hepatic venous system are the least understood aspect of hepatic anatomy. The variations are diverse, and data are lacking with respect to the population of Spain and methods of detection. The objective was to examine morphological patterns of variations in hepatic venous vascularization using cadaveric dissections vs. radiological imaging, and to analyze the findings with respect to Spain and to published studies.

METHODS

Thirty-one livers were anatomically dissected and analyzed for their hepatic venous anatomy and then compared to the venous anatomy of livers examined in 216 CT scans from 119 men and 97 women, ranging between 27 and 89 years of age. Statistical analysis was done using the Chi squared and Fisher homogeneity tests.

RESULTS

The hepatic portal vein showed morphological variations in cadavers vs. CT of 67.3% vs. 67.6% (p-I), 29% vs. 12.2% (p-II), 0% vs. 14.6% (p-III), 0% vs. 14.6% (p-IV), 3.2% vs. 0.5% (p-V) and 6.5% vs. 1.9% (p-VI), respectively in cadavers vs. CT. Hepatic vein pattern variation were found in 64.5% vs. 50.7% (h-I), 32.2% vs. 31.5% (h-II), 0% vs. 2.3% (h-III), 0% vs. 4.7% (h-IV), respectively in dissections vs. CT). In Accessory Hepatic Veins the frequency in pattern variation was 64.5% vs. 18.8% (a-2.1), 29.0% vs. 8.0% (a-2.2), 58.1% vs. 11.3% (a-2.3), 9.7% vs. 0.9% (a-2.4), 67.7% vs. 16.9% (a-2.5), 9.7% vs. 4.2% (a-2.6) and 0% vs. 0.5% (a-2.7), respectively, in cadavers vs. CT. CT showed in 27.2% no accessory hepatic veins. Sex was not a factor influencing patterns of variation.

CONCLUSION

Anatomical variants of the hepatic portal vein, the hepatic vein and accessory hepatic veins are very diverse and show greater variability in the specimens compared to those detected with radiological images, finding a wider spectrum of variations as it allows the clinician to have a more precise definition of the vasculature. A higher precision in the definition of anatomical variations is warranted for surgical planning in liver resection and transplantation.

Feasibility and safety of non-operative management of portal vein aneurysms: a thirty-five year experience

BACKGROUND

Portal vein aneurysms (PVAs) are rare, though clinically challenging with post-operative mortality approaching 20% and no evidence-based treatment guidelines. We aim to describe our experience with PVAs and recommend optimum management strategies.

METHODS

Demographics and clinical details of patients with PVAs admitted to our institution from 1984 to 2019 were reviewed. Clinical presentation, management and outcomes were analysed.

RESULTS

PVAs were identified in 18 patients (median age 56 years, range 20-101 years; 13 female); 10 were incidental and 8 diagnosed during abdominal pain work-up. Median aneurysm diameter at diagnosis was 3.4 cm (1.8-5.5 cm), remaining unchanged at 3.5 cm (1.9-4.8 cm) during a 3.2-year follow-up (4 months-31 years). Aneurysm sites were the main portal vein (n = 12), porto-splenic-junction (n = 3), splenic-SMV-junction (n = 2) and right portal vein (n = 1). Thrombosis occurred in 4 patients; 3 developed clinically insignificant cavernous transformation. Two patients underwent surgery for abdominal pain. Postoperatively, one developed PV thrombosis and PVA recurrence occurred in the second. No aneurysm ruptures or mortalities occurred during follow-up.

CONCLUSION

PVAs follow a clinically indolent course with structural stability and minimal complications over time. Non-operative management is feasible for most patients. Abdominal pain, large size or thrombosis don't appear to confer additional risks and should not, in isolation, merit surgical intervention.

A large asymptomatic portal vein aneurysm in an old man

Ultrasound (US) is a useful tool in diagnosis and follow-up of portal vein aneurysms (PVA). In the absence of international surgical guidelines on PVAs, US can be effectively used in follow-up of asymptomatic patients not suitable for surgery.

Asymptomatic thrombosis of extrahepatic portal vein aneurysm necessitating hybrid operative repair

BACKGROUND

Congenital portal vein aneurysm is a rare vascular anomaly with poorly understood natural history. Whereas asymptomatic aneurysms are often managed conservatively, surgery has been used in symptomatic cases complicated by thrombosis or rupture. Surgical experience in management of portal aneurysms is restricted to case studies with limited comparative data and inconsistent reporting of outcomes. A hybrid open and endovascular approach has rarely been described in the literature.

METHODS

We present a case of an extrahepatic portal aneurysm which demonstrated changes on surveillance imaging concerning for early asymptomatic thrombosis. Acute thrombus was identified at the time of open aneurysm repair. We review the limited literature regarding management of portal vein aneurysms in non-cirrhotic patients.

RESULTS

Our case was complicated by intrahepatic thrombo-embolism, which necessitated hybrid thrombectomy and anticoagulant therapy. The patient remains asymptomatic at three-year follow-up with no recurrent aneurysm or thrombosis on surveillance Doppler and CT imaging.

CONCLUSIONS

Altered hemodynamic appearances on Doppler ultrasound and contrast-enhanced CT may warn of impending thrombosis in portal vein aneurysms. Hybrid open and endovascular surgical repair ensures vessel patency and a durable surgical result.

Portal vein aneurysm with acute portal vein thrombosis masquerading as a pancreatic mass

Portal vein aneurysm (PVA) with portal vein thrombosis (PVT) is an exceedingly rare vascular phenomenon with a limited number of reported cases in the medical literature. We describe a case of a 25-year-old man found to have a congenital PVA with PVT initially believed to be a pancreatic mass. While there remains some incongruity amongst clinicians with such a limited number of reported cases, herein, we describe the general consensus of the diagnostic approach and management of this vascular malformation.

Portal vein aneurysm with complete spontaneous regression after 10 years using conservative treatment

Portal vein aneurysms are rare vascular findings for which there are no optimal treatment guidelines. The scarce knowledge about their etiology, natural history, and management mean that there are limited treatment options. Here, we describe the case of a 69-year-old woman who presented with a 35-mm hypoechoic area in the hilar region of the liver that was accidentally detected by ultrasonography. Color Doppler ultrasonography demonstrated a mass with internal flow contiguous with portal vein, which was confirmed to be a portal vein aneurysm by computed tomography. Given that she experienced no symptoms of impending rupture or thrombosed aneurysms, we adopted a conservative treatment. Follow-up imaging demonstrated slow progression of the aneurysm diameter, from 35 to 43 mm at 3 years, and to 48 mm at 6 years; subsequent imaging after 6 years did not show any change in the diameter from 48 mm. However, the portal vein aneurysm completely regressed with no complications at a follow-up of over 10 years. This case suggests that long-term observation with periodic imaging may be an acceptable therapeutic option for asymptomatic portal vein aneurysms that show no short-term improvement. This case report contributes to a better understanding of how to treat this rare disease.

Sonographic Appearances of Portal Vein Abnormalities

Portal venous system evaluation is required in many clinical circumstances, as substantial morbidity and mortality can be associated with a spectrum of portal vein abnormalities. Portal venous system pathologies can be congenital or acquired, and the knowledge of their imaging appearances will allow for a confident diagnosis and appropriate treatment options. In addition, a firm understanding of anatomical variants is important for planning surgical procedures and percutaneous interventions of the liver. This article will review various imaging appearances of portal venous systems abnormalities.

Common pitfalls and mistakes in pediatric ultrasound

There are many errors and pitfalls that are commonly encountered during ultrasound examinations. In normal ultrasound, pitfalls may arise from anatomic or physiologic variants of pediatric anatomy, settings, artifacts, patient conditions, operator misunderstanding, or inexperienced performance. In limited field and point-of-care ultrasound, common errors are usually due to limited access, misdiagnosis as a result of wrong timing, unsuitable patient conditions, limited transducer options, satisfaction of search, and unfamiliarity with pediatric sonography. Knowledge of these pitfalls helps improve a physician's performance and diagnosis.

The hepatoduodenal ligament revisited: cross-sectional imaging spectrum of non-neoplastic conditions

INTRODUCTION

The hepatoduodenal ligament is frequently involved by conditions affecting the portal triad and surrounding structures, including a vast array of non-neoplastic conditions. Due its unique location between the retroperitoneum and the peritoneal space, the hepatoduodenal ligament is also targeted by inflammatory conditions involving the retroperitoneum and the liver. Finally, the presence of lymphatics and of the biliary tracts makes the hepatoduodenal ligament a route of spread for a variety of infections. The purpose of this pictorial essay is twofold: to review the cross-sectional radiological anatomy and variants of the structures within the hepatoduodenal ligament, and to illustrate the non-neoplastic conditions that may arise within the hepatoduodenal ligament.

CONCLUSION

Familiarity with these specific entities and their cross-sectional imaging findings is fundamental for a more accurate diagnosis.

Aneurysm of the Left Portal Branch

We describe the incidental finding of an aneurysm of the left branch of the portal vein in a patient without liver pathology. The diagnosis was confirmed by Doppler ultrasound.

Computed tomography evaluation of patent paraumbilical vein and its aneurysm in relation to other portosystemic collateral channels in patients with liver cirrhosis and portal hypertension

Purpose

The aim of the study was to evaluate the relationship between the diameter and aneurysmal dilatation of the paraumbilical vein (PUV) and the presence of portosystemic collateral shunts and their relationship with age and portal vein diameter.

Material and methods

The retrospective analysis, performed in the II Department of Radiology, Medical University Hospital in Warsaw, included 126 patients (77 males and 49 females) with patent umbilical vein and signs of portal hypertension due to liver cirrhosis. All patients underwent contrast enhanced abdominal CT. The average age was 54.7 ±12.98. We analysed the number and type of portosystemic collateral channels in respect of age, sex, presence of oesophageal varices, and the diameter of the paraumbilical vein and the portal vein.

Results

Our results disclosed statistically significant negative correlation between patient age and diameter of paraumbilical vein, number of portosystemic collateral channels and diameter of portal vein and positive correlation between diameter of paraumbilical vein and diameter of portal vein. A statistically significant difference in diameter of portal vein and number of collateral channels was found in groups with and without oesophageal varices. No significant difference in age and portal vein diameter was found in these groups.

Conclusions

Our study showed that younger patients with liver cirrhosis are characterised by wider paraumbilical veins and higher number of portosystemic collateral channels. The presence of oesophageal varices does not correlate with age, sex, diameter of paraumbilical vein, and number of collateral portosystemic channels.

Intestinal obstruction with a twist: a rare case of congenital portal vein aneurysm causing intestinal obstruction

Bilious vomiting is often a presenting feature of upper intestinal obstruction in newborn. We present a case of intestinal obstruction in a newborn baby caused by abnormal vascular band arising from portal vein aneurysm in association with a midgut volvulus. Congenital anomalies of portovenous system are very rare, and it usually presents with portal hypertension in late infancy or childhood. In this particular child, the portal vein aneurysm contributed to intestinal obstruction due to both a failure of intestinal rotation and a mechanical band over the transverse colon.

Repeated Plastic Stentings of Common Hepatic Duct for Portal Vein Aneurysm Compression in a Patient Unsuitable for Surgery

Portal vein aneurysms are rare vascular malformations with unclear etiologies and optimal treatment guidelines. Although Doppler ultrasonography is the most commonly used diagnostic tool, there is no gold standard imaging modality. Despite recommendations of surgical treatment for symptomatic aneurysms, there are limited options in the management of portal vein aneurysm-related complications in patients unfit for surgical intervention. We describe an 85-year-old man who presented with abdominal pain and low-grade fever with clinical signs consistent with cholangitis. Endoscopic retrograde cholangiopancreatography revealed a common hepatic duct stricture and concomitant intraductal ultrasonography identified adjacent aneurysmal portal vein dilatation. The final diagnosis of portal vein aneurysm was made using contrast computerized tomography scan. The patient was considered unsuitable for surgery due to his advanced age and multiple comorbidities. Instead, an endoscopic biliary plastic stent was inserted as a therapeutic alternative, which successfully achieved complete resolution of symptoms 3 days after the procedure. The patient was regularly followed at the outpatient clinic with repeated stent replacements every 3 to 4 months. After a follow-up of over 3.5 years, the patient remained symptom-free without signs of portal vein aneurysm compression. The result suggests that repeated stent replacements may be a therapeutic option for biliary compression by portal vein aneurysm in patients contraindicated for surgical intervention.

[Aneurysm of the portal venous system: A rare and unknown pathology]

INTRODUCTION

Portal vein aneurysms are rare, representing 3% of venous aneurysms, with about 200 cases described in the literature, probably underestimated.

CASE REPORT

A 66-year-old man, suspect of splenomegaly, underwent an abdominal ultrasound and a thoraco-abdomino-pelvic CT scan showing a 40mm portal vein aneurysm. Final diagnosis was T-cell hemopathy. Five and six months later, abdominal imaging was stable, suggesting congenital origin due to lack of obliteration of the vitelline vein.

CONCLUSION

Portal vein aneurysms are often asymptomatic and an incidental finding. Monitoring is recommended because of their potential complications (thrombosis, rupture of aneurysm, portal hypertension, adjacent organs compression), annually if asymptomatic or more frequently with sometimes a surgical management in case of clinical manifestations.

Aneurysmen des venösen Systems

Overall, aneurysms of the venous system constitute a rare disease. Up to March 2016, 1,199 venous aneurysms at various locations had been reported in the literature. The most common were aneurysms of the extrahepatic portal vein (n=247), followed by popliteal venous aneurysms (n=223) and, in third place, aneurysms of the internal or external jugular vein (n=143). Venous aneurysms are not usually diagnosed until they have become symptomatic or have led to complications, such as thrombosis and/or pulmonary embolism. First-line treatment of symptomatic aneurysms is resection of the aneurysm and reconstruction of the vein using either direct suture or end-to-end anastomosis, depending on the location. Endovenous repairs have also been described in the literature. Venous aneurysms of the superficial venous system can usually be excised and the vein ligated. Long-term anticoagulation is reserved for isolated cases with thrombotic occlusion and recurrent pulmonary embolisms.

Traumatic Injury to the Portal Vein With Shock Bowel

A portal vein aneurysm is the dilatation of the portal vein due to a defect in the vein wall. This rare disease manifestation is difficult to predict and has the potential for severe complications. We describe the case of a 68-year-old man involved in a motor vehicle collision who presented with abdominal hemorrhage found on ultrasound, hypotension, and vague abdominal pain. The patient underwent an exploratory laparotomy to control bleeding. Surgery and a subsequent abdominal computed tomography revealed the presence of a portal vein pseudoaneurysm and shock bowel. This case highlights the importance of radiologists to consider the prospect of portal vein aneurysm in the differential diagnosis of hypotension following abdominal trauma.

Asymptomatic portal vein aneurysms: To treat, or not to treat?

Background Portal vein aneurysms are rare dilations in the portal venous system, for which the etiology and pathophysiological consequences are poorly understood. Method We reviewed the existing literature as well as present a unique anecdotal case of a patient presenting with a very large portal vein aneurysm that was successfully managed conservatively and non-operatively without anticoagulation, with close follow-up and routine surveillance. Result The rising prevalence of abdominal imaging in clinical practice has increased rates of portal vein aneurysm detection. While asymptomatic aneurysms less than 3 cm can be clinically observed, surgical intervention may be necessary in large asymptomatic aneurysms (>3 cm) with or without thrombus, or small aneurysms with evidence of evolving mural thrombus formation on imaging. Conclusion Portal vein aneurysms present a diagnostic challenge for any surgeon, and the goal for surgical therapy is based on repairing the portal vein aneurysm, and if portal hypertension is present decompressing via surgically constructed shunts.

Portal vein aneurysm in thalassaemia

Arterial aneurysms are more common than visceral venous aneurysms. Portal vein aneurysms being the most common type of visceral venous aneurysms. Here, we present an 18-year-old young woman with thalassaemia major, who presented with headache, palpitation, shortness of breath and a recent increase in blood transfusion rate. On clinical examination, she had hepatosplenomegaly. Ultrasonography revealed hepatosplenomegaly with fusiform dilatation of extrahepatic portal vein, which was confirmed to be portal vein aneurysm on contrast enhanced CT. Though portal vein aneurysms were previously thought to be rare, recently they are increasingly diagnosed with the use of cross-sectional imaging. Recognition of this finding can help to avoid potential confusion with other periportal cystic masses of different aetiologies, especially on sonography.

Congenital Intrahepatic Portosystemic Venous Shunt With an Associated Aneurysm: Sonographic Diagnosis

Intrahepatic portosystemic venous shunts with associated aneurysms are extremely rare anomalous communications between intrahepatic portal veins and systemic veins through intrahepatic venous channels. Intrahepatic portosystemic venous shunts are usually asymptomatic but can be the cause of hepatic encephalopathy and hypoglycemia, especially when a high degree of shunting exists. The sonographic incidental finding of an aneurysmal vascular connection between the left portal vein and left hepatic vein as diagnosed by sonography is presented and discussed. When evaluating patients with suspected symptoms of hepatobiliary disease, sonographers and radiologists should carefully scan and meticulously assess the liver for signs of abnormal venous communications.

Vascular Diseases of the Spleen: A Review

Vascular diseases of the spleen are relatively uncommon in the clinical practice. However, the reported incidence has been progressively increasing, probably due to advances in the imaging modalities used to detect them. This disease condition often presents with non-specific clinical manifestations, but can be associated with significant morbidity and mortality. This review article aims to provide updated clinical information on the different vascular diseases of the splenic vasculature-splenic vein thrombosis, splenic vein aneurysm, splenic artery aneurysm, splenic arteriovenous fistula, and spontaneous splenorenal shunt-in order to aid clinicians in early diagnosis and management.