Portal venous system aneurysms: report of five cases

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.

Operative management of an incidental portal vein aneurysm in the setting of an incarcerated congenital diaphragmatic hernia

Portal vein aneurysms are rare pathologic entities. A 3.7-cm portal vein aneurysm was incidentally discovered in an 80-year-old male patient on imaging for acute abdominal pain secondary to an incarcerated diaphragmatic hernia. The aneurysm was resected, and primary repair of the portal vein was performed during a second-look operation after repair of the incarcerated hernia. Operative intervention was chosen for this patient because of the aneurysm's size and the additional indication for abdominal exploration.

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.

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.

Cross-sectional imaging of congenital and acquired abnormalities of the portal venous system

Knowing the normal anatomy, variations, congenital and acquired pathologies of the portal venous system are important, especially when planning liver surgery and percutaneous interventional procedures. The portal venous system pathologies can be congenital such as agenesis of portal vein (PV) or can be involved by other hepatic disorders such as cirrhosis and malignancies. In this article, we present normal anatomy, variations, and acquired pathologies involving the portal venous system as seen on computed tomography (CT) and magnetic resonance imaging (MRI).

Pancreatic Pseudocyst Eroding Into the Splenoportal Venous Confluence and Mimicking an Arterial Aneurysm

We report the case of a 62-year-old man with chronic pancreatitis who presented with increasing abdominal pain. Sonography, magnetic resonance imaging, contrast-enhanced computed tomography, and ultimately catheter angiography demonstrated a pancreatic pseudocyst that had eroded into the splenoportal venous confluence, mimicking an arterial aneurysm. The diagnostic was confirmed at the time of surgical treatment. This case demonstrates the use of imaging to diagnose complications of pancreatitis, and the difficulty of distinguishing an eroding pseudocyst from an arterial aneurysm.

Extrahepatic Portal Vein Aneurysm

Portal vein aneurysms are rare vascular abnormalities, many of which are incidentally discovered on routine imaging studies. The etiology of portal venous aneurysms is poorly understood, and the management of these lesions is debatable. We report the case of a 61-year-old woman with extrahepatic portal vein aneurysm. We review the nature and significance of this abnormality and discuss appropriate clinical, imaging, and treatment approaches.

Portal vein aneurysm: What to know

Portal vein aneurysm is an unusual vascular dilatation of the portal vein, which was first described by Barzilai and Kleckner in 1956 and since then less than 200 cases have been reported. The aim of this article is to provide an overview of the international literature to better clarify various aspects of this rare nosological entity and provide clear evidence-based summary, when available, of the clinical and surgical management. A systematic literature search of the Pubmed database was performed for all articles related to portal vein aneurysm. All articles published from 1956 to 2014 were examined for a total of 96 reports, including 190 patients. Portal vein aneurysm is defined as a portal vein diameter exceeding 1.9 cm in cirrhotic patients and 1.5 cm in normal livers. It can be congenital or acquired and portal hypertension represents the main cause of the acquired version. Surgical indication is considered in case of rupture, thrombosis or symptomatic aneurysms. Aneurysmectomy and aneurysmorrhaphy are considered in patients with normal liver, while shunt procedures or liver transplantation are the treatment of choice in case of portal hypertension. Being such a rare vascular entity its management should be reserved to high-volume tertiary hepato-biliary centres.

Operative interventions for extrahepatic portomesenteric venous aneurysms and long-term outcomes

BACKGROUND

Extrahepatic portal venous aneurysms (PVAs) are rare, and the pathogenesis is not fully understood. The optimum management of these patients is unknown.

METHODS

Consecutive patients with PVA were identified over an 18-year period (1992-2010). A retrospective review was conducted. Clinical presentation, modality of diagnosis, surgical treatment, 30-day morbidity and mortality, and follow-up are reported.

RESULTS

Four patients were identified who underwent surgical management of an extrahepatic PVA. Operative technique using left renal vein, femoral vein panel graft, polytetrafluoroethylene (ePTFE) graft, and segmental aneurysm wall resected with aneurysmorrhaphy is described. Early complications occurred in 1 patient with an ePTFE graft. The patient returned to the operating room for bleeding. In addition, the same patient had a late graft thrombosis 6 years postoperatively when the anticoagulation was discontinued for pregnancy. The remainder of the patients recovered without complication, and their repairs are still patent with a mean follow-up of 78 months (17-144 months). There were no mortalities in the series.

CONCLUSIONS

Operative intervention for portomesenteric venous aneurysm can be done safely in select patients and should be considered in those with symptoms, rapid growth, mural thrombus, or aneurysms ≥4 cm in diameter. Repair with an autogenous interposition graft affords good long-term patency. Aneurysmorrhaphy may be performed if the remaining venous wall is of good quality.

Prehepatic portal hypertension with aneurysm of the portal vein: unusual but treatable malformative pattern

INTRODUCTION

Portal vein aneurysms (PVAs) are usually located at the vein trunk or at its bifurcation, rarely intra-hepatic, or at the umbilical portion. Etiology remains unclear.

METHODS

Three children with PVA were identified over a 5-year period. PVA anatomy was assessed by Doppler Ultrasound, Angio CT/MRI, and trans-jugular retrograde portography.

RESULTS

Three children with intrahepatic PVA (including the umbilical portion) were identified during assessment for pre-hepatic portal hypertension: all had splenomegaly and hypersplenism. One presented with massive variceal bleeding. In two cases, a portal vein cavernoma was found, and in the third a severe stricture at the portal bifurcation was observed. Restoration of portal venous flow was achieved by a meso-Rex bypass in two cases and transposing the PV into the Rex in one. High hepatopetal portal flow was restored immediately, with follow-up confirming long-term patency and resolution of signs of portal hypertension with time.

CONCLUSIONS

These original observations suggest a common initial malformative pattern consisting of a portal venous stricture/web causing a post-stenotic aneurysmal dilatation of the intrahepatic portal branches complicated by thrombosis and cavernomatous transformation of the portal vein trunk. Importantly, the Meso-Rex bypass allows restoring a normal portal flow and cures the portal hypertension.

Extrahepatic portal vein aneurysm after orthotopic liver transplantation: a case with 9-year ultrasound observations

We report a case of extrahepatic portal vein aneurysm (PVA) in the late postoperative period after orthotopic liver transplantation (OLT). A 46-year-old man underwent OLT in 2001 for treatment of hepatitis B virus-induced cirrhosis and received ultrasound follow-up for 9 years. The long-term ultrasound observations showed that the diameter of the main portal vein had progressively increased from 12 mm in 2001 to 34 mm in 2007, and then remained at 34 mm from 2007 to 2010. The patient did not show any symptoms or complications that required surgical treatment during the clinical follow-up. Our case suggests that PVA after OLT can remain without a sign of deterioration for a long time, and careful observation by ultrasound may be one of the options in the clinical management.

Portal vein aneurysm: a rare occurrence

Portal vein aneurysms (PVA) are a rare vascular anomaly of the portal system, representing fewer than 3% of all venous aneurysms, with only 150 known cases since first reported in l956 by Barzilai and Kleckner. PVA can be divided into 2 categories: extrahepatic and intrahepatic with acquired and congenital etiologies. Bimodal treatment includes medical and surgical approaches. With increased use of noninvasive radiological imaging, PVA will be increasingly recognized in the practice of vascular surgery.

Computed tomography findings in portal vein aneurysm of dogs

In this retrospective study, the appearances of extrahepatic and intrahepatic portal vein aneurysms (PVAs) in dogs were evaluated using multidetector computed tomography (CT). Data from 3060 dogs that underwent abdominal CT were reviewed for focal portal vein dilatation. PVAs were detected in 15/3060 (0.49%) dogs. The bodyweights of dogs with PVAs were significantly higher than the bodyweights of dogs without aneurysms (P=0.0001). Male sex was also significantly associated with PVAs (OR=6.23). Boxers were predisposed to the development of PVA (OR=11.88). Extrahepatic PVAs were always located in the portal vein at the level of the gastroduodenal vein insertion and were saccular in 10/15 dogs and fusiform in 5/15 dogs. One dog had an additional intrahepatic aneurysm of the umbilical part of the left intrahepatic portal branch. No dogs had clinical signs related to the PVA(s), although one dog developed a portal vein thrombosis in the site of the aneurysm.

Complete spontaneous regression of an extrahepatic portal vein aneurysm

Primary portal venous aneurysms are rare; however, they are the most common visceral venous aneurysms, and their pathogenesis is not fully understood. Complications include thrombosis, rupture, and mass effect on adjacent structures. The optimal management of these patients is not known. We describe a patient whose large (6-cm) portal vein aneurysm underwent complete spontaneous regression over several years of serial observation. To our knowledge, this observation has not been reported in the English literature.

Portal vein aneurysms: a case series with literature review

Portal vein aneurysms are a relatively uncommon entity and often an incidental, asymptomatic finding. Recognition of this finding can help to avoid potential confusion with abdominal masses of other etiologies. We would like to present four cases of portal vein aneurysms, and discuss the natural history, imaging findings, and treatment of this condition. One of the cases of portal vein aneurysm presented occurred after liver transplantation, which, to the best of our knowledge, has only been described once in the English-language literature.

Blunt abdominal trauma - An important cause of portal venous pseuodoaneurysm

Aneurysms and pseudoaneurysms of the portal venous system are rarely seen following abdominal trauma but clinicians need to be aware of them as possible vascular complications following blunt trauma. This case report of a 10 year old boy following a handlebar injury demonstrates a clear causal relationship between trauma and portal venous pseudoaneurysm. Portal venous aneurysms have a prevalence of less than 0.4% and most are found in patients with underlying hepatocellular disease. Many are asymptomatic in which case surveillance is an accepted management strategy, with Doppler ultrasound proving useful. Complications including thrombosis, distal embolism, compression of the biliary tree and haemorrhage are usually indications for surgical management. Portal venous pseudoaneurysms may be managed conservatively but transcatheter embolisation can be used if there are ongoing complications or haemorrhage.

Visceral venous aneurysms: clinical presentation, natural history and their management: a systematic review

AIM

Aneurysms of the visceral veins are considered rare clinical entities. The aim is to assess their clinical presentation, natural history and management.

METHODS

An electronic search of the pertinent English and French literature was undertaken. All studies reporting on aneurysms of visceral veins were considered. Cases describing patients with arterial-venous fistulae and extrahepatic or intra-hepatic portosystemic venous shunts were excluded.

RESULTS

Ninety-three reports were identified, including 176 patients with 198 visceral venous aneurysms. Patients' age ranges from 0 to 87 years, and there is no apparent male/female preponderance. The commonest location of visceral venous aneurysms is the portal venous system (87 of 93 reports, 170 of 176 patients, 191 of 198 aneurysms). Aneurysms of the renal veins and inferior mesenteric vein are also described. Portal system venous aneurysms were present with abdominal pain in 44.7% of the patients, gastrointestinal bleeding in 7.3%, and are asymptomatic in 38.2%. Portal hypertension is reported in 30.8% and liver cirrhosis in 28.3%. Thrombosis occurred in 13.6% and rupture in 2.2% of the patients. Adjacent organ compression is reported in 2.2% (organs compressed: common bile duct, duodenum, inferior vena cava). The management ranged from watchful waiting to intervention. In 94% of the cases, aneurysm diameter remained stable and no complications occurred during follow-up. In most of the cases, indications for operation were symptoms and complications. Six cases of renal vein aneurysm are reported; three of them were asymptomatic. Three of these patients were treated surgically.

CONCLUSION

The most frequent location of visceral venous aneurysms is the portal venous system. They are often associated with cirrhosis and portal hypertension. They may be asymptomatic or present with abdominal pain and other symptoms. Watchful waiting is an appropriate treatment, except when complications occur. Most common complications are aneurysm thrombosis and rupture. Other visceral venous aneurysms are extremely rare.

Intrahepatic portosystemic venous shunts: Color Doppler sonography

BACKGROUND

The aim of the study was to evaluate intrahepatic portosystemic venous shunts (IPSVS) patterns and to determine the role of Color Doppler sonography in the diagnosis and evaluation of related hemodynamic changes in portal perfusion.

METHODS

Sonography and Color Doppler imaging were performed in nine patients with IPSVS. Type and Doppler waveform of the shunt were determined; velocity measurements in the portal trunk and portal branches were studied to evaluate the effects of the shunt on intrahepatic circulation. Computed tomography was performed in six patients, magnetic resonance imaging in three patients, and angiography in two patients.

RESULTS

The shunt between the portal and hepatic veins was aneurismal in six patients, while localized peripheral shunt with multiple tortuous vessels in one hepatic segment was observed in three patients. The shunts showed continuous low velocity spectral tracings and in the aneurismal shunts a low velocity bi-directional or helicoidal flow was detected. The feeding portal branches and the draining hepatic veins showed anomalous Doppler tracings and alterations of intrahepatic portal perfusion were observed in three cases.

CONCLUSION

Color Doppler is essential for proper diagnosis of IPSVS and for evaluation of related hemodynamic changes in portal perfusion.

Extrahepatic portal vein aneurysm--report of six patients and review of the literature

Extrahepatic portal vein aneurysm is a rare condition. We report six patients with extrahepatic portal vein aneurysm, four of whom were surgically treated. In addition, a review of the literature was performed to examine natural history, management, and outcomes regarding portal vein aneurysm. Patients seen at our institution with extrahepatic portal vein aneurysm greater than 1.9 cm in diameter were reviewed (1998 to 2006). There were five females and one male; median age was 66.5 (30-77). Computed tomography (CT) scan was utilized for diagnosis in all cases. The median diameter of the aneurysm was 4.7 cm (2.7-6.0). Indications for surgery included gallstone pancreatitis, mass effect on the adjacent duodenum, a peripancreatic mass, and liver cirrhosis. Three patients underwent aneurysm resection, and one patient had an orthotropic liver transplant. Two patients were managed with observation. The median follow-up from first presentation and surgery was 50 months (9-181) and 5 months (2-73), respectively. At last follow-up, five patients were alive with radiologically proven portal vein patency. One patient died 2 months after liver transplantation. There was no case of aneurysmal rupture. One patient had intramural thrombus at presentation that resolved with conservative treatment. This report suggests that symptomatic aneurysms can be safely resected with excellent patency.

Portal venous system aneurysms: imaging, clinical findings, and a possible new etiologic factor

OBJECTIVE

The aims of this study were to present the prevalence, imaging and clinical findings, and possible causes of portal venous system aneurysms.

MATERIALS AND METHODS

From 1998 to 2006, a total of 38 portal venous system aneurysms identified in 25 patients were retrospectively reviewed. The data of seven patients diagnosed using color Doppler sonography or CT before March 2004 were not consecutive, but the data recorded thereafter comprised the analysis of 4,186 consecutive patients who underwent routine abdominal MDCT. The patients were 14 men and 11 women (mean age -/+ SD, 53 -/+ 17 years).

RESULTS

The prevalence of portal venous system aneurysm among 4,186 consecutive patients was 0.43%. There were no differences with respect to patient age, patient sex, and intrahepatic or extrahepatic location of aneurysm between those with and those without portal venous system aneurysm. Seven of the 25 patients with portal venous system aneurysm were symptomatic because of portal vein thrombosis, and six of them had recurrence. These patients had significantly larger aneurysms than those without symptoms. Four of those seven symptomatic patients evaluated for thrombophilia had an underlying defect. Other associated findings were splenomegaly (n = 16), portal hypertension (n = 8), cirrhosis (n = 3), psoriasis (n = 2), portal vein variation (n = 1), chronic pancreatitis (n = 1), and cutis laxa (n =1).

CONCLUSION

Portal venous system aneurysms were rare in our study group but occurred more frequently than previously thought. All thrombosed aneurysms, most with a recurrence, were symptomatic and larger in patients with symptoms of portal venous system aneurysm than in those without symptoms. There were no differences among patients with portal venous system aneurysm and those without portal venous system aneurysm with respect to patient age and patient sex. Among those with aneurysms, there was no difference between subjects with intrahepatic versus extrahepatic aneurysms. A thrombophilic defect probably played a role in development of thrombosis in the portal venous system aneurysm.

Computer Simulation of Hemodynamic Changes After Right Lobectomy in a Liver with Intrahepatic Portal Vein Aneurysm

BACKGROUND/PURPOSE

Intrahepatic portal vein aneurysm is rare and its natural history is unknown. A 22-year-old healthy man, who wished to donate part of his liver to his diseased father, was incidentally diagnosed to have an intrahepatic portal vein aneurysm. The surgical decision of performing live donor hepatectomy for such a patient is normally difficult. We combined modern imaging reconstruction technologies with scientific computing as a new modality to foresee the risks of surgical complications.

METHODS

Cross-sectional computed tomography images were used to reconstruct the three-dimensional image of portal vein distribution using the 3D-Doctor v3.5 software. The reconstructed images were further employed to generate surface and interior meshes with CFX software. Simulated hemodynamic changes in velocity, pressure, and wall stress were determined for the right lobectomy case pre- and postoperatively.

RESULTS

The simulation results indicated that aneurismal pressure would be elevated significantly to 12.03 mmHg after operation. The left segmental portal venous blood flow would increase from 2.95- to 4.25-fold. The area near the branch point of one left segmental portal vein, which supplies blood to liver segment 4, and the portal vein aneurysm would endure high shear stress gradient. The resulting elevated aneurismal pressure may cause the thin wall to enlarge and rupture, while the high shear stress gradient would lead to vascular endothelial cell injury. Living donor surgery was not recommended hemodynamically based on the simulated results.

CONCLUSION

Scientific computing and modern imaging technologies can be applied together to aid surgeons to make the best decision in difficult clinical situations.

Congenital extrahepatic portal vein aneurysm

Portal vein aneurysm is a rare clinical entity, with only 41 published cases in the English-language literature. Twenty-five of them were congenital. We present the case of a 50-year-old woman who was incidentally diagnosed with a congenital extrahepatic portal vein aneurysm during an investigation for dyspepsia. Ultrasonographic features are described with correlation of computed tomographic and magnetic resonance findings. Etiology, clinical significance, and management strategies for these lesions are discussed and a review of the literature regarding this entity is presented.

CT angiography of intrahepatic portal aneurysm

We report a case of an asymptomatic portal vein aneurysm diagnosed at ultrasonography and documented with multidetector computed tomography. We describe the features found at quadriphasic multidetector computed tomography with three-dimensional computed tomographic angiography.

Splenic vein aneurysm with calcification of splenic and portal veins

Splenic vein aneurysm is a rare disease, and calcifications in the portal venous system are also rare. Here we present a case of splenic vein aneurysm associated with calcification of the splenic and portal veins, a condition that to our knowledge has not been reported before.

Portal vein aneurysm as late complication of liver transplantation: a case report

OBJECTIVE

A case of intrahepatic portal vein aneurysm in the late postoperative period after liver transplantation, as well its complications, is reported.

CASE REPORT

A 59-year-old man underwent orthotopic liver transplantation in 1996 for treatment of hepatitis C virus cirrhosis. The patient received a graft from a 10-year-old child. During the follow-up from 1996 to 1998, the patient did not show any alterations. In 1999, during an annual routine exam, a portal vein aneurysm was identified; however, it had no impact on graft function. In November 2002, the patient developed jaundice and serious graft dysfunction requiring hospital admission. Helicoidal CT scan showed an intrahepatic image compatible with a portal vein aneurysm without biliary tract dilatation. During the same hospitalization, he developed upper gastrointestinal bleeding due to variceal rupture as well as kidney and liver failure, and expired on December 31, 2002. The necropsy demonstrated an intrahepatic portal vein aneurysm with portal vein thrombosis and chronic liver disease. The evolution in this case suggests that if there is an intrahepatic portal vein aneurysm after liver transplantation, the patient is likely to experience an eventual recurrence of portal hypertension; retransplant may be an alternative.

Extrahepatic portal vein aneurysm: Two case reports of surgical intervention

We report two cases of extrahepatic portal vein aneurysm, and both of them underwent surgical intervention. The first case had a mild pain in right upper quadrant of the abdomen; the second had no obvious symptoms. Physical examination revealed nothing abnormal. Both of them were diagnosed by magnetic resonance imaging angiography (MRA). One of the aneurysms was located at the main portal vein, the other, at the confluence of the superior mesenteric vein and the splenic vein, and these two places are exactly the most common locations of the extrahepatic portal vein aneurysm reported in the literature (30.7% each site). The first case underwent aneurysmorrhaphy and the second case, aneurysm resection with splene-ctomy. Both of them recovered soon after the operation, and the symptom of the first case was greatly alleviated. During the follow-up of half a year, no complication and adverse effect of surgical intervention was found and the color Doppler ultrasonography revealed no recurrence of the aneurysmal dilation. We suggest that surgical interv-ention can alleviate the symptom of the extrahepatic portal vein aneurysm and prevent its complications effectively and safely for low risk patients.

Reconstruction of the main portal vein for a large saccular aneurysm

BACKGROUND

A large aneurysm of the main portal vein is rare, and the appropriate surgical procedure is uncertain. Reconstruction of a main portal vein affected by a large saccular aneurysm is described.

CASE OUTLINE

Abdominal pain led to the diagnosis of a large saccular aneurysm of the main portal vein in a 58-year-old woman who had undergone cholecystectomy 10 years earlier. At laparotomy a dorsolateral approach to the hepatoduodenal ligament was performed with no attempt at extensive separate exposure of the anatomical structures in the hepatoduodenal ligament, so as to avoid the devascularisation of the common hepatic duct and additional weakening of the portal vein wall. The aneurysm was longitudinally incised, and the portal vein was reconstructed from the walls of the aneurysm with a longitudinal running suture. The rest of the aneurysmal wall was wrapped around the portal vein, leaving it normal in size and contour. Recovery was uneventful. Follow-up CT scan showed a patent portal vein in the region of the former aneurysm.

DISCUSSION

Large saccular aneurysms can rupture, bleed and cause death. The potential hazards of manipulation of large portal vein aneurysms are negligible in comparison with the possible complications of the aneurysm itself. In our opinion the ease with which the main portal vein was dissected and reconstructed make an elective operation in such cases a reasonable approach.

Congenital and acquired anomalies of the portal venous system

Knowledge of the normal anatomy, most frequent variants, and congenital and acquired anomalies of the portal venous system is of great importance for liver surgery and interventional procedures such as creation of transjugular intrahepatic portosystemic shunts. Radiologic studies of the portal venous system include color Doppler ultrasonography (US), computed tomography (CT), magnetic resonance imaging, and arterial or direct portography. Among the most common branching variants of the portal vein are trifurcation, right anterior portal branch arising from the left portal vein, and right posterior portal branch arising from the main portal vein. Agenesis of the right or left portal vein is the most frequently reported congenital anomaly. Venous collateral vessels due to portal hypertension and cavernous transformation of the portal vein are best evaluated with cross-sectional imaging. Intrahepatic portosystemic, arterioportal, and arteriosystemic fistulas and associated perfusion anomalies have characteristic features at dual-phase helical CT. Color Doppler US is the single most useful tool for demonstration of aneurysms of the portal venous system and bland or neoplastic portal vein thrombosis. CT is also the best means of evaluating gas in the portal venous system, which is no longer an ominous sign and must be differentiated from aerobilia.

Doppler sonography of the native liver

Doppler sonography is being used routinely in evaluating the vascular structures of the native liver because of its ease of use, lower cost, easier availability, lack of need for X-ray and accuracy. Doppler sonography can well demonstrate the vascularization of liver tumors, portal vein thrombosis, portal vein abnormalities in patients with portal hypertension and hepatic venous findings in patients with Budd Chiari syndrome. The purpose of this article is to present information about Doppler sonography of the native liver and to show its usefulness in the evaluation of hepatic vascular diseases.