Kent Garber, MD, MPH; Mark D. Girgis, MD
A Rare Case of a Massive Aneurysm at the SMV-Splenic Vein Confluence
Superior mesenteric venous (SMV) aneurysms were first described in the literature in 1982 by Schild et al. A systemic review conducted by Sfyroeras et al evaluated the various anatomic locations of portal venous aneurysms and determined SMV aneurysms account for 9% of the visceral aneurysms. Due to the rare nature of visceral venous aneurysms, treatment has not been standardized, and indications for surgical intervention remain contested. Indications for operation have included the occurrence of gastrointestinal bleed, compression of the common bile duct, acute thrombosis, rupture, abdominal pain, portal hypertension, aneurysmal growth, and prophylactic management.
Case Report: A 63-year-old African American male with a history of hypertension, dyspepsia, and Hepatitis C without cirrhosis or portal hypertension presented with six months of progressively worsening, sharp, epigastric pain radiating to the back. During the subsequent evaluation of his epigastric pain, an aneurysm at the superior mesenteric vein-splenic vein confluence was incidentally discovered. This aneurysm was followed with interval scans, which demonstrated enlargement of the aneurysm to 4.5 cm, requiring resection of the portal venous mesenteric aneurysm with primary anastomosis of the superior mesenteric vein to the portal vein, and ligation of the splenic vein.
Conclusion: Visceral venous aneurysms including portal venous aneurysms and the SMV subset remain a rare clinical entity. Due to improved imaging modalities, there are growing reports in the literature. No consensus has been reached regarding the optimal management of these aneurysms; however, they can be life-threatening if they rupture or thrombose so prophylactic surgical management is generally recommended for larger-sized, rapidly growing, or symptomatic aneurysms. Surgical options include resection, resection with primary anastomosis, or resection with interposition graft, depending upon anatomy. Long-term follow-up may include surveillance imaging and antiplatelet therapy.
Key Words: portal venous, aneurysm, resection, visceral venous, superior mesenteric venous, anastomosis
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