Transhepatic endovascular repair for portal vein haemorrhage

BACKGROUND: Post-surgical bleeding of the main portal vein (PV) is a rare event but difficult to manage surgically. Among the different options of treatment, endovascular stenting of the PV can be considered. We reported two cases of stent-graft placement in PV with subsequent closure of the portal vein access with two percutaneous closure devices deployed simultaneously. CASES PRESENTATION: The first patient was a 43 years-old woman affected with a pseudoaneurysm of the extrahepatic PV, occurred after a duodenocephalopancreasectomy performed for a neuroendocrine tumour of the pancreatic isthmus. The second patient was a 54 years-old man suffering from multiple episodes of bleeding after liver transplantation, due to a PV fissure. In both cases, a stent graft was placed into the portal system, between the PV and the superior mesenteric vein through a right trans-hepatic access to the portal system. In both cases, a final control showed patency of the mesenteric vein and PV and no endoleak detection. At the end of the procedure, two percutaneous closure devices were loaded, to close the transhepatic portal access. In one case, one of the devices did not work and the entry point was managed with a single device, without further complications. No bleeding was seen though the entry point nor at the US examination performed right after the procedure. After procedure, patients were prescribed with low-molecular weight heparin (LMWH) and kept under surveillance. For both patients, CT scan performed within 24h after the procedure, showed a patent stent-graft and no evidence of any venous portal ischemia. The first patient was then transferred to another hospital, to continue observation and medical management. The second one underwent 2 months of hospitalization, during which he developed a pancreatic fistula and mild renal insufficiency. Then, he left the hospital to its native Country to continue his medical. CONCLUSION: PV stent-graft placement seems a feasible option to manage portal bleeding. Trans-hepatic access is an easy and fast approach. The trans-hepatic portal accesses may be successfully managed with the deployment of percutaneous closure devices.