Recurrent hemorrhagic pancreatic pseudocyst with superior mesenteric vein thrombosis treated by pancreaticoduodenectomy and vein graft reconstruction: a case report

Introduction and importance: Hemorrhage into a pancreatic pseudocyst is rare but potentially fatal. Interventional radiology-guided transcatheter arterial embolization (TAE) is often first-line therapy; however, rebleeding is common, and surgery may be required. Inflammation from pancreatitis can make surgery technically challenging, underscoring the importance of careful management. Case presentation: A 68‑year‑old Japanese man with chronic pancreatitis and heavy alcohol use presented with acute abdominal pain. Computed tomography revealed a 25 mm hemorrhagic cystic lesion in the pancreatic head containing a pseudoaneurysm, superior mesenteric vein (SMV) thrombosis, and inflammatory fat stranding. Initial TAE controlled bleeding from a branch of the dorsal pancreatic artery, but recurrent hemorrhage occurred 7 months later, requiring repeat TAE. Three months later, another episode from the anterior superior pancreaticoduodenal artery was embolized. Because of repeated bleeding and persistent SMV thrombosis, pancreaticoduodenectomy with SMV resection and reconstruction was performed using an external iliac vein graft under an Anthron‑coated catheter shunt. The postoperative course was uneventful, and the patient has remained symptom‑free for 2 years. Clinical discussion: This case illustrates the complexity of managing hemorrhagic pancreatic pseudocyst with SMV thrombosis and recurrent bleeding. While endovascular therapy can provide temporary control, repeated episodes may necessitate definitive surgery. An intraoperative Anthron-coated catheter shunt enabled safe SMV reconstruction in this case despite extensive thrombosis. Conclusion: Surgical intervention should be considered in select patients with recurrent hemorrhage and complicating vascular pathology. This case adds to the limited literature and may inform future treatment strategies.