Stentgraft Implantation for the Treatment of Postoperative Hepatic Artery Pseudoaneurysm

Stent-Graft Placement for Hepatic Arterial Hemorrhage after Pancreaticobiliary Surgery: Long-Term Clinical Outcomes

PURPOSE

To evaluate the safety and long-term clinical outcomes of stent-graft placement to treat hepatic arterial hemorrhage after pancreaticobiliary surgery.

MATERIALS AND METHODS

Outcomes were retrospectively evaluated in 61 patients (50 men and 11 women; mean age, 63 years) who underwent stent-graft placement for delayed arterial hemorrhage (after 24 hours) after pancreaticobiliary surgery from 2006 to 2023. Bleeding sites included the gastroduodenal artery stump (n = 54), common or proper hepatic artery (n = 5), and right hepatic artery (n = 2). The stent-grafts used were Viabahn (n = 27), Comvi (n = 11), Jostent (n = 3), Covera (n = 11), and Lifestream (n = 7). Technical and clinical success and adverse events (AE) were evaluated. After stent-graft placement, overall survival (OS), hemorrhage-free survival (HFS), and stent patency were evaluated.

RESULTS

The technical and clinical success rates of stent-graft placement were 97% and 93%, respectively. The severe AE rate was 12% and was significantly higher in patients who underwent pylorus-sacrificing rather than pylorus-preserving surgery (P = .001). None of the severe AEs were associated with patient mortality. Median OS after stent-graft placement was 854 days, and median HFS was 822 days. The 1-, 3-, 5-, and 10-year stent patency rates were 87%, 84%, 79%, and 72%, respectively.

CONCLUSIONS

Stent-graft placement was safe and provided long-term control of hepatic arterial hemorrhage after pancreaticobiliary surgery.

Combined Endovascular Repair of a Giant Symptomatic Hepatic Aneurysm: A Case Report and Comprehensive Literature Review

Hepatic artery aneurysms (HAAs) are an uncommon vascular disease, which account for 20% of visceral artery aneurysms. The majority are usually asymptomatic and discovered accidentally during imaging control, but occasionally, they can present as acute abdominal pain, haemobilia, obstructive jaundice, or gastrointestinal bleeding due to aneurysm sac expansion or rupture with catastrophic consequences. We present the case of a 51-year-old male patient with a giant common HAA of 11.1 cm who was managed endovascularly. A combined endovascular approach was decided due to the anatomy of the aneurysm. Endovascular embolization with coils in the distal part of the aneurysm and deployment of a stent graft proximally to exclude inflow were used. At six months, the aneurysm size was regressed at 5 cm; however, seven months after the operation, the patient presented with pylorus perforation due to coil migration which was managed by coil removal, peripheral gastrectomy, and Roux-en-Y gastric bypass. We provide a narrative literature review regarding the endovascular repair of giant HAAs. The PubMed, Scopus, and Google Scholar databases were searched for articles up to January 2024. Thirty-eight studies (case reports, case series) were retrieved. The conclusion is that giant HAAs are a rare and severe condition in which their treatment can be challenging with unexpected adverse events. The literature review suggests that the endovascular approach whenever feasible is a safe and effective treatment option with low morbidity and mortality.

Usefulness of the hybrid technique of interventional radiology and endoscopic treatment for intestinal bleeding after pancreaticoduodenectomy: a case report

Introduction and importance

In endovascular treatment of ruptured pseudoaneurysm after pancreaticoduodenectomy (PD) with gastrointestinal bleeding, treatment for vasospasm of the culprit vessel from haemorrhagic shock and subsequent reperfusion has not been determined before.

Case presentation

The authors hereby present you with a case of a 59-year-old man with unknown operative method upon arrival at the Emergecy room and who had hematemesis and collapse 6 months post-PD surgery.

Clinical discussion

An initial contrast-enhanced computed tomography (CT) revealed no obvious source of bleeding, so an upper gastrointestinal endoscope was performed. Rebleeding occurred during the examination, and interventional radiology was performed because haemostasis was difficult. Coil embolization was performed for leakage of contrast material from the gastroduodenal artery stump into the gastrointestinal tract. However, because the embolization was uncertain due to vasospasm of the common hepatic artery, endoscopic clipping of the perforation site was also performed to prevent rebleeding due to reperfusion after improvement of vasospasm. A CT scan 5 days later showed reperfusion of the coil-implanted vessel. No rebleeding or hepatic infarction occurred postoperatively.

Conclusion

In this case, the haemostasis by coil embolization was uncertain due to the presence of vasospasm, and clipping was used in combination with the procedure to prevent rebleeding.

Recurrent hepatic artery pseudoaneurysm repair with overlapping tapered stent-graft technique

Hepatic artery pseudoaneurysms (HAPs) are rare but life-threatening complications associated with hepatic artery infusion pump (HAIP) therapy for unresectable liver metastases. Traditional management options include open surgery or stent placement, but these approaches have drawbacks. We present a unique case of a dislodged stent embedded in a HAP, resulting in delayed type-I endoleak. To address this, we employed a novel technique using multiple overlapping tapered stents to reconstruct the hepatic artery. This approach successfully excluded the pseudoaneurysm without endoleak. Stent-graft placement emerges as a safer and more effective option for managing HAP, preserving hepatic arterial flow, and reducing morbidity compared to other methods. However, further research is needed to evaluate this technique's long-term outcomes and potential complications.

Covered stent placement for gastroduodenal artery stump hemorrhage after pancreaticoduodenectomy: long-term patency and risk factor of stent failure

OBJECTIVE

To evaluate the long-term outcomes of covered stent placement in patients with gastroduodenal artery (GDA) stump hemorrhage after pancreaticoduodenectomy (PD) and to identify risk factors of stent failure.

METHODS AND MATERIALS

Covered stent was placed in total of 21 patients for GDA stump hemorrhage after PD from September 2012 to March 2021. Technical and clinical success, complications, and stent patency were retrospectively evaluated. Nine relevant variables were analyzed to determine risk factors for stent failure.

RESULTS

In 20 of 21 patients (95.2%), the GDA stump was completely excluded with covered stent placement. Immediate hemostasis was achieved in the 20 patients and rebleeding from jejunal artery occurred in one patient which was successfully embolized one day after the stent placement. There was no procedure-related complication or early mortality (<30 days). During follow-up period (median 655.5 days), stent thrombosis was found on CT in 10 patients (50.0%, 10/20) without any laboratory or CT abnormalities. One thrombosed stent migrated into the jejunum 20 months after placement. The six-month, one-year, and two-year stent patency were 81.9%, 52.9%, and 37.8%, respectively (median 620 days). The recurrence of primary malignancy was associated with stent failure (HR 5.70; 95% CI 1.18-27.76, p = 0.03).

CONCLUSIONS

Covered stent placement is an effective and safe management of postoperative GDA stump hemorrhage. Stent failure occurred frequently (50%) but did not cause liver ischemia. Stent failure was associated with recurrence of primary malignancy.

ADVANCES IN KNOWLEDGE

1. Covered stent placement is an effective and safe management of postoperative GDA stump hemorrhage.2. Stent failure occurred frequently (50%) but did not cause liver ischemia.3. Stent failure was associated with recurrence of primary malignancy.

Stent-graft placement for hepatic arterial bleeding: assessment of technical efficacy and clinical outcome in a tertiary care center

BACKGROUND

To evaluate technical and clinical results of stent-graft (SG) placement for bleeding from the hepatic artery (HA).

METHODS

All patients intended and treated with SG deployment for bleeding from the HA at single center from January 2012 to May 2020 were retrospectively identified, and procedural details, risk factors for rebleeding, SG occlusion and mortality were analyzed.

RESULTS

Twenty-seven patients (mean age 68.8 ± 10.1) were identified, and 25 patients underwent 26 SG procedures. Twenty-four patients had recent surgery. The technical success rate was 92.8%. Three patients (3/25) had rebleeding (88% clinical success). Intensive-care need before the procedure (p = 0.013) and smaller stent-graft size (≤4 mm, p = 0.032) were related to clinical failure. Twenty-two patients had follow-up imaging. The SG maintained patency in 10 (45.4%) patients at the most recent imaging. Only placement of SG distal to the HA bifurcation (p = 0.012) was related to occlusion. The 30-day and in-hospital mortality rate after SG was 8% and 24%. In-hospital mortality was associated with the intraabdominal septic source (p = 0.010) and revision surgery (p = 0.001).

CONCLUSION

Stent-grafts are effective in the emergent treatment of HA bleeding. Mortality is mainly related to the general condition of the patient, and stent-grafts offer time to treat underlying medical problems sufficiently.

Utilization of an Occlusion Balloon Catheter during Stent-Graft Placement to Treat Postsurgical Visceral Arterial Hemorrhage

The utility of occluding the bleeding artery using an occlusion balloon catheter during stent-graft placement for visceral artery bleeding was evaluated. Stent-graft placement for visceral artery bleeding was performed using a balloon catheter in 6 patients. All bleeding occurred after biliary or pancreatic surgery. Since 1 patient underwent the procedure twice, 7 procedures were assessed in total. Technical success, procedure-related adverse events, and 30-day mortality rates were evaluated. Technical success was defined as the placement of the stent-graft at the target site and the resolution of extravasation or pseudoaneurysm. In all procedures, stent-graft placement was successfully performed (technical success rate, 100%). Focal liver infarction occurred in 2 of 7 patients (29%), but did not require further treatment and was considered a minor adverse event. The 30-day mortality rate was 0%. In conclusion, the use of an occlusion balloon in the feeding artery facilitated successful stent-graft repair of hemorrhage from visceral arteries.

Stent Graft Placement by Pseudoaneurysm of the Hepatic Arteries: Efficacy and Patency Rate in Follow-up

Purpose

To investigate efficacy and patency status of stent graft implantation in the treatment of hepatic artery pseudoaneurysm.

Materials and Methods

A retrospective analysis of patients who had undergone endovascular treatment of hepatic artery pseudoaneurysms between 2011 and 2020 was performed. Medical records were examined to obtain patients’ surgical histories and to screen for active bleeding. Angiographic data on vascular access, target vessel, material used and technical success, defined as the exclusion of the pseudoaneurysm by means of a stent graft with sufficient control of bleeding, were collected. Vessel patency at follow-up CT was analyzed and classified as short-term (< 6 weeks), mid-term (between 6 weeks and 1 year), and long-term patency (> 1 year). In case of stent occlusion, collateralization and signs of hepatic hypoperfusion were examined.

Results

In total, 30 patients were included and of these, 25 and 5 had undergone stent graft implantation and coiling, respectively. In patients with implanted stent grafts, technical success was achieved in 23/25 patients (92%). Follow-up CT scans were available in 16 patients, showing stent graft patency in 9/16 patients (56%). Short-term, mid-term, and long-term short-term stent patency was found in 81% (13/16), 40% (4/10), and 50% (2/4). In patients with stent graft occlusion, 86% (6/7) exhibited maintenance of arterial liver perfusion via collaterals and 14% (1/7) exhibited liver abscess during follow-up.

Conclusion

Stent graft provides an effective treatment for hepatic artery pseudoaneurysms. Even though patency rates decreased as a function of time, stent occlusion was mainly asymptomatic due to sufficient collateralization.

Preventive covered stent placement at the gastroduodenal artery stump in angiogram-negative sentinel hemorrhage after pancreaticoduodenectomy

PURPOSE

To evaluate the clinical outcomes of preventive covered stent placement at the gastroduodenal artery stump in patients with angiogram-negative sentinel hemorrhage after pancreaticoduodenectomy.

METHODS

Between July 2006 and September 2018, patients undergoing computed tomography angiography or diagnostic angiography for sentinel hemorrhage after pancreaticoduodenectomy were retrospectively reviewed. Patients having angiogram-negative angiography and undergoing preventive covered stent placement or conservative treatment were included. Clinical outcomes, technique success, and complications were evaluated.

RESULTS

A total of 25 patients (mean age 62.5 years) were evaluated, including 15 patients underwent preventive covered stent placement at the gastroduodenal artery stump and 10 patients received conservative treatments. The clinical success rates were 50% (5/10) and 86.7% (13/15) for conservative treatments and covered stent groups, respectively (p = 0.07). In the conservative treatment group, delayed massive hemorrhage occurred in five patients, two of whom died of recurrent bleeding due to gastroduodenal artery pseudoaneurysm within 16 days, and two had intraluminal hemorrhage within 5 days. In the covered stent group, one patient had inferior pancreaticoduodenal artery pseudoaneurysm 1 day after the placement of the covered stent, and one had recurrent bleeding due to duodenal ulcer within 14 days. The 30-day mortality was 40% (4/10) and 0 in the conservative treatment and covered stent groups, respectively (p = 0.02). The difference in the overall survival was nonsignificant between the two groups (p = 0.23).

CONCLUSIONS

The preventive covered stent placement at the gastroduodenal artery stump is safe and reduces delayed massive hemorrhage and short-term mortality in patients with angiogram-negative sentinel hemorrhage after pancreaticoduodenectomy.

Endovascular treatment with Viabahn stent-grafts for arterial injury and bleeding at the visceral arteries: initial and midterm results

PURPOSE

The purpose of the study is to evaluate the initial and midterm efficacy and safety of endovascular treatment (EVT) using Viabahn stent-graft (SG) for arterial injury and bleeding (AIB) at the visceral arteries.

MATERIALS AND METHODS

Consecutive patients with visceral AIB who underwent EVT using Viabahn between January 2017 and February 2021 were retrospectively reviewed. Technical success, clinical success, peripheral organ ischemia, peri-procedural complications, bleeding-related mortality, 30-day mortality, neck length, re-bleeding, endoleaks, and patency of the SGs at 1, 3, 6, and 12 months were evaluated.

RESULTS

EVT using Viabahn was performed in 14 patients (mean age: 68.6 years; 12 males) and 15 arteries. The technical and clinical success rates were 100%. The rates of peripheral organ ischemia, peri-procedural complications, bleeding-related mortality, and 30-day mortality were all 0%. The mean neck length was 9.9 mm. No endoleaks or re-bleeding occurred during the follow-up (mean: 732 days). The SG patency was confirmed after 1, 3, 6, and 12 months in 78.6%, 78.6%, 78.6%, and 56.1% of the patients, respectively.

CONCLUSION

EVT using Viabahn for AIB at the visceral arteries was safe and effective. SG occlusions without ischemia often occurred after 12 months.

[Endovascular treatment of arterial bleeding after pancreatic surgery]

Pancreatic surgery is complex and associated with a risk of complications including bleeding. Bleeding after pancreatic surgery is rare, but characterized by high mortality. This review is devoted to classification, diagnosis and treatment strategies for bleeding after pancreatic surgery. Methods and results of endovascular surgery are of special attention.

Fatal arterial hemorrhage after pancreaticoduodenectomy: How do we simultaneously accomplish complete hemostasis and hepatic arterial flow?

BACKGROUND

Although arterial hemorrhage after pancreaticoduodenectomy (PD) is not frequent, it is fatal. Arterial hemorrhage is caused by pseudoaneurysm rupture, and the gastroduodenal artery stump and hepatic artery (HA) are frequent culprit vessels. Diagnostic procedures and imaging modalities are associated with certain difficulties. Simultaneous accomplishment of complete hemostasis and HA flow preservation is difficult after PD. Although complete hemostasis may be obtained by endovascular treatment (EVT) or surgery, liver infarction caused by hepatic ischemia and/or liver abscesses caused by biliary ischemia may occur. We herein discuss therapeutic options for fatal arterial hemorrhage after PD.

AIM

To present our data here along with a discussion of therapeutic strategies for fatal arterial hemorrhage after PD.

METHODS

We retrospectively investigated 16 patients who developed arterial hemorrhage after PD. The patients’ clinical characteristics, diagnostic procedures, actual treatments [transcatheter arterial embolization (TAE), stent-graft placement, or surgery], clinical courses, and outcomes were evaluated.

RESULTS

The frequency of arterial hemorrhage after PD was 5.5%. Pancreatic leakage was observed in 12 patients. The onset of hemorrhage occurred at a median of 18 d after PD. Sentinel bleeding was observed in five patients. The initial EVT procedures were stent-graft placement in seven patients, TAE in six patients, and combined therapy in two patients. The rate of technical success of the initial EVT was 75.0%, and additional EVTs were performed in four patients. Surgical approaches including arterioportal shunting were performed in eight patients. Liver infarction was observed in two patients after TAE. Two patients showed a poor outcome even after successful EVT. These four patients with poor clinical courses and outcomes had a poor clinical condition before EVT. Fourteen patients were successfully treated.

CONCLUSION

Transcatheter placement of a covered stent may be useful for simultaneous accomplishment of complete hemostasis and HA flow preservation.

Hepatic Artery Embolization for Postoperative Hemorrhage: Importance of Arterial Collateral Vessels and Portal Venous Impairment

PURPOSE

To investigate the association between hepatic ischemic complications and hepatic artery (HA) collateral vessels and portal venous (PV) impairment after HA embolization for postoperative hemorrhage.

MATERIALS AND METHODS

From October 2003 to November 2019, 42 patients underwent HA embolization for postoperative hemorrhage. HA collateral vessels were classified according to visualization after embolization (grade 1, none; grade 2, 1-4 segmental HA; and grade 3, ≥4 segmental HA). Transhepatic portal vein stent placements were performed in the same session for 5 patients (11.9%) with poor HA collateral vessels (grade 1 or 2) and compromised PV flow (>70% stenosis). Hepatic ischemic complications were analyzed for relevance to HA collateral vessels and PV compromise.

RESULTS

After HA embolization, HA flow was found to be preserved (grade 3) through intra- and/or extrahepatic collateral vessels in 23 patients (54.8%), and hepatic complications did not occur regardless of PV flow status (0%). Of the 19 patients (45.2%) with poor HA collateral vessels (grade 1 or 2), segmental hepatic infarction occurred in 2 of 15 patients (13.3%) with preserved PV flow (10 naïve and 5 stented). The remaining 4 patients with poor HA collateral vessels and untreated compromised PV flow experienced multisegmental hepatic infarction (n = 3) or hepatic failure (n = 1) (100%) (P < .005).

CONCLUSIONS

After HA embolization, preserved HA flow (≥4 segmental HA) lowered the risk of hepatic complications regardless of the PV flow. Based on these findings, transhepatic PV stent placement seems to be an effective intervention for the prevention of hepatic complications in cases of poor HA collateral vessels and compromised PV flow.

Application of resuscitative endovascular balloon occlusion in post-transplant mycotic hepatic artery pseudoaneurysm rupture in the setting of Aspergillus Constellatus bacteremia

Hepatic artery pseudoaneurysm (HAP) is a rare, highly morbid and frequently fatal complication of liver transplantation. Most are a mycotic mediated weakness of the arterial wall, with associated bacterial or fungal infection of ascitic fluid. As it is usually asymptomatic prior to rupture, the majority present in acute hemorrhagic shock and dire extremis. Resuscitative endovascular balloon occlusion (REBOA) was initially developed for the management of noncompressible hemorrhagic shock in trauma; however, remains underutilized and understudied in the non-trauma setting. We present the case of a mycotic hepatic artery pseudoaneurysm rupture due to Streptococcus constellatus and Klebsiella pneumoniae post directed donor orthoptic liver transplant, in which REBOA was employed in the setting of impending exsanguination as a bridge to definitive surgical intervention. Although this patient passed away of multiorgan system failure prior to re-transplant, this case demonstrates the importance of a heightened suspicion of this devastating complication, especially in the setting of bilioenteric reconstruction and perihepatic fluid collection, as well as the benefit of utilizing resuscitative techniques such as REBOA prior to definitive surgical or endovascular therapy to mitigate the high morbidity and mortality of this condition.

Arterio-biliary fistula caused by a hepatic artery pseudoaneurysm in a recently performed liver transplant: successful resolution and long-term liver implant preservation using a covered coronary stent

Background

The formation of a hepatic artery pseudoaneurysm in a liver implant is a rare but potentially fatal complication. Fistulization of such pseudoaneurysms into the bile duct is sporadic. The most common causes of hepatic artery pseudoaneurysm are infection at the anastomosis site, inadequate surgical technique, and an iatrogenic origin due to minimally invasive procedures. Currently, there is no standardized treatment in neither of these complications, with surgery and various endovascular procedures among the alternatives available. None of these therapeutic approaches has demonstrated a significant increase in long-term liver implant preservation.

Case presentation

A 56-year-old man with a two-month liver transplant presented with massive upper gastrointestinal bleeding and hemobilia shortly after the performance of an endoscopic retrograde cholangiopancreatography due to the presence of a hepatic artery pseudoaneurysm with fistulization into the bile duct. This case report describes the successful treatment of both complications, the hepatic artery pseudoaneurysm and the arterio-biliary fistula, using a covered coronary stent placed in the hepatic artery. A year and a half after treatment, the patient maintains a preserved liver implant and a patent hepatic artery.

Conclusions

Treatment of a hepatic artery pseudoaneurysm with fistulization into bile duct using a covered coronary stent allowed the correct repair of the defect, adequate hemorrhage control, and long-term liver implant preservation.

Risk Factors for In-hospital Mortality After Transarterial Intervention After Postpancreatectomy Hemorrhage

Purpose

Postpancreatectomy hemorrhage (PPH) is one of the leading causes of mortality after pancreatic resection. Late onset PPH is most often treated using a transarterial approach. The aim of this study was to analyze risk factors for in-hospital mortality after endovascular treatment.

Methods

Between 2012 and 2017, patients who were treated endovascular due to PPH were identified from a retrospective analysis of a database. Risk factors for mortality were identified by univariate analysis.

Results

In total, 52 of the 622 patients (8.4%) underwent endovascular treatment due to PPH. The primary technical success achieved was 90.4%. In 59.6% of patients, bleeding control was achieved by placing a stent graft and in 40.4% by coil embolization. The primary 30-day and 1-year patency of the placed covered stents was 89.3% and 71.4%, respectively. The 60-day mortality was 34.6%. The reintervention rate was higher after stent graft placement compared to coiling (39.3% vs. 21.1%, P = 0.012). In the univariate analysis the need for reintervention was associated with a higher in-hospital mortality (21.2% vs. 7.7%, P = 0.049). The use of an antiplatelet agent was associated with a decreased in-hospital mortality in the univariate (11.5% vs. 25%, P = 0.024) and multivariate analysis (HR 3.1, 95% CI 1.1-9, P = 0.034), but did not increase the risk of rebleeding.

Conclusion

Endovascular management of delayed PPH has a high technical success rate. Stent graft placement showed a higher reintervention rate. The need for reintervention was associated with a higher in-hospital mortality but did not differ between coiling and stent graft placement.

Multidisciplinary treatment of left hepatic artery pseudoaneurysm after hepatobiliary resection for gallbladder cancer: a case report

BACKGROUND

When a postoperative hepatic artery pseudoaneurysm develops after massive hepatectomy, both an intervention for the pseudoaneurysm and patency of hepatic artery should be considered because occlusion of the residual hepatic artery results in critical liver failure. However, the treatment strategy for a pseudoaneurysm of the hepatic artery after hepatobiliary resection is not well established.

CASE PRESENTATION

A 65-year-old woman underwent right hepatectomy, extrahepatic duct resection, and portal vein resection, for gallbladder cancer. Although the patient had an uneventful postoperative course, computed tomography on postoperative day 6 showed a 6-mm pseudoaneurysm of the hepatic artery. Angiography revealed the pseudoaneurysm located on the bifurcation of the left hepatic artery to the segment 2 artery plus the segment 3 artery and 4 artery. Stent placement in the left hepatic artery was not feasible because the artery was too narrow, and coiling of the pseudoaneurysm was associated with a risk of occluding the left hepatic artery and inducing critical liver failure. Therefore, portal vein arterialization constructed by anastomosing the ileocecal artery and vein was performed prior to embolization of the pseudoaneurysm to maintain the oxygen level of the remnant liver, even if the left hepatic artery was accidentally occluded. The pseudoaneurysm was selectively embolized without occlusion of the left hepatic artery, and the postoperative laboratory data were within normal limits. Although uncontrollable ascites due to portal hypertension occurred, embolization of the ileocolic shunt rapidly resolved it. The patient was discharged on postoperative day 45.

CONCLUSION

Portal vein arterialization prior to embolization of the aneurysm may be a feasible therapeutic strategy for a pseudoaneurysm that develops after hepatectomy for hepatobiliary malignancy to guarantee arterial inflow to the remnant liver. Early embolization of arterioportal shunting after confirmation of arterial inflow to the liver should be performed to prevent morbidity induced by portal hypertension.

Efficacy and hepatic complications of three endovascular treatment approaches for delayed postpancreatectomy hemorrhage: evolution over 15 years

Background

Delayed postpancreatectomy hemorrhage (PPH) is a fatal complication caused by arterial erosion. This study reports a single-center experience of managing delayed PPH with different endovascular treatment approaches.

Methods

We reviewed the data of patients who had delayed PPH due to hepatic artery or gastroduodenal artery stump perforation and underwent endovascular treatment between 2003 and 2018. We categorized endovascular treatment approaches involving hepatic artery sacrifice, superselective pseudoaneurysm embolization with hepatic artery preservation, and covered stent placement. Technical success rates, hemorrhage recurrence rates, major and minor hepatic complication rates, and 30-day and 1-year mortality rates were assessed.

Results

A total of 18 patients were reviewed; 11 (61%), 4 (22%), and 3 (17%) delayed PPH cases were managed through hepatic artery sacrifice, superselective pseudoaneurysm embolization, and hepatic artery stenting, respectively. Multidetector computed tomography was performed in 14 (78%) patients. The technical success rate was 100%. The overall hemorrhage recurrence rate was 39%, with superselective pseudoaneurysm embolization having a 100% hemorrhage recurrence rate—much higher than that of hepatic artery sacrifice or stent graft placement. The overall major and minor hepatic complication rates were 56% and 83%, respectively. The overall 30-day and 1-year mortality rates were 11% and 25%, respectively. The 30-day and 1-year mortality rates and minor and major hepatic complication rates were similar in each group.

Conclusion

Hepatic artery sacrifice is more effective than superselective pseudoaneurysm embolization in the management of delayed PPH. Covered stent placement may be a reasonable alternative treatment to hepatic artery sacrifice.

Endovascular Reconstruction of the Hepatic Arterial System for the Management of Mycotic Pseudoaneurysm in a Liver Transplant Patient

BACKGROUND

Hepatic artery pseudoaneurysm is a rare but very morbid complication after liver transplant. Treatment options include ligation or endovascular embolization, followed by revascularization. We describe a new endovascular approach by stent exclusion in a high-risk patient.

RESULTS

A 62-year-old male who received a second liver transplant after failed allograft presented with hemobilia and was diagnosed with a hepatic artery pseudoaneurysm in the setting of infection. Given his hostile abdomen, an endovascular approach was sought. We excluded the mycotic pseudoaneurysm with multiple covered stent grafts extending from the common hepatic artery to the right and left hepatic arteries. He was discharged with long-term antibiotics. On his 6-month follow-up visit, his stent was patent and hepatic function was stable.

CONCLUSIONS

Endovascular stent-graft placement for management of hepatic artery pseudoaneurysm after liver transplant should be considered as a lower morbidity alternative to surgical repair, even in the setting of infection.

Long-term clinical outcomes after endovascular management of ruptured pseudoaneurysm in patients undergoing pancreaticoduodenectomy

Purpose

Recent studies have analyzed the short-term clinical outcomes of ndovascular management. However, the long-term outcomes are unknown. This study aimed to investigate clinical outcomes after endovascular management for ruptured pseudoaneurysm in patients after pancreaticoduodenectomy (PD).

Methods

The medical records of 2,783 patients who underwent PD were retrospectively reviewed at a single center. Of 62 patients who received intervention after pseudonaeurysm rupture, 57 patients (91.9%) experienced eventual success of hemostasis. The patients were composed as follows: (embolization only [EMB], n = 30), (stent-graft placement only [STENT], n = 19) and (both embolization and stent-graft placement simultaneously or different times [EMB + STENT], n = 8). Long-term complications were defined as events that occur more than 30 days after the last successful endovascular treatment.

Results

Among 57 patients, short-term stent-graft related complications developed in 3 patients (5.3%) and clinical complication developed in 18 patients (31.5%). Nine (15.8%) had long-term stent-graft related complications, which involved partial thrombosis in 5 cases, occlusion in 3 cases and migration in 1 case. Except for 1 death, the remaining 8 cases did not experience clinical complications. The stent graft primary patency rate was 88.9% after 1 month, 84.2% after 1 year, and 63.2% after 2 years. Of 57 patients, 30 days mortality occurred in 8 patients (14.0%).

Conclusion

After recovery from initial complication, most of patients did not experience fatal clinical complication during long-term follow-up. Endovascular management is an effective and safe management of pseudoaneurysm rupture after PD in terms of long-term safety.

Placement of a Viabahn stent-graft for hepatic artery pseudoaneurysm complicated by arterial dissection caused by a guiding sheath

A 69-year-old man was transferred to our hospital for massive hemorrhage from a right hepatic artery pseudoaneurysm 5 months after surgery for gastric cancer. Stent-graft placement was planned to avoid fatal hepatic infarction, and a guiding sheath was advanced deeply into the tortuous and stenotic right hepatic artery beyond the pseudoaneurysm for safe deployment of a stent-graft. However, this advancement caused arterial dissection of the right hepatic artery. After the guiding sheath was pulled back, a Viabahn stent-graft was successfully advanced over a guidewire to exclude the pseudoaneurysm. We consider that a Viabahn stent-graft is more flexible than a guiding sheath and that advancing a Viabahn stent-graft directly from a proximally placed guiding sheath is safer than advancing a guiding sheath into a tortuous and stenotic abdominal artery.

Bleeding complications after pancreatic surgery: interventional radiology management

Surgical intervention in the pancreas region is complex and carries the risk of complications, also of vascular nature. Bleeding after pancreatic surgery is rare but characterized by high mortality. This review reports epidemiology, classification, diagnosis and treatment strategies of hemorrhage occurring after pancreatic surgery, focusing on the techniques, roles and outcomes of interventional radiology (IR) in this setting. We then describe the roles and techniques of IR in the treatment of other less common types of vascular complications after pancreatic surgery, such as portal vein (PV) stenosis, portal hypertension and bleeding of varices.

Stent graft placement for an incidental finding of hepatic artery pseudoaneurysm post hepatectomy, a case report and literature review

•

Hepatic artery pseudoaneurysm presentation, diagnosis, and treatment options.

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Stent graft placement post hepatic artery pseudoaneurysm is safe and effective.

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General and vascular surgeons should be on the case to manage any complication.

Introduction

Hepatic artery pseudoaneurysm is usually iatrogenic, with bleeding occurring early or late postoperatively.

Case presentation

A 61-year-old man with pseudoaneurysm of the common hepatic artery post hepatectomy treated with a stent-graft. The patient was asymptomatic and the pseudoaneurysm appeared incidentally on follow-up. Selective catheterization of the common hepatic artery showed a pseudo-aneurysm close to its origin. Covered stent was deployed in the main hepatic artery. Completion angiography showed no residual spasm and adequate patency of the common hepatic artery, with complete exclusion of the pseudoaneurysm.

Discussion

Using stentgraft for pseudoaneurysm management has multiple advantages when compared to other traditional techniques. However, stent placement has its own complications.

Conclusion

Stent graft placement post hepatic artery pseudo-aneurysm is safe and effective; however its complications should be evaluated with multidisciplinary team.

Transcatheter Arterial Embolization for Postoperative Bleeding Following Abdominal Surgery

PURPOSE

We aimed to estimate the usefulness of transcatheter arterial embolization (TAE) in patients with postoperative abdominal hemorrhage and to evaluate the effects of pancreatic fistula on clinical outcomes and angiographic findings.

MATERIALS AND METHODS

We enrolled 22 patients (20 males and 2 females; mean age 63 years; range 25-86 years), who underwent transarterial angiography for postoperative hemorrhage after abdominal surgery. This group corresponded to 28 procedures. Technical and clinical success rates were calculated, and clinical findings and outcomes were compared between patients with and without a pancreatic fistula.

RESULTS

Pre-interventional CT was performed in all patients before first angiography, and the location of the bleeding was identified in all but one patient. Active arterial bleeding, identified by extravasation of contrast agent (n = 12), pseudoaneurysm formation (n = 12), and arterial wall irregularity (n = 2) were detected in 28 angiographic procedures, and embolization was performed in 26 instances. Various embolization techniques such as isolation, packing, embolization, and stentgraft implantation were performed. The technical and clinical success rates were 96% (25/26 procedures) and 82% (18/22 patients), respectively. In hemodynamically unstable patients (shock index: heart rate/systolic blood pressure > 1), a 92% (12/13 cases) technical success rate was achieved. There were no significant differences in any evaluated parameters between patients with and without pancreatic fistula.

CONCLUSION

TAE is a safe and effective for treating postoperative hemorrhage even in patients with hemodynamic instability and pancreatic fistula. Additionally, pre-interventional CT is useful for effective, consecutive interventions.

Heparin-bonded stent graft treatment for major visceral arterial injury after upper abdominal surgery

PURPOSE

To analyse technical success, complications, and short- and intermediate-term outcomes after heparin-bonded stent graft implantation for the treatment of major abdominal vessel injury after upper abdominal surgery.

METHODS

This retrospective, IRB-approved analysis included 29 consecutive patients (female: n = 6, male: n = 23, mean age 65.9 ± 11.2 years). All patients underwent angiography and attempted heparin-bonded stent-graft implantation because of a major visceral arterial injury after upper abdominal surgery. Electronic clinical records, angiographic reports and imaging datasets were reviewed to assess technical success and complications. Telephone interviews were performed to obtain follow-up information and to estimate short- (> 30 days) and intermediate-term (> 90 days) outcomes.

RESULTS

Successful stent graft placement was achieved in 82.8% (24/29). Peri-interventional complications were observed in 20.7% (6/29) and delayed, angiography-associated complications were observed in 34.5% (10/29) of the patients. Symptomatic re-bleeding occurred in 24.1% (7/29). Short-term survival (> 30 days) was 72.4% (21/29). Intermediate survival (> 90 days) was 37.9% (11/29).

CONCLUSION

Treatment of major vascular injuries with heparin-bonded stent grafts is feasible with a high technical success rate. However, survival depends on the underlying surgical condition, making interdisciplinary patient management mandatory.

KEY POINTS

• Stent graft implantation is challenging, but has a high technical success rate. • Complications are frequent but surgical conversion is rarely necessary. • Survival depends on the underlying surgical condition causing the vascular injury. • Interdisciplinary management is crucial for the survival of these patients.

Endovascular Repair of 40 Visceral Artery Aneurysms and Pseudoaneurysms with the Viabahn Stent-Graft: Technical Aspects, Clinical Outcome and Mid-Term Patency

PURPOSE

Endovascular repair of true visceral artery aneurysms (VAAs) and pseudoaneurysms (VAPAs) with stent-grafting (SG) can simultaneously allow aneurysm exclusion and vessel preservation, minimizing the risk of ischemic complications. Our aim was to report a single-center experience on SG of visceral aneurysms, focusing on technical aspects, clinical outcome and mid-term patency.

MATERIALS AND METHODS

Consecutive patients affected by VAAs-VAPAs and submitted to endovascular treatment were retrospectively reviewed, and SG cases with the self-expandable peripheral Viabahn stent-graft were analyzed (2003-2017). Aneurysm type, patient number, SG clinical setting, procedural data, peri-procedural complications, technical success, 30-day clinical success, 30-day mortality and follow-up period (aneurysm exclusion, stent-graft patency, ischemic complications) were analyzed.

RESULTS

SG was performed in 40 patients (24 VAPAs/16 VAAs) and in 44 procedures (25 in emergency, 19 in elective treatments), via transfemoral in 37 cases (transaxillary in 7 cases). One peri-procedural complication was recorded (a splenic artery dissection successfully converted to transcatheter embolization). The overall technical and clinical success rates were, respectively, 96 and 84%, with excellent trend in elective treatments (both 100%). Overall 30-day mortality was 12.5% (septic shock after pancreatic surgery). Stent-graft thrombosis occurred in 2 patients within 3 months, with aneurysm exclusion and without ischemic complications. Stent-graft patency and aneurysm exclusion were confirmed at 6, 12 and 36 months in 18, 12 and 7 patients, respectively.

CONCLUSION

SG of VAAs and VAPAs was safe and effective, particularly in elective treatments. The Viabahn stent-graft, flexible and without shape memory, is suitable for endovascular repair of tortuous visceral arteries.