Covered Stents for Late Postoperative Arterial Hemorrhage after Pancreaticoduodenectomy

Endovascular Treatment of Hepatic Artery Pseudoaneurysm after Pancreaticoduodenectomy: A Literature Review

Pancreaticoduodenectomy (PD) is a complex surgical procedure performed in patients with periampullary tumors located within the pancreatic head, the papilla of Vater, the distal common bile duct, and the duodenum. In advanced tumors, the operative technique involves the need for dissection and divestment of the arteries located within the pancreaticoduodenal field, including the common hepatic artery (CHA) and the proper hepatic artery (PHA) and its branches. The second most important cause of post-PD visceral aneurysms is irritation of the peri-pancreatic arterial wall by pancreatic juice in a postoperative pancreatic fistula (POPF). Hepatic artery pseudoaneurysm (HAP) is a very dangerous condition because it is usually asymptomatic, but it is a rare and potentially lethal pathology because of the high risk of its rupture. Therefore, HAP requires treatment. Currently, selective celiac angiography is the gold-standard diagnostic and therapeutic management for postoperative bleeding and pseudoaneurysm in patients following PD. Open surgery and less invasive endovascular treatment are performed in patients with HAP. Endovascular treatment involves transarterial embolization (TAE) and stent graft implantation. The choice of treatment method depends on the general and local conditions, such as the patient's hemodynamic stability and arterial anatomy. In patients in whom preservation of the flow within the hepatic artery (to prevent hepatic ischemia complications such as liver infarction, abscess, or failure) is needed, stent graft implantation is the treatment of choice. This article focuses on a review of two common methods for endovascular HAP treatment. In addition, risk factors and diagnostic tools have been described.

Coronary covered stents in the management of late-onset arterial complications post-hepato-pancreato-biliary surgery

PURPOSE

To retrospectively evaluate the safety, efficacy, and late clinical outcome of coronary covered stent placement for the treatment of late-onset arterial complications after hepato-pancreato-biliary surgery.

MATERIALS AND METHODS

Consecutive patients presenting with post-hepato-pancreato-biliary surgery-related arterial lesions and subsequently treated with a covered coronary stent in the authors institution between January 2012 and November 2021 were included. Primary endpoints were technical and clinical success; secondary endpoints were covered stent patency and end-organ perfusion of the affected artery.

RESULTS

The study included 22 patients (13 men and 9 women) with a mean age of 67 years ± 9.6 years. Initial surgery included pancreaticoduodenectomy (n = 15; 68%), liver transplantation (n = 2; 9%), left hepatectomy (n = 1; 5%), bile duct resection (n = 1; 5%), hepatogastrostomy (n = 1; 5%), and segmental enterectomy (n = 1; 5%). Technically, coronary covered stents were successfully placed in n = 22 patients (100%) without immediate complication. Definitive bleeding control was observed in n = 18 patients (81.1%) with recurrent bleeding within 30 days postintervention in n = 5 patients (23%). No ischemic liver or biliary complications occurred during the follow-up period. The 30-day mortality rate was 0%.

CONCLUSION

Coronary covered stents are a safe and efficient treatment option in most of the patients presenting with late-onset postoperative arterial injuries following hepato-pancreato-biliary surgery and are associated with an acceptable recurrent bleeding rate and no late, ischemic, parenchymal complications.

Anterior superior pancreaticoduodenal artery pseudoaneurysm after distal pancreatectomy with en bloc celiac axis resection successfully treated with balloon-assisted coil embolization

Bleeding is a fatal complication after pancreatectomy. Although coil embolization is a widely accepted treatment option, ischemia of the remaining organs should be prevented. This study reports the successful treatment of intra-abdominal hemorrhage following distal pancreatectomy with en bloc celiac axis resection (DP-CAR) using balloon-assisted coil embolization (BACE). A 59-year-old man was diagnosed with locally advanced pancreatic cancer. The tumor involves the common hepatic artery, splenic artery, and celiac artery. After four cycles of treatment with gemcitabine/nab-paclitaxel, the soft-density masses, surrounding the artery, shrunk. DP-CAR and R0 resections were performed. A minor postoperative pancreatic fistula occurred. Six months postoperatively, the computed tomography showed delayed asymptomatic bleeding from an anterior superior pancreaticoduodenal artery (ASPDA) pseudoaneurysm located near the gastroduodenal artery confluence. BACE was performed by placing a microballoon catheter in the region of confluence of the ASPDA and posterior superior pancreaticoduodenal artery (PSPDA) to prevent coil migration. After inserting the microballoon catheter, coil embolization was performed in the ASPDA. Hepatic blood flow was maintained from the PSPDA. BACE is a useful technique to preserve blood flow to the remnant organs when performing coil embolization for bleeding following a distal pancreatectomy, especially following a DP-CAR.

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.

Hemobilia: An Uncommon But Notable Cause of Upper Gastrointestinal Bleeding

GOAL AND BACKGROUND

A literature review to improve practitioners' knowledge and performance concerning the epidemiology, diagnosis, and management of hemobilia.

STUDY

A search of Pubmed, Google Scholar, and Medline was conducted using the keyword hemobilia and relevant articles were reviewed and analyzed. The findings pertaining to hemobilia etiology, investigation, and management techniques were considered and organized by clinicians practiced in hemobilia.

RESULTS

The majority of current hemobilia cases have an iatrogenic cause from either bile duct or liver manipulation. Blunt trauma is also a significant cause of hemobilia. The classic triad presentation of right upper quadrant pain, jaundice, and upper gastrointestinal bleeding is rarely seen. Computed tomography and magnetic resonance imaging are the preferred diagnostic modalities, and the preferred therapeutic management includes interventional radiology and endoscopic retrograde cholangiopancreatography. Surgery is rarely a therapeutic option.

CONCLUSIONS

With advances in computed tomography and magnetic resonance imaging technology, diagnosis with these less invasive investigations are the favored option. However, traditional catheter angiography is still the gold standard. The management of significant hemobilia is still centered on arterial embolization, but arterial and biliary stents have become accepted alternative therapies.

Endovascular Treatment of Hepatic Artery Pseudoaneurysm after Pancreaticoduodenectomy: Risk Factors Associated with Mortality and Complications

PURPOSE

To evaluate risk factors predicting death and complications of primary therapy for hepatic and gastric duodenal artery pseudoaneurysms following endovascular treatment (EVT) after pancreaticoduodenectomy (PD).

MATERIALS AND METHODS

Between April 2004 and December 2014, 28 patients (mean age, 64.7 y) with post-PD hemorrhage underwent EVT. Prevention of hepatic artery blockage via stents or side-holed catheter grafts was stratified in cases without a replaced hepatic artery. Mortality and major hepatic complications following EVT were evaluated according to age; sex; surgery-EVT interval; presence of portal vein stenosis, shock, and coagulopathy at EVT onset; and post-EVT angiographic findings.

RESULTS

All hemorrhages were successfully treated with microcoils (n = 17; 61%), covered stents (n = 1; 3%), bare stent-assisted coil embolization (n = 5; 18%), or catheter grafts with coil embolization (n = 5; 18%). Hepatic arterial flow was observed after EVT in 18 patients (64%). Mortality and major hepatic complication rates were 28.6% and 32.1%, respectively. Hemorrhagic shock and coagulopathy at EVT onset (n = 8 each; odds ratio [OR], 27; 95% confidence interval [CI], 3.1-235.7; P < .01) were significantly associated with mortality. Coagulopathy at EVT onset (adjusted OR [aOR], 48.1; 95% CI, 3.2-2,931), portal vein stenosis (n = 16; aOR, 16.9; 95% CI, 1.3-721.9), and no visualization of hepatopetal flow through the hepatic arteries (n = 10; aOR, 29.5; 95% CI, 2.1-1,477) were significantly associated with major hepatic complications.

CONCLUSIONS

EVT should be performed as soon as possible before the development of shock or coagulopathy. Hepatic arterial flow visualization decreases major hepatic complications.

Ischemic Liver Injury After Complete Occlusion of Hepatic Artery in the Treatment of Delayed Postoperative Arterial Bleeding

BACKGROUND

Delayed postoperative arterial bleeding is rare and may be life-threatening. When the bleeding source is the hepatic artery, complete ligation or embolization from the proximal to the distal area of the ruptured lesion usually results in complete occlusion of hepatic arterial flow.

METHODS

To evaluate the frequency and severity of ischemic liver injury following complete hepatic artery occlusion, a retrospective study was conducted. Patients who underwent complete hepatic artery occlusion in the treatment of delayed postoperative arterial bleeding between January 2007 and December 2014 in our institution were reviewed. Changes of hepatic function and rates of associated complications and prognosis were analyzed.

RESULTS

A total of 24 patients experienced 26 episodes of bleeding. Nineteen experienced transient liver enzyme elevation alone. There were no signs of acute liver failure after complete hepatic artery occlusion. The rates of liver infarction and liver abscess were 23.8 % (5/21) and 19 % (4/21), respectively. The 30-day mortality rate was 8.3 % (2/24).

CONCLUSION

Complete occlusion of the hepatic artery does not always result in severe hepatic ischemic injury. As a common cause of delayed postoperative bleeding, intra-abdominal infection may be fatal when it is not controlled successfully.

Successful treatment of a common hepatic artery pseudoaneurysm using a coronary covered stent following pancreatoduodenectomy: report of a case

This report presents the case of a common hepatic artery (CHA) pseudoaneurysm secondary to postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD), which was successfully treated using a coronary covered stent. A 70-year-old female underwent subtotal stomach-preserving PD for middle cholangiocarcinoma. POPF was identified on postoperative day (POD) 7, and the patient suddenly lost 500 ml of blood via the abdominal drain on POD 19. Urgent celiac arteriography revealed a CHA pseudoaneurysm. A coronary covered stent was placed to prevent rupture of the pseudoaneurysm and to maintain hepatic arterial flow, instead of performing transarterial embolization. No vascular adverse events were encountered during or after the procedure. Computed tomography and angiography showed a patent stent graft and good hepatic arterial flow 9 months after placement of the stent. Endovascular stent-graft placement not only treated the pseudoaneurysm, but also preserved the arterial blood flow. This report describes the placement of a covered stent graft for delayed hemorrhage after PD.

Ischemic liver injuries after hepatic artery embolization in patients with delayed postoperative hemorrhage following hepatobiliary pancreatic surgery

BACKGROUND

Many collateral pathways to the liver are dissected during hepatobiliary pancreatic surgery and, if the arterial bleeding is massive and a hematoma becomes larger, the adjacent portal vein can be compressed with impairment of the portal venous flow.

PURPOSE

To evaluate the frequency and severity of ischemic liver injuries after hepatic artery embolization in patients with delayed postoperative arterial hemorrhage after hepatobiliary pancreatic surgery.

MATERIAL AND METHODS

Eighteen patients undergoing proper or common hepatic artery embolization for delayed postoperative arterial hemorrhage after hepatobiliary pancreatic surgery achieved hemostasis. To evaluate the frequency and severity of ischemic liver injuries, the liver enzyme levels and CT findings before and after hepatic artery embolization were retrospectively compared and the clinical outcomes after hepatic artery embolization were analyzed. Angiographic findings were also analyzed to reveal any association with development of ischemic liver injuries after hepatic artery embolization.

RESULTS

Ischemic liver injuries were observed in 15 (83%) of 18 patients undergoing hepatic artery embolization for postoperative hemorrhage. Injuries included hepatic infarction combined with abscess in one (5%) patient, hepatic infarction in 12 (67%) patients, and transient hepatic ischemia/dysfunction in two (11%). As for the extent of hepatic infarction, lobar infarction developed in two patients and subsegmental infarction in 11. One patient with right hepatic lobar infarction died of hepatic failure 11 days after hepatic artery embolization. In the other 14 patients with ischemic liver injuries, the elevated liver enzymes returned to baseline levels within two weeks. All of the four patients with portal vein stenosis, four patients with no hepatic arterial flow on post-embolization angiogram, and one patient with both had hepatic infarction after hepatic artery embolization. No ischemic liver injuries developed after hepatic artery embolization in three patients with no portal vein stenosis and bilobar hepatic arterial flow via the left hepatic artery aberrantly arising from the left gastric artery or from the common hepatic artery.

CONCLUSION

Ischemic liver injuries can develop in most patients undergoing hepatic artery embolization for postoperative arterial hemorrhage after hepatobiliary pancreatic surgery; hepatic infarction appears to be the most frequent type of ischemic liver injury. Hepatic artery embolization for postoperative arterial hemorrhage after hepatobiliary pancreatic surgery may carry a great risk of ischemic liver injury if a patient has portal vein stenosis or no aberrant hepatic artery.

Treatment of acute delayed visceral hemorrhage after pancreatic surgery from hepatic arteries with covered stents

BACKGROUND

Delayed visceral hemorrhage following pancreatic surgery is a rare but life-threatening complication. Usually hemorrhage originates from pseudoaneurysms secondary to pancreatic or biliary fistula. Re-laparotomy is often associated with high morbidity and mortality. Endovascular occlusion with metallic coils can stop pseudoaneurysmatic bleeding, but hepatic artery occlusion can result in severe organ damage. Interventional treatment with covered stents is an alternative providing persistent organ perfusion.

RESULTS

In our department endovascular stenting for visceral hemorrhage was introduced in November 2008. From November 2008 until October 2009, 303 patients underwent pancreatic surgery at our institution. Among those, four patients were successfully treated with covered stents for delayed visceral hemorrhage. In all four patients bleeding originated from hepatic arteries. Mean onset of hemorrhage was 24 days after surgery. Endovascular stenting was successful in all four patients. None of these patients required re-operation or died during the study.

CONCLUSION

Treatment of delayed visceral hemorrhage from hepatic arteries after pancreatic surgery with covered stents is safe and effective. Endovascular stenting is associated with a lower morbidity than re-laparotomy or coil embolisation. Emergency angiography with endovascular stenting should be considered for all patients with delayed hemorrhage from hepatic arteries after pancreatic surgery.