Use of a stent graft for bleeding hepatic artery pseudoaneurysm following 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.

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.

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.

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.

Stent graft placement for postsurgical hemorrhage from the hepatic artery: clinical outcome and CT findings

PURPOSE

To evaluate the clinical results and imaging follow-up findings of stent grafts placed for hemorrhage from hepatic arteries following surgery.

MATERIALS AND METHODS

The investigation included 17 patients (14 men and 3 women) who underwent endovascular stent graft placement for hepatic arterial hemorrhage following surgery. Bleeding occurred from the common hepatic artery (n = 1; 6%), right hepatic artery (n = 1; 6%), proper hepatic artery (n = 6; 35%), and gastroduodenal artery stump (n = 9; 53%). Stent graft patency, thrombus at the graft, target hepatic artery diameter, and liver perfusion status were analyzed by comparing computed tomography (CT) scans performed before the procedure with follow-up CT scans. Laboratory data were also analyzed before the procedure and at follow-up intervals.

RESULTS

There were 17 stent grafts placed in 17 patients. The mean follow-up period was 356 days (range, 1-2,119 d). The stent graft primary patency rate was 79.5% at 1 month, 69.6% at 6 months, and 69.6% at 1 year. The clinical success rate was 82% (14 of 17 patients), and the technical success rate was 94% (16 of 17 patients). Mortality related to the stent graft was 12% (2 of 17 patients). Occlusion occurred in 4 of 16 stent grafts (25%). There was one technical failure. The mean stent graft diameter was 6.2 mm (range, 3.5-8.0 mm), and the degree of stent graft oversizing was 38% of the hepatic artery diameter on CT scans and 58% on angiography. Hepatic parenchymal perfusion was preserved in 80% of patients (12 of 15).

CONCLUSIONS

Hepatic artery hemorrhage following surgery can be treated effectively with stent graft placement.

Hepatic artery pseudoaneurysm after surgical treatment for pancreatic cancer: minimally invasive angiographic techniques as the preferred treatment

BACKGROUND

Delayed intra-abdominal bleeding related to hepatic artery pseudoaneurysm is a potentially lethal complication after pancreaticoduodenectomy for pancreatic cancer. Locally advanced tumors, which result in vessel erosion or extensive operative skeletonization, may contribute to weakness of the arterial wall. Reoperation is often technically difficult with high rate of mortality; therefore, alternative less invasive options are ideal.

AIMS

The study was to present an alternative endovascular treatment of a large hepatic artery pseudoaneurysm after pancreatic resection for locally advanced multicystic adenocarcinoma.

MATERIALS AND METHODS

Transcatheteric mesenteric angiography with deployment of detachable coils in the pseudoaneurysm sac was utilized to manage the hepatic artery pseudoaneurysm.

RESULTS

Completion angiography confirmed cessation of contrast enhancement in the pseudoaneurysm sac with preservation of normal antegrade hepatic artery flow.

CONCLUSION

Minimally invasive angiographic technique is the preferred treatment for hepatic artery pseudoaneurysm after pancreatic resections.

Treatment of post-liver transplant hepatic artery pseudoaneurysm with balloon angioplasty after failed stent graft placement

Hepatic artery pseudoaneurysm is a rare complication following liver transplantation but can lead to life threatening hemorrhage if not treated effectively and in a timely manner. We describe a hepatic artery pseudoaneurysm that occurred after liver transplantation in a 53-year-old woman. The pseudoaneurysm was initially treated by implantation of a balloon-expandable covered stent-graft, but an endoleak was observed 6 days later. The endoleak was successfully resolved by further balloon angioplasty, which expanded the cylindrical stent to a conical stent, matching the anatomy of the anastomotic hepatic artery. Follow-up ultrasound examinations demonstrated patent hepatic arteries, with no evidence of pseudoaneurysm. Balloon-expandable covered stent-graft may be utilized to treat hepatic artery pseudoaneurysm following liver transplantation, due to the remodeling ability of stent-grafts, enabling them to fit the diseased vessels.

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.

Endovascular management of extrahepatic artery hemorrhage after pancreatobiliary surgery: clinical features and outcomes of transcatheter arterial embolization and stent-graft placement

OBJECTIVE

The objective of our study was to analyze the technical and clinical outcomes of endovascular treatment of patients with extrahepatic artery hemorrhage after pancreatobiliary surgery.

MATERIALS AND METHODS

From January 2000 to September 2009, 27 patients who had undergone pancreaticobiliary surgery had an extrahepatic artery hemorrhage with or without a pseudoaneurysm were enrolled in this retrospective study. All patients underwent diagnostic angiography and endovascular treatment-either transcatheter arterial embolization (TAE) (n = 20) or stent-graft placement (n = 7).

RESULTS

Bleeding sites were located in the gastroduodenal artery stump (n = 14), proper hepatic artery (n = 10), and common hepatic artery (n = 3). In the TAE group, the initial technical and clinical success rates were 100% and 90%, respectively. Two patients died of hepatic failure and multiorgan failure within 7 days after TAE. Hepatic ischemia and infarction were observed in six (33.3%, 6/18) and eight (44.4%, 8/18) patients, respectively. Hepatic abscess was observed in one patient (5.6%, 1/18) with hepatic infarction. The development of hepatic infarction was significantly associated with a serum aspartate aminotransferase (AST) level of more than 700 IU/L and a serum alanine transferase (ALT) level of more than 500 IU/L (p = 0.031 for both, Fisher exact test). In the stent-graft group, the initial technical and clinical success rates were 100% for both. Early stent thrombosis with bile duct necrosis was observed in one patient (14.3%). During the mean follow-up period of 22.8 months (range, 8-43 months), the intrahepatic arteries were patent on follow-up CT.

CONCLUSION

The endovascular treatments of TAE and stent-graft placement can be performed safely in most patients and are effective treatment options for extrahepatic artery hemorrhage after pancreatobiliary surgery. Moreover, stent-graft placement is better than TAE for preserving intrahepatic arterial flow without rebleeding from the extrahepatic artery.

Transcatheter arterial embolization of gastroduodenal artery stump pseudoaneurysms after pancreaticoduodenectomy: safety and efficacy of two embolization techniques

PURPOSE

To evaluate the safety and efficacy of two transcatheter arterial embolization (TAE) techniques used to treat pseudoaneurysms of the gastroduodenal artery (GDA) stump after pancreaticoduodenectomy.

MATERIALS AND METHODS

Between March 2003 and March 2008, 16 patients were treated with TAE for pseudoaneurysms of the GDA stump after pancreaticoduodenectomy. Two embolization techniques were employed: endovascular trapping of the hepatic artery (embolization of the hepatic artery proximal and distal to GDA stump; group A; n = 13) and selective embolization of the GDA stump and/or pseudoaneurysm sparing hepatic arterial flow (group B; n = 3). Technical success, initial hemostasis, recurrence of bleeding, and complications were compared between the two groups retrospectively.

RESULTS

All TAE procedures were technically successful and immediate hemostasis was achieved in all patients. There was no recurrent bleeding in group A; however, all three patients in group B experienced recurrent bleeding after initial hemostasis (P = .002), and these patients required subsequent embolization with the endovascular trapping technique. Two patients died of multiple organ failure (one patient in each group) despite successful hemostasis. Three patients experienced subsegmental (n = 1, group A) and multisegmental (n = 2, group B) liver infarction, which were successfully managed with conservative treatment. There was a higher incidence of major complications in group B (15.4% vs 100%; P = .018).

CONCLUSIONS

Endovascular trapping of the hepatic artery is a safe and effective treatment of pseudoaneurysms of the GDA stump after pancreaticoduodenectomy. Hepatic ischemic complications are not rare, but can be conservatively managed. Selective embolization of the GDA stump and/or pseudoaneurysm is frequently associated with recurrence of bleeding, which eventually leads to major complications.

Emergency stent graft implantation for ruptured visceral artery pseudoaneurysm

BACKGROUND

Literature series that include visceral artery pseudoaneurysms rarely separate them from true aneurysms, although they address different issues. Guidelines for optimal management of these lesions are lacking. We report our experience of stent graft treatment of these lesions with midterm results.

METHODS

We retrospectively reviewed all patients with a visceral pseudoaneurysm who were treated with a stent graft in our institution. Patient history, clinical characteristics, procedure details, and outcome were recorded and analyzed.

RESULTS

From March 2004 to June 2009, 10 consecutive patients (9 men), who were a mean age of 59 years, were treated for symptomatic visceral artery pseudoaneurysm, with hemorrhagic shock in 8 patients (80%), after pancreaticoduodenectomy in 8, gastrectomy in 1, and abdominal trauma in 1. A mean of 24 days (range, 7-60 days) passed between the initial surgery or trauma and pseudoaneurysm diagnosis. Septic complications were associated in six patients (60%). The pseudoaneurysm was in the hepatic artery in 8 patients, the splenic artery in 1, and the superior mesenteric artery in 1. Technical and clinical success was achieved in 80% of patients. Two failures of catheterization were followed by redo surgery and death (20%). No patients died postoperatively, and no complications among the patients who were treated successfully. Mean follow-up was 37 months (range, 10-63 months). All stent grafts were patent, with no signs of infection. Two patients died secondary to neoplasm. No rebleeding or recurrent aneurysms were noted.

CONCLUSION

Stent graft exclusion of visceral artery pseudoaneurysm seems to be a valid therapeutic approach regardless of the patient's septic or hemodynamic status.

Hemorrhagic complications after Whipple surgery: imaging and radiologic intervention

OBJECTIVE

The aim of this pictorial essay is to illustrate the radiologic patterns, sites of bleeding, and vascular interventional techniques used in the management of postpancreatectomy hemorrhage.

CONCLUSION

Hemorrhagic complications occur in fewer than 10% of patients after Whipple pancreatoduodenectomy but account for as many as 38% of deaths. Bleeding typically occurs from the stump of the gastroduodenal artery, but other sites of bleeding are increasingly recognized.

Successful embolization assisted by covered stents for a pseudoaneurysm following pancreatic surgery

Delayed intra-abdominal hemorrhage after pancreatic surgery is a potentially lethal complication. Transarterial coil embolization and/or the placing of an endovascular stent are minimally invasive and effective procedures. An artery that is extensively eroded and rendered friable due to operative skeletonization or postoperative inflammation sometimes contributes to delayed intra-abdominal hemorrhage or rebleeding after coil embolization. This report presents a case of successful management of postoperative hemorrhage in a-74-year-old Japanese male. He experienced bleeding from a pseudoaneurysm of the brittle hepatic artery following total pancreatectomy. Initially the pseudoaneurysm was successfully treated with covered coronary stent-grafts, but rebleeding occurred 1 mo later due to the brittleness of the artery. Rebleeding was definitively managed by the complete packing of the stent by coil embolization. He remains stable at 18 mo following the final embolization. A stent graft can be used for protecting a brittle artery to avoid injury by coil embolization.

Hemobilia and cystic artery stump pseudoaneurysm associated with liver abscess after a laparoscopic cholecystectomy: report of a case

A 63-year-old woman was admitted for cholecystitis and underwent a laparoscopic cholecystectomy (LC). She experienced abdominal pain and hemobilia 11 days after the LC. Angiography was performed but it did not show any source of bleeding. Thereafter, at 27 days after LC, a repeat angiogram was performed which revealed a pseudoaneurysm (PA) arising from a cystic artery stump and an embolized PA sack. However, another PA arising from near the embolized PA and liver abscess was observed 4 days after embolization. The arterial collateral flow was evaluated by endovascular balloon occlusion of the right hepatic artery and it was embolized proximal and distal to the bleeding point. The embolization of the partial hepatic artery was effective for PA when packing the PA sack proved to be insufficient. In patients with liver cirrhosis or liver abscess who require an adequate arterial liver flow, it is important to evaluate the collateral arterial flow before hepatic artery embolization.