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

Hemorrhage Sites and Mitigation Strategies After Pancreaticoduodenectomy

Importance

Postpancreatectomy hemorrhage is an uncommon but highly morbid complication of pancreaticoduodenectomy. Clinical evidence often draws suspicion to the gastroduodenal artery stump, even without a clear source.

Objective

To determine the frequency of gastroduodenal artery bleeding compared to other sites and the results of mitigation strategies.

Design, Setting, and Participants

This cohort study involved a retrospective analysis of data for consecutive patients who had pancreaticoduodenectomy from 2011 to 2021 at Memorial Sloan Kettering Cancer Center (MSK) and Thomas Jefferson University Hospital (TJUH).

Exposures

Demographic, perioperative, and disease-related variables.

Main Outcomes and Measures

The incidence, location, treatment, and outcomes of primary (initial) and secondary (recurrent) hemorrhage requiring invasive intervention were analyzed. Imaging studies were re-reviewed by interventional radiologists to confirm sites.

Results

Inclusion criteria were met by 3040 patients (n = 1761 MSK, n = 1279 TJUH). Patients from both institutions were similar in age (median [IQR] age at MSK, 67 [59-74] years, and at TJUH, 68 [60-75] years) and sex (at MSK, 814 female [46.5%] and 947 male [53.8%], and at TJUH, 623 [48.7%] and 623 male [51.3%]). Primary hemorrhage occurred in 90 patients (3.0%), of which the gastroduodenal artery was the source in 15 (16.7%), unidentified sites in 24 (26.7%), and non-gastroduodenal artery sites in 51 (56.7%). Secondary hemorrhage occurred in 23 patients; in 4 (17.4%), the gastroduodenal artery was the source. Of all hemorrhage events (n = 117), the gastroduodenal artery was the source in 19 (16.2%, 0.63% incidence in all pancreaticoduodenectomies). Gastroduodenal artery hemorrhage was more often associated with soft gland texture (14 [93.3%] vs 41 [62.1%]; P = .02) and later presentation (median [IQR], 21 [15-26] vs 10 days [5-18]; P = .002). Twenty-three patients underwent empirical gastroduodenal artery embolization or stent placement, 7 (30.4%) of whom subsequently experienced secondary hemorrhage. Twenty percent of all gastroduodenal artery embolizations/stents (8/40 patients), including 13% (3/13 patients) of empirical treatments, were associated with significant morbidity (7 hepatic infarction, 4 biliary stricture), with a 90-day mortality rate of 38.5% (n = 5) for patients with these complications vs 7.8% without (n = 6; P = .008). Ninety-day mortality was 12.2% (n = 11) for patients with hemorrhage (3 patients [20%] with primary gastroduodenal vs 8 [10.7%] for all others; P = .38) compared with 2% (n = 59) for patients without hemorrhage.

Conclusions and Relevance

In this study, postpancreatectomy hemorrhage was uncommon and the spectrum was broad, with the gastroduodenal artery responsible for a minority of bleeding events. Empirical gastroduodenal artery embolization/stent without obvious sequelae of recent hemorrhage was associated with significant morbidity and rebleeding and should not be routine practice. Successful treatment of postpancreatectomy hemorrhage requires careful assessment of all potential sources, even after gastroduodenal artery mitigation.

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.

Management and outcomes of pseudoaneurysms presenting with late hemorrhage following pancreatic surgery: A six-year experience from a tertiary care center

BACKGROUND/PURPOSE

Late hemorrhage following pancreatic surgery is associated with significant morbidity and mortality. Pseudoaneurysm (PSA) is an important source of late hemorrhage, which is effectively and safely managed by embolization. We aim to retrospectively review the outcomes of embolization for pseudoaneurysms causing late post-pancreatectomy hemorrhage over a period of six-years at our tertiary care center.

METHODS

Between 2014 and 2020, 616 pancreatic surgeries were performed and 25 patients had late hemorrhage (occurring > 24 hours post-operatively). The clinical parameters related to late hemorrhage, associated complications, embolization details, treatment success and their short-and long-term outcomes were analyzed.

RESULTS

Sixteen of 25 patients had PSA on digital subtraction angiography. Embolization was performed in these patients with technical and clinical success rates of 94.1% and 100%, respectively. Compared to patients without PSA, patients with PSA had significant hemoglobin drop (2.5 g/dL vs. 1.5 g/dL, p = 0.01), higher incidence of sentinel bleed (50% vs. 11.1%, p = 0.05) and lower requirement for surgery for bleeding (0% vs. 44.4%, p = 0.02). Clincally relevant postoperative pancreatic fistula and bile leak were seen in 72% and 52% of patients, respectively. Eight of these embolized patients died due to sepsis. The long-term outcome was good, once the patients were discharged.

CONCLUSION

Late hemorrhage after pancreatic surgery was associated with high mortality due to complications such as pancreatic fistula and bile leak. Sentinel bleeding was an important clinical indicator of PSA. Angiographic embolization is safe and effective without any adverse short or long-term outcomes.

Comparing the Clinical Efficacy of Coil Embolization in GDA Stump versus Common Hepatic Artery in Postoperative Hemorrhage after Pancreatoduodenectomy

BACKGROUND

Hemorrhage after pancreaticoduodenectomy is an uncommon but fatal complication. In this retrospective study, the different treatment modalities and outcomes for treating post-pancreaticoduodenectomy hemorrhage are analyzed.

METHODS

Our hospital imaging database was queried to identify patients who had undergone pancreaticoduodenectomy during the period of 2004-2019. The patients were retrospectively split into three groups, according to their treatment: conservative treatment without embolization (group A: A1, negative angiography; A2, positive angiography), hepatic artery sacrifice/embolization (group B: B1, complete; B2, incomplete), and gastroduodenal artery (GDA) stump embolization (group C).

RESULTS

There were 24 patients who received angiography or transarterial embolization (TAE) treatment 37 times (cases). In group A, high re-bleeding rates (60%, 6/10 cases) were observed, with 50% (4/8 cases) for subgroup A1 and 100% (2/2 cases) for subgroup A2. In group B, the re-bleeding rates were lowest (21.1%, 4/19 cases) with 0% (0/16 cases) for subgroup B1 and 100% (4/4 cases) for subgroup B2. The rate of post-TAE complications (such as hepatic failure, infarct, and/or abscess) in group B was not low (35.3%, 6/16 patients), especially in patients with underlying liver disease, such as liver cirrhosis and post-hepatectomy (100% (3/3 patients), vs. 23.1% (3/13 patients); p = 0.036, p < 0.05). The highest rate of re-bleeding (62.5%, 5/8 cases) was observed for group C. There was a significant difference in the re-bleeding rates of subgroup B1 and group C (p = 0.00017). The more iterations of angiography, the higher the mortality rate (18.2% (2/11 patients), <3 times vs. 60% (3/5 patients), ≥3 times; p = 0.245).

CONCLUSIONS

The complete sacrifice of the hepatic artery is an effective first-line treatment for pseudoaneurysm or for the rupture of the GDA stump after pancreaticoduodenectomy. Hepatic complications are not uncommon and are highly associated with underlying liver disease. Conservative treatment, the selective embolization of the GDA stump, and incomplete hepatic artery embolization do not provide enduring treatment effects.

Efficacy and safety of endovascular therapy for delayed hepatic artery post-pancreatectomy hemorrhage: development of extrahepatic collateral circulation and complications of post endovascular therapy

Background

Endovascular therapy (ET) for delayed hepatic artery post-pancreatectomy hemorrhage (HA-PPH) may require complete hepatic artery occlusion (HAO). Nonetheless, the development of extrahepatic collateral circulation (EHC) and the relationship between radiological factors (EHC, portal vein stenosis, and HAO) and adverse hepatic events after ET remain unclear. This study aimed to evaluate the efficacy and safety of ET for delayed PPH and examine the development of EHC.

Methods

A total of 19 ET cases for delayed HA-PPH were reviewed. Hepatic adverse events, portal vein stenosis, HAO, and mortality rate after ET were evaluated. Moreover, EHC from the left gastric artery (LGA), right inferior phrenic artery (RIPA), left inferior phrenic artery (LIPA), right internal thoracic artery (RITA), left internal thoracic artery (LITA), renal artery (RA), omental artery (OA), intercostal artery (IA), and branch of superior mesenteric artery (BSMA) was assessed using angiogram and computed tomography angiography (CTA).

Results

All cases were successfully treated using transcatheter arterial embolization (n = 17) and stent-graft placement (n = 2) without mortality. EHC from the LGA (8/19), RIPA (10/19), LIPA (4/19), and RITA (3/19) was observed on post-ET CTA. The incidence of hepatic adverse events was significant in the group with both HAO and portal vein stenosis (p < 0.001) and absence of EHC from LIPA and RITA (p < 0.05).

Conclusion

ET for delayed HA-PPH might be effective and safe. While avoiding both HAO and portal vein stenosis is important, the development of EHCs from LIPA and RITA may prevent hepatic adverse events after ET.

Spontaneous cessation of postpancreatectomy hemorrhage in a patient with celiac artery stenosis

Postpancreatectomy hemorrhage (PPH) is a severe complication of pancreatic surgery. This condition often develops on the background of pancreatic fistula. In our report, we demonstrate an unusual case of spontaneous cessation of severe postpancreatectomy common hepatic artery (СHA) hemorrhage after distal pancreatectomy in a patient with celiac artery stenosis (CAS). A 64-year-old male diagnosed with pancreatic tail tumor underwent extended distal pancreatectomy. He developed pancreatic fistula and was discharged with an abdominal drain, and was readmitted with severe postpancreatectomy hemorrhage from a pseudoaneurysm of the CHA. The bleeding stopped spontaneously due to CHA thrombosis. The patient developed no ischemic symptoms. Spontaneous severe postpancreatectomy hemorrhage cessation is an extremely rare phenomenon. Vascular anomalies must be considered when attempting interventional radiology treatment. CHA probably may be sacrificed with no ischemic consequences in case of severe hemorrhage in patients with CAS.

Outcomes of Arterial Embolization vs Covered Stents for Delayed Massive Hemorrhage After Pancreatic or Biliary Surgery

BACKGROUND

Covered stent placement (CSP) is gaining popularity for the management of delayed massive hemorrhage (DMH) after pancreatic or biliary surgery. However, early studies have produced conflicting results regarding the potential advantages of the procedure. We aimed to compare the short- and medium-term outcomes of arterial embolization (AE) and CSP for DMH.

METHODS

We analyzed data for patients who underwent AE or CSP as an endovascular treatment (EVT) for DMH from the common hepatic artery (CHA) and its distal arteries between January 2009 and December 2019. We evaluated the major hepatic complications, in-hospital mortality, and 1-year mortality associated with the procedures, according to age, sex, reintervention, arterial variant, interval between surgery and EVT, and portal vein stenosis.

RESULTS

All hemorrhages were treated using AE (n = 50) or CSP (n = 20). CSP was associated with no in-hospital mortality (32% vs. 0%, p = 0.003), and lower incidences of major hepatic complications (44% vs. 10%, p = 0.011) and 1-year mortality (54% vs. 25%, p = 0.035) compared with AE, respectively. There was no significant difference in technical success and reintervention rates. Compared with AE, the risk-adjusted odds ratios for CSP (95% confidence intervals) for major hepatic complications and 1-year mortality were 0.06 (0.01-0.39) and 0.19 (0.05-0.71), respectively.

CONCLUSIONS

CSP is superior to AE regarding major hepatic complications and in-hospital- and 1-year mortality in patients with DMH from hepatic arteries.

Endovascular therapy choices for different sites of delayed postoperative arterial hemorrhage after hepatobiliary pancreatic surgery: a retrospective study

Background

Angiography and subsequent endovascular therapy is an effective technique for delayed postoperative arterial hemorrhage (PAH) after hepatobiliary pancreatic surgery. In this research, we aimed to evaluate endovascular therapy choices for different sites of delayed PAH after hepatobiliary pancreatic surgery.

Methods

A total of 85 patients with delayed PAH who underwent endovascular therapy at the Department of Radioactive Intervention of Eastern Hepatobiliary Surgery Hospital were retrospectively enrolled. According to the hemorrhage site, participants were divided into 3 groups, all of whom then received embolization, covered stent placement, or a combination of both. Ongoing or recurrent hemorrhages, intervention times, complications associated with intervention, and mortality rate were documented. The chi-squared (χ²) test was used for statistical analysis.

Results

A total of 22 participants with arterial branch hemorrhage underwent superselective embolization. Overall, 81.8% (18/22) of patients underwent embolization once. The successful hemostasis rate was 77.3% (17/22), and the mortality rate was 13.6% (3/22). A total of 53 participants with arterial trunk hemorrhage underwent embolization or covered stent placement. The rate of multi-time intervention, failure to achieve hemostasis, complications associated with intervention, and mortality was lower in the stent group than in the embolization group, and there was a significant difference in complications between the 2 groups (χ²=4.93, P=0.026). Among a total of 10 patients with multisite hemorrhage who underwent embolization, covered stent placement, or a combination, the successful hemostasis rate was 20%; and the mortality rate was 70%.

Conclusions

Superselective embolization is a safe treatment method for arterial branch hemorrhage, and covered stent placement may be a better choice for arterial trunk hemorrhage. Verification of these findings is required via additional large population studies.

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.

Delayed Postoperative Hemorrhage Complicating Major Supramesocolic Surgery Management and Outcomes

BACKGROUND

The place of surgery and interventional radiology in the management of delayed (> 24 h) hemorrhage (DHR) complicating supramesocolic surgery is still to define. The aim of the study was to evaluate outcomes of DHR using a combined multimodal strategy.

METHODS

Between 2005 and 2019, 57 patients (median age 64 years) experienced 86 DHR episodes after pancreatic resection (n = 26), liver transplantation (n = 24) and other (n = 7). Hemodynamically stable patients underwent computed tomography evaluation followed by interventional radiology (IR) treatment (stenting and/or embolization) or surveillance. Hemodynamically unstable patients were offered upfront surgery. Failure to identify the leak was managed by either prophylactic stenting/embolization of the most likely bleeding source or surveillance.

RESULTS

Mortality was 32% (n = 18). Bleeding recurrence occurred in 22 patients (39%) and was multiple in 7 (12%). Sentinel bleeding was recorded in 77 (81%) of episodes, and the bleeding source could not be identified in 26 (30%). Failure to control bleeding was recorded in 9 (28%) of 32 episodes managed by surgery and 4 (11%) of 41 episodes managed by IR (p = 0.14). Recurrence was similar after stenting and embolization (n = 4/18, 22% vs n = 8/26, 31%, p = 0.75) of the bleeding source. Recurrence was significantly lower after prophylactic IR management than surveillance of an unidentified bleeding source (n = 2/10, 20% vs. n = 11/16, 69%, p = 0.042).

CONCLUSION

IR management should be favored for the treatment of DHR in hemodynamically stable patients. Prophylactic IR management of an unidentified leak decreases recurrence risks.

Management of late hemorrhage after pancreatic surgery: treatment strategy and prognosis

Objective

Postpancreatectomy hemorrhage is a life-threatening complication. Hemorrhage occurring >24 hours after the index operation is defined as late hemorrhage. This study was performed to analyze the therapeutic management and prognostic factors of late hemorrhage after pancreatectomy.

Methods

We identified 87 patients with late hemorrhage among 2031 patients who underwent pancreatic surgery from January 2013 to December 2017. The patients’ demographic characteristics, perioperative treatment, hemorrhage details, and prognosis were retrospectively analyzed.

Results

Of the 87 patients, 53 were men. Bleeding occurred at a mean of 8.9 ± 6.0 days postoperatively. Extraluminal and intraluminal hemorrhage occurred in 58 and 29 patients, respectively. The primary intervention was successful in 66 patients, and 16 patients required a secondary intervention. The primary and total recovery rates were 72.4% and 89.7%, respectively. Of the 87 patients, 9 died. Male sex, hemorrhage on a later postoperative day, a significantly decreased hemoglobin level, and pancreatic fistula showed statistical significance as possible risk factors for mortality.

Conclusions

Male sex, hemorrhage on a later postoperative day, a significantly decreased hemoglobin level, and pancreatic fistula are possible risk factors for mortality in patients with late hemorrhage after pancreatectomy. Hemorrhage is a dynamic process, and a secondary intervention may be necessary.