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Aly AK, Yarmohammadi H, Bajwa R, Silk M, Hsu M, Moskowitz C, Santos E, Moussa AM. Stent Graft Placement for the Treatment of Hepatic Artery Injury in Patients with Cancer: Primary Patency and Clinical Outcomes. J Vasc Interv Radiol 2023; 34:79-85.e1. [PMID: 36265819 PMCID: PMC10445798 DOI: 10.1016/j.jvir.2022.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/27/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022] Open
Abstract
PURPOSE To evaluate the safety, primary patency, and clinical outcomes of hepatic artery stent graft (SG) placement for vascular injuries. MATERIALS AND METHODS Patients treated with hepatic arterial SG placement for vascular injuries between September 2018 and September 2021 were reviewed. Data on demographic characteristics, indication, stent graft characteristics, antiplatelet/anticoagulant use, clinical success rate, complications, and type of follow-up imaging were collected. Follow-up images were reviewed by 2 independent reviewers to assess primary patency. A time-to-event analysis was performed. The median duration of stent graft patency was estimated using Kaplan-Meier curves. A Cox proportional hazard model was used to evaluate factors related to stent graft patency. RESULTS Thirty-five patients were treated with hepatic arterial SG placement, 11 for postoperative bleeds and 24 for hepatic artery infusion pump catheter-related complications. Clinical success was achieved in 32 (91%) patients (95% CI, 77-98). The median primary patency was 87 days (95% CI, 73-293). Stent grafts of ≥6-mm diameter retained patency for a longer duration than that with stent grafts of smaller diameters (6 mm vs 5 mm; hazard ratio, 0.35; 95% CI, 0.14-0.88; P = .026; and 7+ mm vs 5 mm; hazard ratio, 0.27; 95% CI, 0.09-0.83; P = .023). Anticoagulation/antiplatelet regimen was not associated with increased stent graft patency duration (P > .05). Only minor complications were reported in 2 (5.7%) patients. CONCLUSIONS Stent grafts can be used safely and effectively to treat injuries of the hepatic artery. Stent graft diameters of ≥6 mm seem to provide more durable patency.
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Affiliation(s)
- Ahmed K Aly
- Division of Interventional Radiology, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Hooman Yarmohammadi
- Division of Interventional Radiology, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Raazi Bajwa
- Division of Body Imaging, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mikhail Silk
- Division of Interventional Radiology, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Meier Hsu
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chaya Moskowitz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ernesto Santos
- Division of Interventional Radiology, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amgad M Moussa
- Division of Interventional Radiology, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
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Nozawa Y, Ymazoe S, Masuda K, Takigawa Y, Kobashi Y, Ikeda K, Fukuda T, Michimoto K. Efficacy and safety of endovascular therapy for delayed hepatic artery post-pancreatectomy hemorrhage: development of extrahepatic collateral circulation and complications of post endovascular therapy. CVIR Endovasc 2022; 5:47. [PMID: 36063252 PMCID: PMC9445144 DOI: 10.1186/s42155-022-00326-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 08/31/2022] [Indexed: 11/12/2022] Open
Abstract
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.
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Watanabe Y, Nakazawa K, Takase K, Watanabe Y, Okada K, Aikawa M, Okamoto K, Koyama I. Outcomes of Arterial Embolization vs Covered Stents for Delayed Massive Hemorrhage After Pancreatic or Biliary Surgery. J Gastrointest Surg 2022; 26:1187-1197. [PMID: 35091861 DOI: 10.1007/s11605-022-05259-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 01/22/2022] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Yukihiro Watanabe
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, 1397-1 Yamane350-1298, Japan.
| | - Ken Nakazawa
- Department of Radiology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Kenichiro Takase
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, 1397-1 Yamane350-1298, Japan
| | - Yuichiro Watanabe
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, 1397-1 Yamane350-1298, Japan
| | - Katsuya Okada
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, 1397-1 Yamane350-1298, Japan
| | - Masayasu Aikawa
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, 1397-1 Yamane350-1298, Japan
| | - Kojun Okamoto
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, 1397-1 Yamane350-1298, Japan
| | - Isamu Koyama
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, 1397-1 Yamane350-1298, Japan
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4
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Öcal O, Mühlmann M, Puhr-Westerheide D, Fabritius M, Deniz S, Wildgruber M, D'Haese J, Werner J, Ricke J, Seidensticker M. Stent-graft placement for hepatic arterial bleeding: assessment of technical efficacy and clinical outcome in a tertiary care center. HPB (Oxford) 2022; 24:672-680. [PMID: 34635433 DOI: 10.1016/j.hpb.2021.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 07/09/2021] [Accepted: 09/06/2021] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Osman Öcal
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Marc Mühlmann
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | | | - Matthias Fabritius
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Sinan Deniz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Moritz Wildgruber
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Jan D'Haese
- Department of General, Visceral, and Transplantation Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Max Seidensticker
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany.
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Xie F, Wang J, Yang Q. Recurrent pyogenic liver abscess after pancreatoduodenectomy caused by common hepatic artery injury: A case report. World J Clin Cases 2021; 9:9198-9204. [PMID: 34786405 PMCID: PMC8567520 DOI: 10.12998/wjcc.v9.i30.9198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/28/2021] [Accepted: 09/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) has been increasingly performed as a safe treatment option for periampullary malignant and benign disorders. However, the operation may result in significant postoperative complications. Here, we present a case that recurrent pyogenic liver abscess after PD is caused by common hepatic artery injury in atypical celiac axis anatomy.
CASE SUMMARY A 56-year-old man with a 1-d history of fever and shivering was diagnosed with hepatic abscess. One year and five months ago, he underwent PD at a local hospital to treat chronic pancreatitis. After the operation, the patient had recurrent intrahepatic abscesses for 4 times, and the symptoms were relieved after percutaneous transhepatic cholangial drainage combining with anti-inflammatory therapy in the local hospital. Further examination showed that the recurrent liver abscess after PD was caused by common hepatic artery injury due to abnormal abdominal vascular anatomy. The patient underwent percutaneous drainage but continued to have recurrent episodes. His condition was eventually cured by right hepatectomy. In this case, preoperative examination of the patient’s anatomical variations with computed tomography would have played a pivotal role in avoiding arterial injuries.
CONCLUSION A careful computed tomography analysis should be considered mandatory not only to define the operability (with radical intent) of PD candidates but also to identify atypical arterial patterns and plan the optimal surgical strategy.
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Affiliation(s)
- Fei Xie
- Department of Hepatobiliary Surgery, The First People's Hospital of Neijiang, Neijiang 641000, Sichuan Province, China
| | - Jie Wang
- Department of Hepatobiliary Surgery, The First People's Hospital of Neijiang, Neijiang 641000, Sichuan Province, China
| | - Qin Yang
- Department of Gastroenterology, The First People's Hospital of Neijiang, Neijiang 641000, Sichuan Province, China
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Okano H, Okado R, Ito H, Asakawa H, Nose K, Tsuruga S, Tochio T, Kumazawa H, Sakuno T, Isono Y, Tanaka H, Matsusaki S, Sase T, Saito T, Mukai K, Nishimura A. Ischemic hepatitis with infectious endocarditis: A case report. Biomed Rep 2021; 15:97. [PMID: 34631052 PMCID: PMC8493543 DOI: 10.3892/br.2021.1473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/02/2021] [Indexed: 11/15/2022] Open
Abstract
A 58-year-old woman was admitted to Suzuka General Hospital with fever. She was diagnosed with infectious endocarditis based on the presence of anterior mitral leaflet vegetation on the echocardiography analysis and isolation of Pseudomonas guariconensis by blood culture. During treatment, the hepatic enzymes levels, including aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH) and alkaline phosphatase (ALP) were increased without any abdominal symptoms. Prolonged prothrombin time (PT) and prothrombin time international normalized ratio were observed, and acute hepatic failure was diagnosed. However, the hepatic injury resolved spontaneously with restoration of the PT value after the hepatic enzymes (AST, ALT, LDH and ALP) peaked. Diffusion-weighted imaging of hepatic magnetic resonance imaging showed diffuse high intensity of the entire liver except for part of the left lobe. The hepatic injury was diagnosed as ischemic hepatitis caused by embolization from the vegetation associated with infectious endocarditis. The recovery from hepatic ischemia was thought to be due to hepatic blood supply from extrahepatic collateral blood. After antibiotic treatment, the patient underwent resection of the vegetation on the anterior mitral valve leaflet. Hepatic artery occlusion is rare, but it may cause severe hepatic complications. During follow-up of infectious endocarditis, clinicians should be aware of the potential for whole organ ischemic damage caused by vessel occlusion, as well as hepatic ischemic damage.
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Affiliation(s)
- Hiroshi Okano
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Ryo Okado
- Department of Cardiology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Hisato Ito
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Mie University, Tsu, Mie 514-8507, Japan
| | - Hiroki Asakawa
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Kenji Nose
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Satomi Tsuruga
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Tomomasa Tochio
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Hiroaki Kumazawa
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Takashi Sakuno
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Yoshiaki Isono
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Hiroki Tanaka
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Shimpei Matsusaki
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Tomohiro Sase
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Tomonori Saito
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Katsumi Mukai
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Akira Nishimura
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
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Gao X, de Jonge J, Verhagen H, Dinkelaar W, Ten Raa S, van Rijn MJ. Unsuccessful Stent Graft Repair of a Hepatic Artery Aneurysm Presenting with Haemobilia: Case Report and Comprehensive Literature Review. EJVES Vasc Forum 2021; 52:30-36. [PMID: 34382030 PMCID: PMC8339217 DOI: 10.1016/j.ejvsvf.2021.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/31/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022] Open
Abstract
Aims To discuss treatment strategies for non-traumatic, non-iatrogenic hepatic artery aneurysms (HAAs) in the presence of an arteriobiliary fistula, illustrated by a case and followed by a comprehensive review of the literature. Methods Following the PRISMA guidelines, 24 eligible HAA cases presenting with haemobilia were identified. Characteristics of patients, aneurysms, treatment strategies and their outcomes were collected. Results A 69 year old patient with no previous hepatobiliary intervention or trauma, presented with jaundice and haemobilia caused by a HAA. Initial treatment by endovascular stenting was chosen to prevent ischaemic liver complications. Unfortunately, this strategy failed because of stent migration due to ongoing infection leading to a type 1A endoleak. The patient had to be converted to open surgery with ligation of the HAA. The patient recovered uneventfully and no complications occurred during the following 12 months. Comprehensive literature review Of the 24 cases, nine had a true HAA and 15 were pseudo/mycotic aneurysms, mainly caused by endocarditis or cholecystitis. The majority were located in the right hepatic artery. In 20 cases, an endovascular first approach was chosen with embolisation, none with covered stents. Three of these cases had to be converted to open surgery because of rebleeding. In all open (primary or secondary) cases, ligation of the HAA was performed. One patient in these series died. No liver ischaemia or abscesses were reported, although one patient developed an ischaemic gallbladder. Conclusions Patients who present with a HAA and haemobilia may be treated safely by embolisation or open ligation. Using a covered stent graft in these patients can cause problems due to ongoing infection and should be monitored closely by imaging. Publication bias and lack of long term follow up imply cautious interpretation of these findings. In patients presenting with haemobilia in the presence of a non-traumatic and non-iatrogenic hepatic artery aneurysmEndocarditis and cholecystitis are the most common causes The main treatment modality is embolisation Liver ischaemia and liver abscesses have not been reported after treatment Close surveillance is recommended as the area has to be considered contaminated Treatment should be performed by a multidisciplinary team
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Affiliation(s)
- Xing Gao
- Department of Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Jeroen de Jonge
- Department of Hepatobiliary and Transplantation Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Hence Verhagen
- Department of Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Wouter Dinkelaar
- Department of Interventional Radiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Sander Ten Raa
- Department of Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Marie Josee van Rijn
- Department of Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
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Kamada Y, Hori T, Yamamoto H, Harada H, Yamamoto M, Yamada M, Yazawa T, Sasaki B, Tani M, Sato A, Katsura H, Tani R, Aoyama R, Sasaki Y, Okada M, Zaima M. Fatal arterial hemorrhage after pancreaticoduodenectomy: How do we simultaneously accomplish complete hemostasis and hepatic arterial flow? World J Hepatol 2021; 13:483-503. [PMID: 33959229 PMCID: PMC8080554 DOI: 10.4254/wjh.v13.i4.483] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/07/2021] [Accepted: 03/19/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Yasuyuki Kamada
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan
| | - Tomohide Hori
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan
| | - Hidekazu Yamamoto
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan
| | - Hideki Harada
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan
| | - Michihiro Yamamoto
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan
| | - Masahiro Yamada
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan
| | - Takefumi Yazawa
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan
| | - Ben Sasaki
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan
| | - Masaki Tani
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan
| | - Asahi Sato
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan
| | - Hikotaro Katsura
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan
| | - Ryotaro Tani
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan
| | - Ryuhei Aoyama
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan
| | - Yudai Sasaki
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan
| | - Masaharu Okada
- Department of Cardiovascular Medicine, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan
| | - Masazumi Zaima
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Shiga, Japan
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9
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Wu Y, Dai J, Shen J, Zhang X, Peng W, Li C, Wen T. Complete embolisation of the proper hepatic artery for delayed haemorrhage after pancreaticoduodenectomy: a case report. J Int Med Res 2020; 48:300060520961216. [PMID: 33050769 PMCID: PMC7570303 DOI: 10.1177/0300060520961216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Postpancreatectomy haemorrhage (PPH) is a rare and life-threatening complication that can occur after pancreaticoduodenectomy (PD). Recently, radiological intervention has become a first-line approach for the diagnosis and treatment of late PPH in haemodynamically stable patients. Surgical intervention should be performed in haemodynamically unstable patients. We report the case of a 54-year-old man who underwent PD for ampullary carcinoma. On postoperative day (POD) 20, he developed a late PPH in the context of pancreatic fistula that was accompanied by hypotension and tachycardia. Therefore, emergency relaparotomy was performed, but the bleeding site was not detected due to severe adhesions in the surgical field. Thus, urgent angiography was performed immediately, and active bleeding was detected from the distal part of the proper hepatic artery. Coil embolisation of the proper hepatic artery trunk was successfully performed. No intrahepatic abscess or liver failure was subsequently observed, and the patient left our hospital on POD 27. This case shows that radiological intervention is a first choice for the diagnosis and treatment of haemodynamically stable late PPH and that it also might still be a first choice and also be safer and more effective than surgical intervention even with unstable haemodynamics.
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Affiliation(s)
- Youwei Wu
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Junlong Dai
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Junyi Shen
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoyun Zhang
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Peng
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Chuan Li
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
| | - Tianfu Wen
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University, Chengdu, China
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10
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Han SC, Kim TH, Yang HC, Chong JU. Hepatic artery pseudoaneurysm after pancreaticoduodenectomy treated with coil embolization in combination with portomesenteric venous stenting. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Seung Chul Han
- Division of Vascular and Interventional Radiology, Department of Radiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Tae Hwan Kim
- Division of Vascular and Interventional Radiology, Department of Radiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Hee Chul Yang
- Division of Vascular and Interventional Radiology, Department of Radiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jae Uk Chong
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
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11
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Wolk S, Radosa CG, Distler M, Held HC, Kühn JP, Weitz J, Welsch T, Hoffmann RT. Risk Factors for In-hospital Mortality After Transarterial Intervention After Postpancreatectomy Hemorrhage. Cardiovasc Intervent Radiol 2020; 43:1342-1352. [PMID: 32435837 PMCID: PMC7441056 DOI: 10.1007/s00270-020-02509-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/28/2020] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Steffen Wolk
- Department of Visceral, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christoph Georg Radosa
- Institute for Diagnostic and Interventional Radiology, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Hanns-Christoph Held
- Department of Visceral, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jens-Peter Kühn
- Institute for Diagnostic and Interventional Radiology, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ralf-Thorsten Hoffmann
- Institute for Diagnostic and Interventional Radiology, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
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12
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Yan J, Feng H, Wang H, Yuan F, Yang C, Liang X, Chen W, Wang J. Hepatic artery classification based on three-dimensional CT. Br J Surg 2020; 107:906-916. [PMID: 32057096 DOI: 10.1002/bjs.11458] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/22/2019] [Accepted: 11/12/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Precise classification of the hepatic artery is helpful for preoperative surgical planning in hepatobiliary-pancreatic surgery. However, the anatomy of hepatic arteries is variable. This study investigated anatomical variation using three-dimensional visualization and evaluation (3DVE) to develop a nomenclature system. METHODS The origin and course of the hepatic artery were tracked and analysed by using three-dimensional visualization of CT images acquired between 2013 and 2017. The new classification and nomenclature system, named CRL, was developed based on the origins of the common, right and left hepatic arteries. RESULTS Scans from 770 adults were evaluated. Preoperative 3DVE correlated better with surgical findings than the original CT images alone. Using the CRL classification system, hepatic arteries were divided into nine subtypes. Only 87·4-89·2 per cent of the hepatic arteries of 610 living-donor liver transplant donors were depicted in Michels', Hiatt's or Varotti's classification, compared with 100 per cent identified by the CRL classification. The CRL classification was validated against external data sets from previous studies, with 99·6-100·0 per cent of patients classified by the CRL system. CONCLUSION The CRL classification covers hepatic artery variants and may be used for planning liver surgery.
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Affiliation(s)
- J Yan
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - H Feng
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - H Wang
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, China.,University of Queensland Diamantina Institute, University of Queensland, Woolloongabba, Queensland 4102, Australia
| | - F Yuan
- Graduate School, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - C Yang
- Graduate School, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - X Liang
- University of Queensland Diamantina Institute, University of Queensland, Woolloongabba, Queensland 4102, Australia
| | - W Chen
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - J Wang
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, China
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13
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Tashkandi A, Rhaiem R, Adlani I, Fossaert V, Sommacale D, Kianmanesh R, Piardi T. Sequential treatment of rupture of pseudoaneurysm of hepatic artery with peritoneal patch and radiological embolization. J Surg Case Rep 2019; 2019:rjz103. [PMID: 30967936 PMCID: PMC6451181 DOI: 10.1093/jscr/rjz103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 03/19/2019] [Indexed: 01/23/2023] Open
Abstract
Bleeding after pancreatico-duodenectomy (PD) is a serious complication with high rates of morbidity and mortality. Interventional radiology techniques’ using embolization and/or stenting is the optimal management. In case of hemodynamic instability, surgical treatment is mandatory, but its mortality rate is considerable. Herein, we report the management of massive bleeding in a 52-year-old-male patient, 3 weeks after PD. The patient suffered severe hemorrhage with two cardiac arrests and surgical treatment was performed immediately after resuscitation. A defect in the distal part of the hepatic artery was repaired using a peritoneal patch. A postoperative CT scan confirmed bleeding control and the presence of a pseudoaneurysm within the patch area. The second step of the treatment was to perform selective embolization. The course was uneventful, and the patient was discharged 6 weeks later.
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Affiliation(s)
- A Tashkandi
- Department of General and Digestive Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, Reims, France.,Department of Surgery, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - R Rhaiem
- Department of General and Digestive Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, Reims, France
| | - I Adlani
- Department of Radiology, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, Reims, France
| | - V Fossaert
- Department of General and Digestive Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, Reims, France
| | - D Sommacale
- Department of General and Digestive Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, Reims, France
| | - R Kianmanesh
- Department of General and Digestive Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, Reims, France
| | - T Piardi
- Department of General and Digestive Surgery, Hôpital Robert Debré, Centre Hospitalier Universitaire de Reims, Université de Reims Champagne-Ardenne, Reims, France
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14
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Dousse D, Bloom E, Suc B. Pancreaticoduodenectomy complicated by Budd-Chiari syndrome: A case report and review of literature. World J Gastrointest Surg 2018; 10:107-110. [PMID: 30622679 PMCID: PMC6314861 DOI: 10.4240/wjgs.v10.i9.107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 11/04/2018] [Accepted: 11/08/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreaticoduodenectomy (PD)-induced morbidity, consisting mainly of the pancreatic fistula and its hemorrhagic and infectious consequences, is well described in the literature, in terms of its definition, risk factors, preventive measures, and standardized management of complications. However, some life-threatening complications remain atypical and undescribed.
CASE SUMMARY We report here the case of a 69-year-old patient with Budd-Chiari syndrome that occurred after arterial embolization of postpancreatectomy hemorrhage. Diagnosis was established with biological findings (i.e., acute liver failure) and radiological findings (i.e., compressive hematoma of the retrohepatic vena cava). Emergency surgical revision was performed to evacuate the hematoma. The postoperative course was uneventful, with rapid recovery of liver function. To our knowledge, post-PD Budd-Chiari syndrome has never been described in the literature.
CONCLUSION Acute liver failure in early post-PD should prompt investigation to rule out Budd-Chiari syndrome.
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Affiliation(s)
- Damien Dousse
- Department of Visceral Surgery, Toulouse-Purpan University Hospital, 31059 Toulouse Cedex 9, France
- Department of Visceral Surgery, Toulouse-Rangueil University Hospital, 31059 Toulouse Cedex 9, France
| | - Eric Bloom
- Department of Visceral Surgery, Toulouse-Purpan University Hospital, 31059 Toulouse Cedex 9, France
| | - Bertrand Suc
- Department of Visceral Surgery, Toulouse-Rangueil University Hospital, 31059 Toulouse Cedex 9, France
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15
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Wolk S, Grützmann R, Rahbari NN, Hoffmann RT, Plodeck V, Weitz J, Welsch T, Distler M. Management of clinically relevant postpancreatectomy hemorrhage (PPH) over two decades - A comparative study of 1 450 consecutive patients undergoing pancreatic resection. Pancreatology 2017; 17:943-950. [PMID: 29111264 DOI: 10.1016/j.pan.2017.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/13/2017] [Accepted: 10/22/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES PPH is the main cause of mortality (up to 50%) after pancreatic resection. Due to differences in time of onset, localization and clinical impairment, there is no consistent management algorithm. METHODS Between 1994 and 2014 the occurrence of PPH in 115 out of 1 450 patients from a prospectively collected database was analyzed. The cohort was divided into two time periods: 1994-2009 and 2010-2014. The differences between the two groups were analyzed. RESULTS The overall incidence of PPH was 7.9%. The main causes of hemorrhage were the pancreatic anastomosis (31.1%) and the splanchnic arteries (23.5%). In the first period, there were more anastomotic hemorrhages (40.0% vs. 20.4%, p = 0.02), while in the second period more hemorrhages from the splanchnic arteries occurred (12.3% vs. 37%, p = 0.002). Bleeding control was achieved by relaparotomy (45.7%), noninterventionally (22.8%), endoscopically (19.7%) and angiographically (13.4%). In the second period, the relevance of interventional angiography significantly increased (24.6% vs. 4.3%, p = 0.001), whereas endoscopy lost importance (7% vs. 30%, p = 0.001). The in-hospital case fatality rate after PPH was 27.4%, with higher case fatality rate following extraluminal hemorrhage (23.9% vs. 3.4%, p < 0.001). CONCLUSIONS A shift in the management of PPH could be seen over the two periods. Interventional angiography has gained more importance in the treatment of severe extraluminal hemorrhage of the splanchnic arteries. Adequate treatment of PPH is crucial to improve the outcome.
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Affiliation(s)
- Steffen Wolk
- Department of General, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Robert Grützmann
- Department of Surgery, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Nuh N Rahbari
- Department of General, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Ralf T Hoffmann
- Institute of Radiology, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Verena Plodeck
- Institute of Radiology, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of General, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of General, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Marius Distler
- Department of General, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany.
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16
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Zhou TY, Sun JH, Zhang YL, Zhou GH, Nie CH, Zhu TY, Chen SQ, Wang BQ, Wang WL, Zheng SS. Post-pancreaticoduodenectomy hemorrhage: DSA diagnosis and endovascular treatment. Oncotarget 2017; 8:73684-73692. [PMID: 29088736 PMCID: PMC5650291 DOI: 10.18632/oncotarget.17450] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 04/14/2017] [Indexed: 12/23/2022] Open
Abstract
Objective To explore the diagnostic value of digital subtraction angiography (DSA) and the effectiveness of endovascular treatment for a post-pancreaticoduodenectomy hemorrhage (PPH). Results During the DSA examination, positive results were found in 29 patients, yielding a positive rate of 69.0%. The manifestations of the DSA examination included contrast medium extravasation, pseudoaneurysm, and artery walls coarse. All 29 patients with positive results underwent endovascular treatment, including transartery embolization (TAE) in 28 patients and covered stents placement in one patient. The technical success and clinical success rates were 100% and 72.4%, respectively. Re-bleeding occurred in 8 of the 29 patients after the first treatment (27.6%). The mortality of PPH was 17.2% (5 of 29). Two of the five PPH patients died following severe infections, and three died from multiple organ failure. Materials and Methods A DSA examination was conducted using clinical and imaging data of 42 patients, and endovascular treatment for delayed PPH was retrospectively analyzed. Conclusions DSA examination is a minimally invasive and rapid method for the diagnosis of delayed PPH. For patients with positive DSA results, endovascular treatment can be performed rapidly, safely, and effectively. Therefore, the DSA examination and endovascular treatment could be considered a preferred treatment approach for delayed PPH.
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Affiliation(s)
- Tan-Yang Zhou
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Zhejiang Province, Hangzhou 310003, China.,Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Jun-Hui Sun
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Zhejiang Province, Hangzhou 310003, China.,Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Yue-Lin Zhang
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Zhejiang Province, Hangzhou 310003, China.,Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Guan-Hui Zhou
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Zhejiang Province, Hangzhou 310003, China.,Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Chun-Hui Nie
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Zhejiang Province, Hangzhou 310003, China.,Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Tong-Yin Zhu
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Zhejiang Province, Hangzhou 310003, China.,Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Sheng-Qun Chen
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Zhejiang Province, Hangzhou 310003, China.,Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Bao-Quan Wang
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Zhejiang Province, Hangzhou 310003, China.,Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Wei-Lin Wang
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Zhejiang Province, Hangzhou 310003, China.,Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Shu-Sen Zheng
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, Zhejiang Province, Hangzhou 310003, China.,Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Zhejiang University, Hangzhou, Zhejiang, 310003, China
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17
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Yamamoto M, Zaima M, Yamamoto H, Harada H, Kawamura J, Yamada M, Yazawa T, Kawasoe J. Liver necrosis shortly after pancreaticoduodenectomy with resection of the replaced left hepatic artery. World J Surg Oncol 2017; 15:77. [PMID: 28399882 PMCID: PMC5387288 DOI: 10.1186/s12957-017-1151-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/02/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Surgeons, in general, underestimate the replaced left hepatic artery (rLHA) that arises from the left gastric artery (LGA), compared with the replaced right hepatic artery (rRHA), especially in standard gastric cancer surgery. During pancreaticoduodenectomy (PD), preservation of the rRHA arising from the superior mesenteric artery (SMA) is widely accepted to prevent critical postoperative complications, such as liver necrosis, bile duct ischemia, and biliary anastomotic leakage. In contrast, details of complication onset following rLHA resection remain unknown. We report two cases of postoperative liver necrosis shortly after rLHA resection during PD for advanced gastric cancer. CASE PRESENTATION Both cases had advanced gastric cancer with infiltration of the pancreatic head. In case 1, the rLHA comprised segment 2/3 artery (A2 + A3), which arose from the LGA. The rRHA originated from the SMA, and the segment 4 artery (A4) was a branch of the rRHA. We conducted PD with combined en bloc resection of both the rLHA and rRHA, and anastomosis between the distal and proximal stumps of the rRHA and LGA, respectively. The divided A2 + A3 was not reconstructed. In case 2, the rLHA comprised segment 2 artery (A2) only, which arose from the LGA. The segment 3/4 artery and the RHAs originated from the proper hepatic artery. We undertook PD with combined en bloc resection of A2 without vascular reconstruction. In both patients, serious necrosis of the lateral segment of the liver occurred within 6 days after PD. Case 1 recovered with conservative management, whereas case 2 required lateral segmentectomy of the liver. Pathologically, the necrotic area in case 2 was apparently circumscribed and confined to segment 2 of the liver, potentially implicating rLHA resection during PD as causing hepatic necrosis. CONCLUSIONS During PD, rLHA resection can cause serious liver necrosis. Therefore, this artery should be preserved as far as oncologically acceptable. In cases that require rLHA resection during PD due to tumor conditions, surgeons should carefully monitor postoperative course while keeping in mind the possible necessity of urgent hepatectomy.
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Affiliation(s)
- Michihiro Yamamoto
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan.
| | - Masazumi Zaima
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
| | - Hidekazu Yamamoto
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
| | - Hideki Harada
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
| | - Junichiro Kawamura
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
| | - Masahiro Yamada
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
| | - Tekefumi Yazawa
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
| | - Junya Kawasoe
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
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18
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Endovascular Treatment of Hepatic Artery Pseudoaneurysm after Pancreaticoduodenectomy: Risk Factors Associated with Mortality and Complications. J Vasc Interv Radiol 2016; 28:50-59.e5. [PMID: 27321887 DOI: 10.1016/j.jvir.2016.04.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 04/01/2016] [Accepted: 04/01/2016] [Indexed: 12/11/2022] Open
Abstract
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.
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19
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Ibukuro K, Fukuda H, Tobe K, Akita K, Takeguchi T. The vascular anatomy of the ligaments of the liver: gross anatomy, imaging and clinical applications. Br J Radiol 2016; 89:20150925. [PMID: 27163944 DOI: 10.1259/bjr.20150925] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The vessels that communicate between the liver and adjacent structures require bridges between them. The bridges comprise the ligaments of the liver as follows: the falciform ligament, right and left coronary ligaments, lesser omentum including the hepatogastric ligament and hepatoduodenal ligament. Each ligament has specific communications between the intrahepatic and extrahapetic vessels. The venous communications called as the portosystemic shunt would become apparent in patients with portal hypertension, intrahepatic portal vein thrombosis and superior vena cava syndrome. The location of the venous communication is related to the pseudolesion or focal enhancement of the liver demonstrated on the CT scan. The arterial communications called collateral vascularization would become apparent in patients with hepatic artery occlusion, especially post-transhepatic arterial embolization, or in patients with the hepatic tumour abutting diaphragm. The knowledge of these collateral arteries is necessary to accomplish the effective transarterial embolization for the hepatic tumours. We reviewed the vessels in these ligaments using contrast-enhanced CT scans and angiography and discussed the clinical applications. Cadaver dissection photos were included as supplementary images for readers to recognize the actual spatial anatomy of the vessel in each ligament.
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Affiliation(s)
- Kenji Ibukuro
- 1 Department of Diagnostic Radiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Hozumi Fukuda
- 1 Department of Diagnostic Radiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Kimiko Tobe
- 1 Department of Diagnostic Radiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Keiichi Akita
- 2 Department of Clinical Anatomy, Tokyo Medical & Dental University, Tokyo, Japan
| | - Takaya Takeguchi
- 3 Department of Radiology, Japanese Red Cross Musashino Hospital, Musashino-shi, Tokyo, Japan
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20
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Recommendation of treatment strategy for postpancreatectomy hemorrhage: Lessons from a single-center experience in 35 patients. Pancreatology 2016; 16:454-63. [PMID: 26935829 DOI: 10.1016/j.pan.2016.02.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 02/07/2016] [Accepted: 02/08/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postpancreatectomy hemorrhage (PPH) is a life-threatening complication of pancreatic surgery. The shift from surgical to radiological intervention was recently reported in retrospective cohort studies, but it has remained controversial as to which emergent intervention provides optimal management. METHODS All 553 patients who underwent standard pancreatic resection at Kobe University Hospital between January 2003 and December 2013 were included. Patient data and complication data were identified from a prospective database. RESULTS The overall incidence of PPH was 6% (35 of 553 patients). Ten patients underwent endoscopic intervention or observation monitoring, or suffered hemorrhagic sudden death. Among the remaining 25 PPH patients, primary surgical intervention was successful in the 6 hemodynamically unstable PPH patients. Primary radiological intervention could successfully stop the bleeding in 15 of the 17 patients with late-PPH. Nine patients who had bleeding from the hepatic artery after pancreaticoduodenectomy were rescued by endovascular embolization of the artery-trunk. The in-hospital mortality of PPH was 20% (7 of 35). Four of the 5 PPH patients who died following any intervention eventually died due to the other complications associated with prolonged pancreatic fistula. CONCLUSIONS The leading treatment has been radiological intervention. Endovascular embolization of the hepatic artery-trunk can be securely performed only if blood flow to the liver by an alternate route is confirmed. To reduce mortality of PPH patients, it is necessary to prevent other complications associated with pancreatic fistula following hemostasis. Proactive surgical intervention such as abscess drainage or remnant pancreatectomy is a key consideration.
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21
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Covered Stents and Coil Embolization for Treatment of Postpancreatectomy Arterial Hemorrhage. J Vasc Interv Radiol 2016; 27:73-9. [DOI: 10.1016/j.jvir.2015.09.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 09/18/2015] [Accepted: 09/26/2015] [Indexed: 12/12/2022] Open
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22
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Ischemic Liver Injury After Complete Occlusion of Hepatic Artery in the Treatment of Delayed Postoperative Arterial Bleeding. J Gastrointest Surg 2015; 19:2235-42. [PMID: 26334251 DOI: 10.1007/s11605-015-2930-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 08/19/2015] [Indexed: 01/31/2023]
Abstract
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.
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23
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Pancreaticoduodenectomy in the presence of a common hepatic artery originating from the superior mesenteric artery. Technical implications. Int J Surg 2015; 17:1-4. [DOI: 10.1016/j.ijsu.2015.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Accepted: 03/09/2015] [Indexed: 01/17/2023]
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Lim SJ, Park KB, Hyun DH, Do YS, Park HS, Shin SW, Cho SK, Choi DW. Stent graft placement for postsurgical hemorrhage from the hepatic artery: clinical outcome and CT findings. J Vasc Interv Radiol 2014; 25:1539-48. [PMID: 25149115 DOI: 10.1016/j.jvir.2014.06.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 06/24/2014] [Accepted: 06/24/2014] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Seong Joo Lim
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
| | - Kwang Bo Park
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea.
| | - Dong Ho Hyun
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
| | - Young Soo Do
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
| | - Hong Suk Park
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
| | - Sung Wook Shin
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
| | - Sung Ki Cho
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
| | - Dong Wook Choi
- Division of Hepato-Biliary and Pancreas, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
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25
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Mousa AY, Abu-Halimah S, Alhalbouni S, Hass SM, Yang C, Gill G, AbuRahma AF, Bates M. Amyloidosis and spontaneous hepatic bleeding, transcatheter therapy for hepatic parenchymal bleeding with massive intraperitoneal hemorrhage: a case report and review of the literature. Vascular 2013; 22:356-60. [PMID: 23929426 DOI: 10.1177/1708538113492725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Hepatic hemorrhage can be devastating, especially in patients with underlying hepatic pathology. This is a case report of a 50-year-old man who presented to the emergency room with Stage 3 shock as evidenced by a systolic blood pressure of 90 mmHg, a heart rate of 125 beats per minute, respiration of 32, with delayed capillary refill and agitation. At this time, he was found to have a massive spontaneous intra-abdominal hemorrhage with an advanced stage of amyloidosis with multiple organ malfunctions. The initial diagnosis was based on an abdominal computed tomography scan and the patient was taken expeditiously to a hybrid angiography suite for a celiac angiogram. An intraoperative diagnosis of extravasation from amyloid related vasculopathy was made based on the angiographic appearance of hepatic circulation. Coil embolization of the feeding branch of the bleeder was achieved using the interlock coil system and a completion angiogram was done showing complete cessation of active bleeding. The postoperative phase was uneventful and the patient was discharged home on postoperative day three. His postoperative visit at five months later was unremarkable.
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Affiliation(s)
- Albeir Y Mousa
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, USA
| | - Shadi Abu-Halimah
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, USA
| | - Saadi Alhalbouni
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, USA
| | - Stephen M Hass
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, USA
| | - Calvin Yang
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, USA
| | - Gurpreet Gill
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, USA
| | - Ali F AbuRahma
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, USA
| | - Mark Bates
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, USA
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Sakaguchi T, Suzuki S, Hiraide T, Shibasaki Y, Morita Y, Suzuki A, Fukumoto K, Inaba K, Takehara Y, Nasu H, Kamiya M, Yamashita S, Ushio T, Konno H. Anomalous arterial ramification in the right liver. Surg Today 2012. [DOI: 10.1007/s00595-012-0420-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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27
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Stampfl U, Hackert T, Sommer CM, Klauss M, Bellemann N, Siebert S, Werner J, Richter GM, Kauczor HU, Radeleff B. Superselective Embolization for the Management of Postpancreatectomy Hemorrhage: A Single-Center Experience in 25 Patients. J Vasc Interv Radiol 2012; 23:504-10. [DOI: 10.1016/j.jvir.2011.12.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2011] [Revised: 12/11/2011] [Accepted: 12/12/2011] [Indexed: 12/14/2022] Open
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