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

Abstract

Objective: To evaluate the long-term outcomes of covered stent placement in patients with gastroduodenal artery (GDA) stump hemorrhage after pancreaticoduodenectomy (PD) and to identify risk factors of stent failure. Methods and materials: Covered stent was placed in total of 21 patients for GDA stump hemorrhage after PD from September 2012 to March 2021. Technical and clinical success, complications, and stent patency were retrospectively evaluated. Nine relevant variables were analyzed to determine risk factors for stent failure. Results: In 20 of 21 patients (95.2%), the GDA stump was completely excluded with covered stent placement. Immediate hemostasis was achieved in the 20 patients and rebleeding from jejunal artery occurred in one patient which was successfully embolized 1 day after the stent placement. There was no procedure-related complication or early mortality (<30 days). During follow-up period (median 655.5 days), stent thrombosis was found on CT in 10 patients (50.0%, 10/20) without any laboratory or CT abnormalities. One thrombosed stent migrated into the jejunum 20 months after placement. The 6 month, 1 year, and 2 year stent patency were 81.9%, 52.9%, and 37.8%, respectively (median 620 days). The recurrence of primary malignancy was associated with stent failure (HR 5.70; 95% CI 1.18–27.76, p = 0.03). Conclusions: Covered stent placement is an effective and safe management of postoperative GDA stump hemorrhage. Stent failure occurred frequently (50%) but did not cause liver ischemia. Stent failure was associated with recurrence of primary malignancy. Advances in knowledge 1. Covered stent placement is an effective and safe management of postoperative GDA stump hemorrhage 2. Stent failure occurred frequently (50%) but did not cause liver ischemia. 3. Stent failure was associated with recurrence of primary malignancy.

Hemorrhage Sites and Mitigation Strategies After Pancreaticoduodenectomy

“…Patients with GDA embolization and stent placement were analyzed together because of the high incidence of hepatic arterial occlusion with both procedures. 19,20,22 Data for continuous variables were expressed as median (IQR) and compared between groups using Wilcoxon rank sum and Kruskal-Wallis tests. Data for categorical variables were expressed as number of events (percentage) and compared between groups using Fisher exact tests.…”

“…Studies have demonstrated hepatic artery embolization for postoperative bleeding can preserve hepatic flow if there are sufficient arterial collaterals, although there is significant risk of segmental hepatic infarction, which increases with compromised portal vein flow . Additionally, Min et al demonstrated covered stents convey patency rates of 52.9% and 37.8% at 1 and 2 years, respectively.…”

“…The sequelae of GDA embolization/stent placement were assessed, including subsequent secondary PPH events, resulting morbidity, and 90-day mortality. Patients with GDA embolization and stent placement were analyzed together because of the high incidence of hepatic arterial occlusion with both procedures …”

“…The perception that the GDA accounts for a high proportion of PPH has led to mitigation strategies, including empirical GDA embolization or common hepatic artery (CHA) stent placement in the absence of a clearly defined bleeding source and/or the use of a pedicled tissue wrap around the CHA during resection . While these strategies have been increasingly but varyingly adopted, the anatomical spectrum of PPH is not well defined, and the true incidence of GDA PPH and interdependent benefit of these approaches remain unclear …”

“…[15][16][17][18] While these strategies have been increasingly but varyingly adopted, the anatomical spectrum of PPH is not well defined, and the true incidence of GDA PPH and interdependent benefit of these approaches remain unclear. 15,19,20 We hypothesized the GDA accounts for a relatively low proportion of all PPH events, and specific GDA-targeting interventions might have less benefit than previously suggested.…”