Effectiveness and outcome of endovascular therapy for late-onset postpancreatectomy hemorrhage using covered stents and embolization

Abstract

Endovascular treatment using either covered stents or embolization techniques is an effective and safe emergency therapy for life-threatening postpancreatectomy hemorrhage with good clinical success rates and long-term results. Covered stent placement preserving vessel patency in the early postoperative phase should be preferred to embolization if it is technically feasible.

Bleeding complications after pancreatic surgery: interventional radiology management

“…While early PPH occurs by definition within 24 h from resection, DPH can occur many days and even weeks later, with a median onset reported of 10-27 days after surgery (10,17,27), a range as wide as 4-240 days postoperation (28), and a large part of events occurring after discharge from hospital (2,11). Intraluminal PPH is defined as the occurrence of blood draining from the nasogastric tube, hematemesis, or melena, and is frequently associated with ulcers at the anastomotic site or anastomotic fistulae possibly causing rupture of a PSA.…”

“…The management is still ultimately decided on the basis of the characteristics and clinical status of the individual patient, together with the institutional preference and expertise. However, IR is widely considered as the potential first-line treatment in patients that are hemodynamically stable, while an aggressive surgical intervention is the preferred option in patients that are unstable or when others treatments have failed (17,28). Surgery continues to have an important role in the treatment of the causes of hemorrhage (as abdominal collections or fistulae) in patients where acute bleeding has been successfully managed by IR (37).…”

“…Transcatheter arterial embolization is a well established, safe and effective treatment for ruptured PSA (59,61,(66)(67)(68) as hemostasis is reached in 80% to 100% of patients (1). According to different papers, the gastroduodenal artery (GDA) stump is the most common bleeding site, followed by common hepatic artery (CHA), left hepatic artery, dorsal pancreatic artery, gastric artery, splenic artery (Figure 1), and the superior mesenteric artery, in different orders according to some different experiences (1,14,27,28,52,69). The majority of DPH are, according to the ISGPS classification, extraluminal (30).…”

“…In the last years, thanks to the advancements in technology and the wide commercial availability, an increasing number of papers have described the use of stent-grafts for endovascular repair of visceral aneurysms and PSAs (74). In the particular setting of a PPH, placing a stent-graft instead of using permanent embolic agents allows to maintain the hepato-portal blood flow and to reduce complications such as postembolization syndrome, liver abscess formation, and liver failure (28). For these reasons some authors have suggested that releasing a stent-graft into the hepatic artery, excluding the GDA stump, should be considered as a first-line procedure (9,75).…”

“…The vascular access is generally performed via a transfemoral approach, but in case of marked angulation of the celiac axis or median arcuate ligament syndrome, which is associated with higher rates of technical failure and complications, some authors have suggested a brachial or transhepatic access (29,77,78). In an emergency setting, when time becomes crucial, stent-graft placement can lead to immediate exclusion of the target PSA with a relatively short operative time (28). Moreover, stent graft implantation has been associated with a lower use of fluoroscopy during the procedure (58).…”