Fatal arterial hemorrhage after pancreaticoduodenectomy: How do we simultaneously accomplish complete hemostasis and hepatic arterial flow?

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.

Endovascular treatment for delayed post-pancreaticoduodenectomy hemorrhage of unusual origin (splenic artery branch)

“…16 There remains a paucity of reports describing delayed SAB bleeding after PD in detail, the subsequent endovascular results, and the survival prognosis of the patients, with the reports being limited to several case reports and small case series. 9 , 10 , 12 , 17 , 18 This present study reports the outcomes of endovascular procedures to treat the SAB erosions for delayed PPH.…”

Usefulness of the hybrid technique of interventional radiology and endoscopic treatment for intestinal bleeding after pancreaticoduodenectomy: a case report

“…Pseudoaneurysms after PD often occur in the GDA stump and HA 11 . If the bleeding site is in the GDA but is short and difficult to catheterize, as in the present case, EVT of the CHA is the treatment of choice.…”

“…When coil embolization is selected, complications such as hepatic infarction, liver failure, and liver abscess caused by hepatic ischaemia due to embolization have been reported 13 , 14 . To avoid these complications, the usefulness of stent-graft placement has been reported 11 . On the other hand, few institutions have stent grafts permanently installed, and these grafts require skilled experience and ample time for implantation 15 .…”

Comments and illustrations of the WFUMB CEUS liver guidelines: Rare vascular pathology, part II

“…In the study of Shindo et al, 19% of all patients undergoing pancreaticoduodenectomy developed hepatic infarction, with hepatic artery and celiac trunk resection being the most important risk factors [37]. Liver infarctions resulting from endovascular treatment of bleeding events after pancreaticoduodenectomy were described in 12.5% [38].…”