Published online Apr 27, 2021. doi: 10.4254/wjh.v13.i4.483
Peer-review started: February 3, 2021
First decision: March 1, 2021
Revised: March 7, 2021
Accepted: March 19, 2021
Article in press: March 19, 2021
Published online: April 27, 2021
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.
To present our data here along with a discussion of therapeutic strategies for fatal arterial hemorrhage after PD.
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.
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.
Transcatheter placement of a covered stent may be useful for simultaneous accomplishment of complete hemostasis and HA flow preservation.
Core Tip: Arterial hemorrhage after pancreaticoduodenectomy is fatal. This hemorrhage is caused by pseudoaneurysm rupture, and the gastroduodenal artery stump and hepatic artery are frequent culprit vessels. Simultaneous accomplishment of complete hemostasis and hepatic artery flow preservation is difficult after pancreaticoduodenectomy. Although complete hemostasis may be obtained by transcatheter arterial embolization or surgery, liver infarction and/or abscesses may occur. We here evaluate our experience including actual treatments (transcatheter arterial embolization, stent-graft placement, or surgery), and discuss therapeutic strategies. Transcatheter placement of a covered stent is useful for simultaneous accomplishment of complete hemostasis and hepatic arterial flow preservation.