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

Table 1 Patients characteristics

Case number	Primary disease	Type of PD	Lymphadenectomy (categorization1)	Nerve dissection	Associated pancreatitis	Pancreatic leakage	Postoperative complications	Hemorrhage oncet2	Sentinel bleeding	Symptoms	Sepsis	Shock	Liver ischemia
1	Insulinoma	SSpPD	No	No	No	Yes	-	7	No	Active bleeding from intraperitoneal drain	Yes	Yes	No
2	Gastric cancer	PD	Yes (D2)	No	No	Yes	-	20	No	Bleeding from wound	Yes	Yes	No
3	Gallbladder cancer	HPD	Yes (regional)	Yes	No	Yes	-	58	No	Hematemesis	No	No	No
4	Neuroendoicrine tumor	Lasparoscopic PD	No	No	No	Yes	-	18	Yes	Active bleeding from intraperitoneal drain	No	Yes	No
5	Bile duct cancer	PD	Yes (regional)	No	Yes	No	Digestive anastomotic failure	11	No	Active bleeding from intraperitoneal drain	No	No	No
6	Pancreatic cancer	SSpPD	Yes (D2)	Yes	Yes	Yes	-	22	No	Active bleeding from intraperitoneal drain	No	No	No
7	Bile duct cancer	SSpPD	Yes (regional)	Yes	No	Yes	-	14	No	Active bleeding from intraperitoneal drain	Yes	No	No
8	Gastric cancer	PD	Yes (D2+)	No	No	No	Ruptured suture (staple line)	32	Yes	Active bleeding fromintraperitoneal drain	Yes	Yes	No
9	Pancreatic cancer	SSpPD	Yes (D2)	Yes	Yes	No	-	6	Yes	Active bleeding from intraperitoneal drain	Yes	Yes	No
10	Pancreatic cancer	SSpPD	Yes (D2)	Yes	Yes	Yes	-	16	No	Melena	No	No	Yes
11	Pancreatic metastasis from renal cancer	SSpPD	No	No	No	Yes	-	30	Yes	Active bleeding from intraperitoneal drain	No	Yes	No
12	Ampullary cancer	SSpPD	Yes (D1)	No	No	Yes	-	6	Yes	Active bleeding from intraperitoneal drain	No	Yes	No
13	Pancreatic cancer	PD	Yes (D2)	Yes	Yes	Yes	-	14	No	Active bleeding from intraperitoneal drain	Yes	Yes	No
14	Intraductal papillary mucinous neoplasm	PpPD	No	No	No	Yes	-	22	No	Active bleeding from intraperitoneal drain	Yes	Yes	No
15	Pancreatic cancer	SSpPD	Yes (D1)	No	Yes	No	Biliary necrosis	12	No	Active bleeding from intraperitoneal drain	Yes	Yes	No
							Ruptured cholangiojejunostomy
16	Pancreatic cancer	SSpPD	Yes (D2)	Yes	Yes	Yes	-	28	No	Abdominal pain	Yes	Yes	Yes

¹Intentional lymphadenectomy according to Japanese guidelines.

²Postoperative day after pancreaticoduodenectomy. HPD: Hepatopancreatoduodenectomy; PD: Pancreaticoduodenectomy; PpPD: Pylorus-preserving pancreaticoduodenectomy; SSpPD: Subtotal stomach-preserving pancreaticoduodenectomy.

Table 2 Definitive diagnosis

Case number	Bleeding site	Diagnostic modality	CT angiographic findings	Angiographic findings	Time from hemorrhage onset to definitive diagnosis (d)	Time from hemorrhage onset to EVT (d)
1	RGA	CT angiography	Extravasation	Extravasation	0	0
2	SA	CT angiography	Extravasation	Extravasation	0	141
3	RHA	CT angiography	Enlargement of pseudoaneurysm	Pseudoaneurysm; Extravasation	1	0
4	Cholangiojejunostomy	Clinical findings2	None	None	0	0
5	DPA	CT angiography	Extravasation	Extravasation	0	0
6	GDA stump	CT angiography	Extravasation	Extravasation	0	0
7	RHA	CT angiography	Extravasation	Extravasation	0	0
8	GDA stump	CT angiography	Pseudoaneurysm; Extravasation	Pseudoaneurysm	0	0
9	DPA	CT angiography	Extravasation	Extravasation; Pseudoaneurysm	0	0
10	PHA	CT angiography	Pseudoaneurysm	Obstruction of CHA; Pseudoaneurysm	0	1
11	RHA	CT angiography	Pseudoaneurysm	Pseudoaneurysm	0	0
12	GDA stump	Laparotomy3	None (hematoma only)	None (stenosis of CHA)	0	0
13	GDA stump	Angiography	Extravasation	Extravasation	0	0
14	GDA stump	CT angiography	Extravasation	Extravasation; Pseudoaneurysm	0	0
15	GDA stump	CT angiography	Minor extravasation	Extravasation; Pseudoaneurysm	0	1
16	GDA stump	CT angiography	Pseudoaneurysm; Extravasation	Pseudoaneurysm; Extravasation	0	0

¹Hematemesis and endoscopic findings.

²Two surgical approaches were challenged during 14 d.

³Bleeding from the GDA was detected during laparotomy, even though computed tomography angiography and angiographic findings did not revealed extravasation. The endovascular treatment was done under the laparotomy. CHA: Common hepatic artery; CT: Computed tomography; DPA: Dorsal pancreatic artery; EVT: Endovascular treatment; GDA: Gastroduodenal artery; RGA: Right gastric artery; RHA: Right hepatic artery; PHA: Proper hepatic artery; SA: Splenic artery.

Table 3 Endovascular treatment

Case number	Treated artery (target and range)	TAE	Stent-graft placement			Technical success during EVT	Reasons for failed or incomplete EVT	Additional surgical approaches (day number2)	Additional EVT (day number2)	Antiplatelet and/or anticoagulation agents (number)	Long-term results of EVT
											TAE		Stent-graft placement
			Stent type (number1)	Size (mm)	Length (mm)						Collateral circulation (yr)3	Recanalization (yr)3	Patency (y)3
1	RGA	Coiling	-			Yes	-	No	No	No	No (4.39)	No (4.39)	-
2	CA; SA	-; Coiling	Covered stent (1); -	3.5; -	19; -	No	Stenosis	Hemostasis (-7 and -6)	Stent regrafting (+ 1); Coiling (+ 1)	No	-	-	-
3	PHA-LHA	-	Covered stent (1)	3.5	19	Yes	-	No	No	Yes (1)	-	-	Patent (0.72)
4	SMA branch; RHA	Coiling; -	-; Covered stent (1)	-; 3.5	-; 19	Yes	-	Lavage and cholangio-jejunal anastomosis (+ 7)	Stent regrafting (+ 28)	No	No (6.14); -	No (6.14); -	-; Patent (6.14)
5	SA branch	Coiling	-			Yes	-	No	No	Yes (1)	No (0.46)	No (0.46)	-
6	CHA-PHA	-	Covered stent (1)	3.5	19	Yes	-	No	No	No	-	-	Patent (0.93)
7	RHA	-	Covered stent (1)	3.5	19	Yes	-	Lavage and cholangio-jejunal anastomosis (+ 3)	No	No	-	-	Patent (1.27)
8	GDA	Coiling	-	-	-	No	Subtle bleeding4	No	No	No	No (0.24)	No (0.24)	-
9	DPA	Coiling	-	-	-	Yes	-	No	No	No	No (0.44)	No (0.44)	-
10	-	-	-	-	-	No	Stenosis	Hemostasis and ligation of CHA (± 0)	No	Yes (2)	-	-	Patent (1.95)
11	RHA	-	Covered stent (2)	3.0	19	Yes	-	Removal of hematoma (- 18)	Stent regrafting (+33)	Yes (2)	-	-	Patent (1.53)
12	CHA-PHA	-	Covered stent (1)	3.5	19	Yes	-	Removal of hematoma (± 0)	No	No	-	-	Patent (0.98)
13	CHA-PHA	Coiling	-	-	-	Yes	-	No	No	No	Yes (1.53)	No (1.53)	-
14	GDA	Coiling	-	-	-	No	Difficulty in packing	Arterio-portal shunting5 (+ 4)	CHA coiling (+ 4)	Yes (1)	Yes (7.72)	No (7.72)	-
15	GDA	-	Covered stent (1)	3.5	19	Yes	-	No	No	No	-	-	Patent (0.00)
16	GDA	-	Covered stent (2)	2.6	19	Yes	-	Removal of hematoma (± 0)	No	No	-	-	Patent (0.01)

¹The second stentgraft was implanted in overlapping fashion.

²The day number from the initial endovascular treatment (EVT).

³Findings in the latest dynamic image studies (time from the initial EVT).

⁴Subtle bleeding was observed at the end of EVT, but thereafter, complete hemostasis was fainally obtained.

⁵Shunt creation between the iliocecal artery and vein. CA: Celiac artery; CHA: Common hepatic artery; EVT: Endovascular treatment; GDA: Gastroduodenal artery; LHA: Left hepatic artery; RHA: Right hepatic artery; PHA: Proper hepatic artery; RGA: Right gastric artery; SA: Splenic artery; SMA: Superior mesenteric artery; TAE: Transcatheter arterial embolization.

Table 4 Clinical course and outcome after endovascular treatment

Case number	Complication after EVT	Liver infarction after EVT	Hospital death (day number1 and POD)	Clinical success2	Follow-up term (yr)	Cause of death	Prognosis (dead or alive)
1	-	No	No	Yes	5.57	Cancer-related death	Dead
2	-	No	Yes (+ 61 and 94)	Yes	0.26	Cancer-related death	Dead
3	-	No	No	Yes	0.72	Cancer-related death	Dead
4	-	No	No	Yes	8.36	-	Alive
5	-	No	No	Yes	0.56	Cancer-related death	Dead
6	Bleeding	No	No	Yes	1.04	Cancer-related death	Dead
7	-	No	No	Yes	1.34	Cancer-related death	Dead
8	-	No	No	Yes	0.52	Cancer-related death	Dead
9	-	No	No	Yes	0.47	Cancer-related death	Dead
10	-	No	No	Yes	1.95	-	Alive
11	-	No	No	Yes	1.69	-	Alive
12	-	No	No	Yes	1.46	-	Alive
13	-	Yes	No	Yes	1.74	Cancer-related death	Dead
14	Bleeding; Liver abscess	Yes	No	Yes	9.55	-	Alive
15	-	No	Yes (+ 1 and 14)	No	0.04	Bleeding, sepsis and DIC	Dead
16	-	No	Yes (+ 3 and 31)	No	0.08	Liver failure	Dead

¹The day number from the initial EVT.

²Short-term clinical outcome. EVT: Endovascular treatment; DIC: Disseminated intravascular coagulation; POD: Postoperative day after pancreaticoduodenectomy.