Management of bleeding from pseudoaneurysms following pancreaticoduodenectomy

Abstract

Aim: To review the clinical course and the management of pseudoaneurysms post-pancreaticoduodenectomy.

Methods: Medical records of 907 patients who underwent pancreaticoduodenectomies from January 1995 to May 2007 were evaluated retrospectively. The clinical course, management strategy, and outcome of ruptured pseudoaneurysms cases were analyzed.

Results: Twenty-seven (3.0%) of 907 cases had post-operative hemorrhage from ruptured pseudoaneurysms. Pancreatic fistula was evident in 12 (44%) cases. Sentinel bleeding appeared in 21 (77.8%) cases. Of the 27 cases, 11 (41%) cases demonstrated bleeding pseudoaneurysm of the ligated gastroduodenal artery, 8 (30%) of the right, proper, common hepatic artery, 2 (7%) of the right gastric artery, and 4 (15%) of the peripancreatic arteries. The remaining two patients died due to sudden-onset massive hemorrhage and pseudoaneurysm rupture was suspected. Emergent operation was performed on 2 cases directly without angiography. Angiography was attempted in 23 cases. Eighteen (78.2%) cases succeeded to hemostasis; the five failed cases were explored. After embolization of the hepatic artery, five cases developed liver abscesses or infarction and a single case of hepatic failure expired. Gastroduodenal artery embolization with common hepatic artery stent insertion was performed to enhance hepatic artery flow in a single case and was successfully controlled.

Conclusion: Bleeding pseudoaneurysms are among the most serious and fatal complications following pancreaticoduodenectomy. Diagnostic angiography has been preferred over endoscopy and is rapidly becoming the standard therapeutic treatment for bleeding pseudoaneurysms.

Figure 1

Number of cases based on the onset of pseudoaneurysm rupture.

Figure 2

Flow chart summarizing the outcome of patients with hemorrhage from ruptured pseudoaneurysms. DIC: Disseminated intravascular coagulation; ARDS: Acute respiratory distress syndrome.

Figure 3

Angiograph. A: A pseudoaneurysm (arrow) of the gastroduodenal artery; B: A pseudoaneurysm (arrow) of the right hepatic artery; C: A ruptured pseudoaneurysm (arrow) of the right gastric artery.

Figure 4

Abdominal CT scan. A: Liver abscess that may have developed after common hepatic artery embolization (arrow); B: An area of liver infarction following common hepatic artery embolization (arrow).

Figure 5

Angiograph. A: A stent graft of the common hepatic artery placed to manage the gastroduodenal artery pseudoaneurysm (arrow); B: A stent graft insertion for a pseudoaneurysm in the superior mesenteric artery (arrow).