Stent-grafts placement for treatment of massive hemorrhage from ruptured hepatic artery after pancreaticoduodenectomy

Abstract

Aim: To present a series of cases with life-threatening hemorrhage from ruptured hepatic artery pseudoaneurysm after pancreaticoduodenectomy (PD) treated with placement of stent-grafts.

Methods: Massive hemorrhage from ruptured hepatic artery pseudoaneurysm after PD in 9 patients (6 men, 3 women) at the age of 23-75 years (mean 48 years), were treated with placement of percutaneous endovascular balloon-expandable coronary stent-grafts. All patients were not suitable for embolization because of a non-patent portal vein. One or more stent-grafts, ranging 3-6 mm in diameter and 16-55 mm in length, were placed to exclude ruptured pseudoaneurysm. Follow-up data, including clinical condition, liver function tests, and Doppler ultrasound examination, were recorded at the outpatient clinic.

Results: Immediate technical success was achieved in all the 9 patients. All stent-grafts were deployed in the intended position for immediate cessation of bleeding and preservation of satisfactory hepatic arterial blood flow. No significant procedure-related complications occurred. Recurrent bleeding occurred in 2 patients at 16 and 24 h, respectively, after placement of stent-grafts and treated with surgical revision. One patient died of sepsis 12 d after the interventional procedure. The remaining 6 patients were survived when they were discharged. The mean follow-up time was 10.5 mo (range 4-16 mo). No patient had recurrent bleeding after discharge. Doppler ultrasound examination verified the patency of hepatic artery and stent-grafts during the follow-up.

Conclusion: Placement of stent-grafts is an effective and safe procedure for acute life-threatening hemorrhage from ruptured hepatic artery pseudoaneurysm.

Figure 1

A 75-year-old female with pancreatic head malignancy underwent a pylorus-preserving pancreaticoduodenectomy (Case 1). A: Selective angiography of the common hepatic artery shows a large ruptured hepatic artery pseudoaneurysm with extravasation of contrast medium (arrows); B: Angiography after two stent-grafts placement demonstrates exclusion of the aneurysm and preserved hepatic artery blood flow through the stent-grafts (arrows). Note the splenic artery was embolized 4 d ago due to bleeding from the splenic artery (curved arrow).

Figure 2

A 23-year-old female with pancreatic trauma underwent a pylorus-preserving pancreaticoduodenectomy (Case 2). A: Emergent selective angiography of the celiac trunk demonstrates massive extravasation of contrast medium into the abdominal cavity from the ruptured hepatic artery pseudoaneurysm (arrows). Note the splenic artery was embolized 6 d ago due to bleeding from the splenic artery (curved arrow); B: Digital substraction superior mesenteric artery angiogram with delayed phase demonstrates no visualization of the portal vein, and remarkable pooling of contrast medium at the branches of the SMV (arrows); C: Angiography after two pieces of stent-grafts placement shows exclusion of the bleeding hepatic pseudoaneurysm and good hepatic arterial blood flow through the stent-grafts (curved arrow). Note the spasm of the proximal hepatic artery (arrow).