Stent graft treatment for ruptured pseudoaneurysms of the splanchnic arteries after pancreaticoduodenectomy: a case report

Abstract

Background: Hemorrhage due to a ruptured splanchnic pseudoaneurysm followed by the formation of a postoperative pancreatic fistula is the most severe complication of a pancreatectomy, sometimes leading to a fatal outcome. Stent graft placement to control the hemorrhage due to the pseudoaneurysm is a validated treatment option, but once the stent graft is infected, infection control is complicated. We report a case of a ruptured pseudoaneurysm of the splanchnic artery after pancreaticoduodenectomy to evaluate the stent graft treatment.

Case presentation: A 77-year-old man underwent pylorus-preserving pancreaticoduodenectomy for suspected distal bile duct cancer. Hemorrhage from a pseudoaneurysm of the common hepatic artery due to the formation of the pancreatic fistula was detected on postoperative day 9, and a stent graft was successfully placed with the preservation of hepatic arterial blood flow. On postoperative day 12, new-onset hemorrhage from a pseudoaneurysm of the right hepatic artery developed, and a stent graft was similarly placed, but immediately occluded. Refractory pancreatic and biliary fistulas developed and required continuous drainage. On postoperative day 85, computed tomography revealed the presence of air within the latter stent graft, which indicated infection of the stent graft. The patient died due to sepsis caused by the graft infection.

Conclusion: Stent graft placement for the treatment of hemorrhage of a pseudoaneurysm secondary to a postoperative pancreatic fistula, following pancreaticoduodenectomy, is an effective treatment option as it achieves immediate hemostasis and maintains end-organ perfusion. However, stent graft infection is the most detrimental complication.

Keywords: Pancreaticoduodenectomy; Pseudoaneurysm; Stent graft.

Fig. 1

Pre- and postoperative angiogram. a Angiogram reveals contrast extravasation from the pseudoaneurysm at the CHA (arrow). The RHA is branched independently from the CHA (arrowhead). b A stent graft, 6 mm in diameter and 5 cm in length, is placed from the CHA and distal part of the replaced RHA to the LHA (arrows). c Angiogram shows contrast extravasation from the RHA (arrow). d A stent graft, 5 mm in diameter and 5 cm in length, was placed in the RHA, but occluded soon after (arrows)

Fig. 2

Enhanced CT on POD 85. CT reveals the presence of air within the occluded stent graft, which indicates stent graft infection (arrow)