Clinical efficacy of coil embolization in treating pseudoaneurysm post-Whipple operation

Abstract

The present study aimed to evaluate the clinical efficacy and safety of angiography and coil embolization for pseudoaneurysm post-pancreatoduodenectomy (PD). A total of 17 patients with gastrointestinal or abdominal hemorrhage after PD were included in the present study. Angiography was performed on the celiac artery, common hepatic artery, splenic artery, gastroduodenal artery and superior mesenteric artery to determine the size of the pseudoaneurysm, the parent artery and its collateral branches. A variety of embolization techniques have been applied to embolize pseudoaneurysm, including the sac packing technique, proximal embolization, exclusion technique and sandwich technique. Different techniques with coils were used for embolization and the clinical effects of embolization were analyzed. A total of 18 pseudoaneurysms were identified in 17 patients. In 2 patients, severe technical complications occurred, including migration of the coil and rupture of pseudoaneurysm, and one of them died, which may have been associated with this complication. No serious clinical complications were observed in the other patients. A total of 7 patients had mild clinical complications, including mild abdominal and dorsal pain, which were alleviated after symptomatic management. A total of 15 patients with definite pseudoaneurysm were successfully embolized without re-bleeding and complications. The clinical success rate was 94.1% (16/17). In conclusion, a variety of embolization techniques may be applied for the treatment of pseudoaneurysm after PD, which have high technical and clinical success rates and small trauma. It is recommended in emergency situations, but care should be taken to avoid serious technical complications.

Keywords: Whipple operation; bleeding; pancreatoduodenectomy; pseudoaneurysm.

Figure 1

Representative case of a 63-year-old female patient (case no. 1; Table I) diagnosed with duodenal adenocarcinoma. (A) Digital subtraction angiography images indicated a suspected pseudoaneurysm (arrow) in one branch of the gastroduodenal artery, which was confirmed as a saccular pseudoaneurysm (arrow) by (B) superselective catheterization to gastroduodenal arteriography. (C) Another irregular pseudoaneurysm is found by local magnification angiography (arrow). (D) A proximal embolization technique and exclusion technique were used, respectively, since the pseudoaneurysms arose from the end of a branch (arrow) and a branch with both inflow and outflow of the parental artery (arrowhead).

Figure 2

Representative case of a 57-year-old male patient (case no. 2; Table I) diagnosed with pancreatic head cancer. (A) Digital subtraction angiography indicated a short-necked pseudoaneurysm (arrow) arising from the GDA, which was irregular and spasmodic (arrowhead). (B) An exclusion technique, i.e. embolization of the inflow and outflow embolization of the parent artery (arrow) was used, since the pseudoaneurysm arose from the main trunk of the GDA, which had collateral supply. GDA, gastroduodenal artery.

Figure 3

Representative case of a 74-year-old male patient (case no. 3; Table I) diagnosed with pancreatic head cancer. (A) Arteriography indicated a large-size pseudoaneurysm (arrowhead) arising from the hepatic artery. At the same time, subcapsular blood or fluid was visible and the liver was compressed and shifted inwards (arrows). (B) An exclusion technique was used for embolization. (C) Coil migration (arrows) occurred when embolization of the end of the proper hepatic artery was performed. (D) The coil protruded out of the vascular cavity during proximal embolization, which was considered as the parent artery rupture or penetration into the pseudoaneurysm (arrowhead).

Figure 4

Representative case of a 71-year-old male patient (case no. 4; Table I) diagnosed with pancreatic head cancer. Sentinel hemorrhage was considered. (A) Arteriography indicated that a residual saccular pseudoaneurysm arose from the gastroduodenal artery stump (arrow). (B) The sac packing technique was used. During the extraction of the catheter, the patient complained of abdominal pain, which was followed by a significant drop in blood pressure. (C) Re-angiography confirmed active bleeding (arrow), which was considered to arise from pseudoaneurysm rupture. Therefore, (D) the sandwich technique was adopted for remedial treatment (arrowheads).