Endovascular management of post-pancreatectomy hemorrhage caused by a hepatic artery pseudoaneurysm: Case report and review of the literature

Abstract

Pancreaticoduodenectomy is the standard surgical treatment for a range of malignant and some benign diseases. The mortality rate associated with this procedure has decreased to less than 3% in recent years, although the morbidity remains high at 6-40%. Common complications may include delayed gastric emptying, pancreatic fistula, intra-abdominal abscess, and gastrointestinal or intra-abdominal bleeding, among others. Bleeding and pseudoaneurysm formation are likely to be the most significant complications. This is a case report about gastrointestinal bleeding following a Whipple procedure from an aberrant hepatic artery originating from the superior mesenteric artery (SMA), treated by endovascular means. The SMA was cannulated under local anesthesia and direct puncture of the common femoral artery. Catheterization and angiogram of the aberrant right hepatic artery identified the pseudoaneurysm and bleeding site at its bifurcation. Coil embolization resulted in pseudoaneurysm occlusion and bleeding management. Hepatic perfusion was not affected as the main vasculature of the liver, namely the common hepatic artery, remained intact. The management of hemorrhage following pancreatectomy represents a significant challenge, particularly given the vulnerability of the patient cohort and the necessity for re-operation in an anatomically challenging environment. Endovascular intervention is the preferred method of treatment when applicable, as it can be performed under local anesthesia and is associated with less morbidity.

Keywords: endovascular management; hepatic artery pseudoaneurysm; post-pancreatectomy hemorrhage.

Figure 1

Anatomy explanation from the 3D reconstructed image.

Figure 2

CTA. Arrows show hepatic artery pseudoaneurysm: (a) axial view, (b) axial MPR, (c) coronal MPR, (d) 3d reconstruction.

Figure 3

Intra-op angiography. The arrow shows the contrast extravagation.

Figure 4

Final angiography with coils in place. No hemorrhage identified. Arrow indicates the previous site of extravagation.