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Sah R, Rawal SB, Malla S, Rayamajhi J, Bhat PS. Bleeding pseudoaneurysms in postoperative upper gastrointestinal surgery patients: a single -center experience. J Surg Case Rep 2025; 2025:rjaf048. [PMID: 39931032 PMCID: PMC11809240 DOI: 10.1093/jscr/rjaf048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2025] [Accepted: 01/22/2025] [Indexed: 02/13/2025] Open
Abstract
Visceral artery pseudoaneurysms are rare but life-threatening complications following upper gastrointestinal (GI) surgery. This case series reviews six patients (male-to-female ratio 3:3) who developed pseudoaneurysms, presenting with diverse clinical manifestations. Four patients (66.6%) experienced bleeding, including hemoperitoneum and upper GI bleeding, with one also reporting nausea and vomiting. Two patients (33.3%) developed anastomotic site leakage, leading to hemoperitoneum in one and bile-induced intra-abdominal infection in the other. The pseudoaneurysms involved the proper hepatic artery (n = 3), common hepatic artery (n = 2), right hepatic artery (n = 1), jejunal artery (n = 1), and splenic artery (n = 1). All patients underwent interventional radiology procedures, with angioembolization performed in each case. Recurrent bleeding required re-embolization in three cases: two from previously treated sites and one from a new pseudoaneurysm. Bleeding occurred between the 5th and 27th postoperative days, and one patient succumbed. Early diagnosis and timely endovascular management are critical for improved outcomes in these patients.
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Affiliation(s)
- Raju Sah
- Department of Surgical Gastroenterology, Nepal Mediciti Hospital, Karyabinayak, Lalitpur 44600, Nepal
| | - Sushil Bahadur Rawal
- Department of Surgical Gastroenterology, Nepal Mediciti Hospital, Karyabinayak, Lalitpur 44600, Nepal
| | - Srijan Malla
- Department of Surgical Gastroenterology, Nepal Mediciti Hospital, Karyabinayak, Lalitpur 44600, Nepal
| | - Jyoti Rayamajhi
- Department of Surgical Gastroenterology, Nepal Mediciti Hospital, Karyabinayak, Lalitpur 44600, Nepal
| | - Pawan Singh Bhat
- Department of Surgical Gastroenterology, Nepal Mediciti Hospital, Karyabinayak, Lalitpur 44600, Nepal
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Jabłońska B, Mrowiec S. Endovascular Treatment of Hepatic Artery Pseudoaneurysm after Pancreaticoduodenectomy: A Literature Review. Life (Basel) 2024; 14:920. [PMID: 39202663 PMCID: PMC11355561 DOI: 10.3390/life14080920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 07/13/2024] [Accepted: 07/22/2024] [Indexed: 09/03/2024] Open
Abstract
Pancreaticoduodenectomy (PD) is a complex surgical procedure performed in patients with periampullary tumors located within the pancreatic head, the papilla of Vater, the distal common bile duct, and the duodenum. In advanced tumors, the operative technique involves the need for dissection and divestment of the arteries located within the pancreaticoduodenal field, including the common hepatic artery (CHA) and the proper hepatic artery (PHA) and its branches. The second most important cause of post-PD visceral aneurysms is irritation of the peri-pancreatic arterial wall by pancreatic juice in a postoperative pancreatic fistula (POPF). Hepatic artery pseudoaneurysm (HAP) is a very dangerous condition because it is usually asymptomatic, but it is a rare and potentially lethal pathology because of the high risk of its rupture. Therefore, HAP requires treatment. Currently, selective celiac angiography is the gold-standard diagnostic and therapeutic management for postoperative bleeding and pseudoaneurysm in patients following PD. Open surgery and less invasive endovascular treatment are performed in patients with HAP. Endovascular treatment involves transarterial embolization (TAE) and stent graft implantation. The choice of treatment method depends on the general and local conditions, such as the patient's hemodynamic stability and arterial anatomy. In patients in whom preservation of the flow within the hepatic artery (to prevent hepatic ischemia complications such as liver infarction, abscess, or failure) is needed, stent graft implantation is the treatment of choice. This article focuses on a review of two common methods for endovascular HAP treatment. In addition, risk factors and diagnostic tools have been described.
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Affiliation(s)
- Beata Jabłońska
- Department of Digestive Tract Surgery, Medical University of Silesia, 40-752 Katowice, Poland;
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Kim Y, Kim JH, Kim JH, Kim GH, Ko HK, Chu HH, Shin JH, Gwon DI, Ko GY. Stent-Graft Placement for Hepatic Arterial Hemorrhage after Pancreaticobiliary Surgery: Long-Term Clinical Outcomes. J Vasc Interv Radiol 2024; 35:963-970. [PMID: 38519001 DOI: 10.1016/j.jvir.2024.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 03/11/2024] [Accepted: 03/14/2024] [Indexed: 03/24/2024] Open
Abstract
PURPOSE To evaluate the safety and long-term clinical outcomes of stent-graft placement to treat hepatic arterial hemorrhage after pancreaticobiliary surgery. MATERIALS AND METHODS Outcomes were retrospectively evaluated in 61 patients (50 men and 11 women; mean age, 63 years) who underwent stent-graft placement for delayed arterial hemorrhage (after 24 hours) after pancreaticobiliary surgery from 2006 to 2023. Bleeding sites included the gastroduodenal artery stump (n = 54), common or proper hepatic artery (n = 5), and right hepatic artery (n = 2). The stent-grafts used were Viabahn (n = 27), Comvi (n = 11), Jostent (n = 3), Covera (n = 11), and Lifestream (n = 7). Technical and clinical success and adverse events (AE) were evaluated. After stent-graft placement, overall survival (OS), hemorrhage-free survival (HFS), and stent patency were evaluated. RESULTS The technical and clinical success rates of stent-graft placement were 97% and 93%, respectively. The severe AE rate was 12% and was significantly higher in patients who underwent pylorus-sacrificing rather than pylorus-preserving surgery (P = .001). None of the severe AEs were associated with patient mortality. Median OS after stent-graft placement was 854 days, and median HFS was 822 days. The 1-, 3-, 5-, and 10-year stent patency rates were 87%, 84%, 79%, and 72%, respectively. CONCLUSIONS Stent-graft placement was safe and provided long-term control of hepatic arterial hemorrhage after pancreaticobiliary surgery.
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Affiliation(s)
- Yonghun Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea; Department of Radiology, Ajou University Hospital, Ajou University College of Medicine, Suwon, South Korea
| | - Jin Hyoung Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea; Department of Radiology, Ajou University Hospital, Ajou University College of Medicine, Suwon, South Korea.
| | - Ji Hoon Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gun Ha Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Heung-Kyu Ko
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hee Ho Chu
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dong Il Gwon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gi-Young Ko
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Ielpo B, Alborino S, Melloul E, Salvatori F, Lai Q, Rossi M, Demartines N, Di Saverio S. Interventional treatment options for management of delayed arterial hemorrhage after major hepato-pancreatic-biliary surgery. Hepatobiliary Pancreat Dis Int 2023; 22:648-649. [PMID: 36882358 DOI: 10.1016/j.hbpd.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/09/2023] [Indexed: 03/09/2023]
Affiliation(s)
- Benedetto Ielpo
- Unidad de Cirugía Hepatobiliopancreática, Hospital del Mar, Barcelona, Spain
| | - Salvatore Alborino
- Interventional Radiology Unit, Macerata Hospital, Macerata, AV4, ASUR Marche, Italy
| | - Emmanuel Melloul
- HBP and Liver Transplant Surgery Unit, Visceral Surgery Dept, CHUV, University of Lausanne, Lausanne, Switzerland
| | - Fabio Salvatori
- Interventional Radiology Unit, Macerata Hospital, Macerata, AV4, ASUR Marche, Italy
| | - Quirino Lai
- HBP and Liver Transplant Surgery Unit, Policlinico Umberto I, La Sapienza University of Rome, Rome, Italy
| | - Massimo Rossi
- HBP and Liver Transplant Surgery Unit, Policlinico Umberto I, La Sapienza University of Rome, Rome, Italy
| | - Nicolas Demartines
- HBP and Liver Transplant Surgery Unit, Visceral Surgery Dept, CHUV, University of Lausanne, Lausanne, Switzerland
| | - Salomone Di Saverio
- General Surgery Unit, San Benedetto del Tronto Hospital, San Benedetto del Tronto, AV5, ASUR Marche, Italy.
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Wang XD, Ge NJ, He CJ, Zhu JJ, Xu W, Yang YF. Endovascular treatment of delayed arterial hemorrhage after radical operation for hilar cholangiocarcinoma. Hepatobiliary Pancreat Dis Int 2023; 22:403-405. [PMID: 36858893 DOI: 10.1016/j.hbpd.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 02/09/2023] [Indexed: 03/03/2023]
Affiliation(s)
- Xiang-Dong Wang
- Department of Interventional Radiology, Shanghai Eastern Hepatobiliary Surgery Hospital, Shanghai 200438, China
| | - Nai-Jian Ge
- Department of Interventional Radiology, Shanghai Eastern Hepatobiliary Surgery Hospital, Shanghai 200438, China
| | - Cheng-Jian He
- Department of Interventional Radiology, Shanghai Eastern Hepatobiliary Surgery Hospital, Shanghai 200438, China
| | - Jun-Jun Zhu
- Department of Interventional Radiology, Shanghai Eastern Hepatobiliary Surgery Hospital, Shanghai 200438, China
| | - Wei Xu
- Department of Interventional Radiology, Shanghai Eastern Hepatobiliary Surgery Hospital, Shanghai 200438, China
| | - Ye-Fa Yang
- Department of Interventional Radiology, Shanghai Eastern Hepatobiliary Surgery Hospital, Shanghai 200438, China.
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Regarding "Effectiveness and outcome of endovascular therapy for late-onset postpancreatectomy hemorrhage using covered stents and embolization". J Vasc Surg 2017; 65:1244. [PMID: 28342518 DOI: 10.1016/j.jvs.2016.11.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 11/17/2016] [Indexed: 11/23/2022]
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Ischemic Liver Injury After Complete Occlusion of Hepatic Artery in the Treatment of Delayed Postoperative Arterial Bleeding. J Gastrointest Surg 2015; 19:2235-42. [PMID: 26334251 DOI: 10.1007/s11605-015-2930-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 08/19/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed postoperative arterial bleeding is rare and may be life-threatening. When the bleeding source is the hepatic artery, complete ligation or embolization from the proximal to the distal area of the ruptured lesion usually results in complete occlusion of hepatic arterial flow. METHODS To evaluate the frequency and severity of ischemic liver injury following complete hepatic artery occlusion, a retrospective study was conducted. Patients who underwent complete hepatic artery occlusion in the treatment of delayed postoperative arterial bleeding between January 2007 and December 2014 in our institution were reviewed. Changes of hepatic function and rates of associated complications and prognosis were analyzed. RESULTS A total of 24 patients experienced 26 episodes of bleeding. Nineteen experienced transient liver enzyme elevation alone. There were no signs of acute liver failure after complete hepatic artery occlusion. The rates of liver infarction and liver abscess were 23.8 % (5/21) and 19 % (4/21), respectively. The 30-day mortality rate was 8.3 % (2/24). CONCLUSION Complete occlusion of the hepatic artery does not always result in severe hepatic ischemic injury. As a common cause of delayed postoperative bleeding, intra-abdominal infection may be fatal when it is not controlled successfully.
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Vachhani PG, Copelan A, Remer EM, Kapoor B. Iatrogenic hepatopancreaticobiliary injuries: a review. Semin Intervent Radiol 2015; 32:182-94. [PMID: 26038625 DOI: 10.1055/s-0035-1549377] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Iatrogenic hepatopancreaticobiliary injuries occur after various types of surgical and nonsurgical procedures. Symptomatically, these injuries may lead to a variety of clinical presentations, including tachycardia and hypotension from hemobilia or hemorrhage. Iatrogenic injuries may be identified during the intervention, immediately afterwards, or have a delayed presentation. These injuries are categorized into nonvascular and vascular injuries. Nonvascular injuries include biliary injuries such as biliary leak or stricture, pancreatic injury, and the development of fluid collections such as abscesses. Vascular injuries include pseudoaneurysms, arteriovenous fistulas, dissection, and perforation. Imaging studies such as ultrasound, computed tomography, magnetic resonance imaging, and digital subtraction angiography are critical for proper diagnosis of these conditions. In this article, we describe the clinical and imaging presentations of these iatrogenic injuries and the armamentarium of minimally invasive procedures (percutaneous drainage catheter placement, balloon dilatation, stenting, and coil embolization) that are useful in their management.
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Affiliation(s)
| | - Alexander Copelan
- Department of Diagnostic Radiology, William Beaumont Hospital, Royal Oak, Michigan
| | - Erick M Remer
- Department of Abdominal Radiology, Cleveland Clinic, Cleveland, Ohio
| | - Baljendra Kapoor
- Department of Interventional Radiology, Cleveland Clinic, Cleveland, Ohio
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Lü PH, Zhang XC, Wang LF, Chen ZL, Shi HB. Stent graft in the treatment of pseudoaneurysms of the hepatic arteries. Vasc Endovascular Surg 2014; 47:551-4. [PMID: 24052448 DOI: 10.1177/1538574413488460] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The purpose of our study was to evaluate the technical feasibility, procedural complications, clinical follow-up, and computed tomography (CT) scan outcomes of hepatic artery pseudoaneurysms (HAPs) treated with stent graft. METHODS Between October 2004 and October 2009, we treated 8 patients with HAPs with stent graft. RESULTS Stent graft deployment was technically successful in all the patients. Complete exclusion of the pseudoaneurysm preserving patency of the hepatic artery was achieved in 6 patients. Total occlusion of the common hepatic artery was observed in 1 patient, and vasospasm of proper hepatic artery and endoleak from distal stent margin were observed in another patient. The 2 patient were controlled through occlusion parent artery with coils. After these procedures, symptoms of bleeding and abdominal pain disappeared. Follow-up enhanced CT scan was performed at an average of 14 months (range, 6-26 months), which showed complete disappearance of the HAP and patency of the stent without intrastent stenosis in 6 patients who had successful deployment of the stent. CONCLUSIONS Endovascular treatment of HAPs using stent graft can maintain the hepatic artery blood flow and could be considered as an alternative to embolization.
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Affiliation(s)
- Peng-Hua Lü
- 1Department of Radiology, First Hospital Affiliated to Nanjing University, Nanjing, China
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Watanabe M, Shiozawa K, Mimura T, Ito K, Kamata I, Kishimoto Y, Momiyama K, Igarashi Y, Sumino Y. Hepatic artery pseudoaneurysm after endoscopic biliary stenting for bile duct cancer. World J Radiol 2012; 4:115-20. [PMID: 22468193 PMCID: PMC3314928 DOI: 10.4329/wjr.v4.i3.115] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 11/14/2011] [Accepted: 11/21/2011] [Indexed: 02/06/2023] Open
Abstract
We report a case of a pseudoaneurysm of the right hepatic artery observed 9 mo after the endoscopic placement of a Wallstent, for bile duct stenosis, which was treated with transcatheter arterial embolization. The patient presented with obstructive jaundice and was diagnosed with inoperable common bile duct cancer. A plastic stent was inserted endoscopically to drain the bile, and chemotherapy was initiated. Abdominal pain and jaundice appeared approximately 6 mo after the beginning of chemotherapy. A diagnosis of stent occlusion and cholangitis was made, and the plastic stent was removed and substituted with a self-expandable metallic stent (SEMS) endoscopically. Nine months after SEMS insertion, contrast-enhanced computed tomography showed a pseudoaneurysm of the right hepatic artery protruding into the common bile duct lumen and in contact with the SEMS. The shape and size of the pseudoaneurysm and diameter of its neck was determined by contrast-enhanced ultrasonography using Sonazoid. A micro-catheter was led into the pseudoaneurysm in the right hepatic artery, GDC™ Detachable Coils were placed, and IDC™ Detachable Coils were then placed in the right hepatic artery on the distal and proximal sides of the pseudoaneurysm using the isolation method. There have been a few reports on pseudoaneurysm associated with stent placement in the biliary tract employing percutaneous transhepatic procedures, however, reports of pseudoaneurysms associated with endoscopic SEMS placement are very rare.
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Boufi M, Belmir H, Hartung O, Ramis O, Beyer L, Alimi YS. Emergency stent graft implantation for ruptured visceral artery pseudoaneurysm. J Vasc Surg 2011; 53:1625-31. [PMID: 21530142 DOI: 10.1016/j.jvs.2011.02.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2010] [Revised: 02/09/2011] [Accepted: 02/09/2011] [Indexed: 12/17/2022]
Abstract
BACKGROUND Literature series that include visceral artery pseudoaneurysms rarely separate them from true aneurysms, although they address different issues. Guidelines for optimal management of these lesions are lacking. We report our experience of stent graft treatment of these lesions with midterm results. METHODS We retrospectively reviewed all patients with a visceral pseudoaneurysm who were treated with a stent graft in our institution. Patient history, clinical characteristics, procedure details, and outcome were recorded and analyzed. RESULTS From March 2004 to June 2009, 10 consecutive patients (9 men), who were a mean age of 59 years, were treated for symptomatic visceral artery pseudoaneurysm, with hemorrhagic shock in 8 patients (80%), after pancreaticoduodenectomy in 8, gastrectomy in 1, and abdominal trauma in 1. A mean of 24 days (range, 7-60 days) passed between the initial surgery or trauma and pseudoaneurysm diagnosis. Septic complications were associated in six patients (60%). The pseudoaneurysm was in the hepatic artery in 8 patients, the splenic artery in 1, and the superior mesenteric artery in 1. Technical and clinical success was achieved in 80% of patients. Two failures of catheterization were followed by redo surgery and death (20%). No patients died postoperatively, and no complications among the patients who were treated successfully. Mean follow-up was 37 months (range, 10-63 months). All stent grafts were patent, with no signs of infection. Two patients died secondary to neoplasm. No rebleeding or recurrent aneurysms were noted. CONCLUSION Stent graft exclusion of visceral artery pseudoaneurysm seems to be a valid therapeutic approach regardless of the patient's septic or hemodynamic status.
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Affiliation(s)
- Mourad Boufi
- Department of Vascular Surgery, University Hospital Nord, Marseille, France.
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Gwon DI, Ko GY, Sung KB, Shin JH, Kim JH, Yoon HK. Endovascular management of extrahepatic artery hemorrhage after pancreatobiliary surgery: clinical features and outcomes of transcatheter arterial embolization and stent-graft placement. AJR Am J Roentgenol 2011; 196:W627-W634. [PMID: 21512055 DOI: 10.2214/ajr.10.5148] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The objective of our study was to analyze the technical and clinical outcomes of endovascular treatment of patients with extrahepatic artery hemorrhage after pancreatobiliary surgery. MATERIALS AND METHODS From January 2000 to September 2009, 27 patients who had undergone pancreaticobiliary surgery had an extrahepatic artery hemorrhage with or without a pseudoaneurysm were enrolled in this retrospective study. All patients underwent diagnostic angiography and endovascular treatment-either transcatheter arterial embolization (TAE) (n = 20) or stent-graft placement (n = 7). RESULTS Bleeding sites were located in the gastroduodenal artery stump (n = 14), proper hepatic artery (n = 10), and common hepatic artery (n = 3). In the TAE group, the initial technical and clinical success rates were 100% and 90%, respectively. Two patients died of hepatic failure and multiorgan failure within 7 days after TAE. Hepatic ischemia and infarction were observed in six (33.3%, 6/18) and eight (44.4%, 8/18) patients, respectively. Hepatic abscess was observed in one patient (5.6%, 1/18) with hepatic infarction. The development of hepatic infarction was significantly associated with a serum aspartate aminotransferase (AST) level of more than 700 IU/L and a serum alanine transferase (ALT) level of more than 500 IU/L (p = 0.031 for both, Fisher exact test). In the stent-graft group, the initial technical and clinical success rates were 100% for both. Early stent thrombosis with bile duct necrosis was observed in one patient (14.3%). During the mean follow-up period of 22.8 months (range, 8-43 months), the intrahepatic arteries were patent on follow-up CT. CONCLUSION The endovascular treatments of TAE and stent-graft placement can be performed safely in most patients and are effective treatment options for extrahepatic artery hemorrhage after pancreatobiliary surgery. Moreover, stent-graft placement is better than TAE for preserving intrahepatic arterial flow without rebleeding from the extrahepatic artery.
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Affiliation(s)
- Dong Il Gwon
- Department of Radiology, Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Asanbyeongwon-gil, Songpa-gu, Seoul, Korea.
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Huisman M, van den Bosch MAAJ, Mooiweer E, Molenaar IQ, van Herwaarden JA. Endovascular treatment of a patient with an aneurysm of the proper hepatic artery and a duodenal fistula. J Vasc Surg 2011; 53:814-7. [PMID: 21211935 DOI: 10.1016/j.jvs.2010.10.089] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 10/14/2010] [Accepted: 10/15/2010] [Indexed: 10/18/2022]
Abstract
Aneurysms of the proper hepatic artery comprise a rare but potentially dangerous entity for which treatment is performed both surgically and endovascularly. Covered stents are generally used for endovascular treatment of such aneurysms. When the aneurysm is contaminated due to an enteric fistula, however, use of a covered stent is considered inappropriate. This case report describes the endovascular repair of a proper hepatic artery aneurysm using overlapping bare metal stents after the patient was surgically treated for duodenal hemorrhage.
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Affiliation(s)
- Merel Huisman
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
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Tanaka K, Ohigashi H, Takahashi H, Gotoh K, Yamada T, Miyashiro I, Yano M, Ishikawa O. Successful embolization assisted by covered stents for a pseudoaneurysm following pancreatic surgery. World J Gastrointest Surg 2010; 2:295-8. [PMID: 21160899 PMCID: PMC2999694 DOI: 10.4240/wjgs.v2.i9.295] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Revised: 07/12/2010] [Accepted: 07/19/2010] [Indexed: 02/06/2023] Open
Abstract
Delayed intra-abdominal hemorrhage after pancreatic surgery is a potentially lethal complication. Transarterial coil embolization and/or the placing of an endovascular stent are minimally invasive and effective procedures. An artery that is extensively eroded and rendered friable due to operative skeletonization or postoperative inflammation sometimes contributes to delayed intra-abdominal hemorrhage or rebleeding after coil embolization. This report presents a case of successful management of postoperative hemorrhage in a-74-year-old Japanese male. He experienced bleeding from a pseudoaneurysm of the brittle hepatic artery following total pancreatectomy. Initially the pseudoaneurysm was successfully treated with covered coronary stent-grafts, but rebleeding occurred 1 mo later due to the brittleness of the artery. Rebleeding was definitively managed by the complete packing of the stent by coil embolization. He remains stable at 18 mo following the final embolization. A stent graft can be used for protecting a brittle artery to avoid injury by coil embolization.
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Affiliation(s)
- Koji Tanaka
- Koji Tanaka, Hiroaki Ohigashi, Hidenori Takahashi, Kunihito Gotoh, Terumasa Yamada, Isao Miyashiro, Masahiko Yano, Osamu Ishikawa, Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases,1-3-3 Nakamichi, Higashinari-ku, Osaka 537-8511, Japan
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Liver abscess after common hepatic artery embolization for delayed hemorrhage following pancreaticoduodenectomy: a case report. Case Rep Med 2010; 2010:280430. [PMID: 20589213 PMCID: PMC2892662 DOI: 10.1155/2010/280430] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Revised: 04/23/2010] [Accepted: 04/26/2010] [Indexed: 12/19/2022] Open
Abstract
A 55-year-old man underwent pancreaticoduodenectomy for bile duct carcinoma in March 2009. The patient developed anastomotic leakage and had a short episode of hemorrhage from the drainage tubes with spontaneous disappearance. CT and upper endoscopy did not reveal the source of bleeding. A massive life-threatening hemorrhage occurred on the 18th postsurgical day. Emergency angiography showed a 2.7-cm pseudoaneurysm of the gastroduodenal artery stump, and hepatic artery embolization was performed. After embolization, an abscess appeared in segments 2/3 of the liver without involving the right lobe. We treated conservatively by drainage and antibiotics. During the course of therapy after embolization, the patient experienced several episodes of high fever but did not develop hepatic failure. On the 68th day after embolization, the abscess had penetrated to the lesser sac, which was immediately treated by percutaneous drainage. Anastomotic leakage was treated by continuous irrigation from the drain, for which complete resolution was achieved by the 34th day after embolization. The patient was discharged 101 days after embolization. Imaging and the clinical course demonstrate a unique mechanism of abscess formation after embolization.
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Hylton JR, Pevec WC. Successful treatment of an iatrogenic right hepatic artery pseudoaneurysm and stenosis with a stent graft. J Vasc Surg 2010; 51:1510-3. [DOI: 10.1016/j.jvs.2009.12.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2009] [Revised: 12/11/2009] [Accepted: 12/16/2009] [Indexed: 10/19/2022]
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Francisco LE, Asunción LC, Antonio CA, Ricardo RC, Manuel RP, Caridad MH. Post-traumatic hepatic artery pseudoaneurysm treated with endovascular embolization and thrombin injection. World J Hepatol 2010; 2:87-90. [PMID: 21160978 PMCID: PMC2999272 DOI: 10.4254/wjh.v2.i2.87] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2009] [Revised: 01/14/2010] [Accepted: 01/21/2010] [Indexed: 02/06/2023] Open
Abstract
Post-traumatic hepatic artery pseudoaneurysm is uncommon, appearing in approximately 1% of hepatic trauma cases. Most are extrahepatic (80%) and have a late onset. Although they are usually asymptomatic, they should always be treated becasue of the high risk of complications, especially breakage. Currently the treatment of choice is endovascular embolization with coils or the exclusion of the pseudoaneurysm using other intravascular devices. Recently there have been accounts of a treatment that combines embolization with coils and image-guided percutaneous human thrombin injection. We present a case of post-traumatic hepatic artery pseudoaneurysm that was successfully treated using this combined technique.
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Affiliation(s)
- Lloret Estañ Francisco
- Lloret Estañ Francisco, Capel Alemán Antonio, Reus Pinado Manuel, Section of Vascular and Interventional Radiology, Department of Radiology, University General Hospital Virgen de la Arrixaca. Ctra Murcia-Cartagena, 30120 El Palmar, Murcia, Spain
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18
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Ginat DT, Saad WEA, Waldman DL, Davies MG. Stent-Graft Placement for Management of Iatrogenic Hepatic Artery Branch Pseudoaneurysm After Liver Transplantation. Vasc Endovascular Surg 2009; 43:513-7. [DOI: 10.1177/1538574409334831] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pseudoaneurysm of the hepatic arteries is uncommon following liver transplantation and is usually iatrogenic. We describe a case of balloon angioplasty of a left hepatic artery stenosis complicated by an iatrogenic pseudoaneurysm. Resolution of the stenosis and the pseudoaneurysm was achieved through a combination of a bare stent and a balloon-expandable covered stent. The completion angiogram demonstrated excellent appearance of the patent hepatic arteries with exclusion of the pseudoaneurysm. No surgery was required. The graft and the patient did well for the following 6 months. Doppler ultrasound examination at 2 and 6 months postintervention revealed patent hepatic arteries and no evidence of the pseudoaneurysm.
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Affiliation(s)
- Daniel T. Ginat
- Department of Imaging Science and Interventional Radiology, University of Rochester Medical Center, Rochester, New York,
| | - Wael E. A. Saad
- Department of Imaging Science and Interventional Radiology, University of Rochester Medical Center, Rochester, New York
| | - David L. Waldman
- Department of Imaging Science and Interventional Radiology, University of Rochester Medical Center, Rochester, New York
| | - Mark G. Davies
- Department of Imaging Science and Interventional Radiology, University of Rochester Medical Center, Rochester, New York
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19
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Sasaki K, Ueda K, Nishiyama A, Yoshida K, Sako A, Sato M, Okumura M. Successful utilization of coronary covered stents to treat a common hepatic artery pseudoaneurysm secondary to pancreatic fistula after Whipple's procedure: report of a case. Surg Today 2009; 39:68-71. [PMID: 19132473 DOI: 10.1007/s00595-008-3775-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2007] [Accepted: 02/20/2008] [Indexed: 11/27/2022]
Abstract
A 73-year-old man underwent a pylorus-preserving Whipple's procedure for distal cholangiocarcinoma. His postoperative course was complicated by the formation of a pancreatic fistula, which was initially managed conservatively. On postoperative day (POD) 86, he lost 100 ml of blood from the site of the pancreatic fistula. Contrast-enhanced computed tomography (CT) showed a pseudoaneurysm, 12 mm in diameter, in the common hepatic artery. The diameter of the pseudoaneurysm increased to 15 mm on POD 89, so we implanted coronary covered stents to prevent massive bleeding from rupture and to retain hepatic arterial flow. Six days after implantation, computed tomography findings confirmed a thrombosed pseudoaneurysm as well as patent hepatic arterial flow. Follow-up CT 18 months after surgery showed patent hepatic arterial flow. There have been no signs of rebleeding or abnormal liver function.
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Affiliation(s)
- Kazuhito Sasaki
- Department of Surgery, Hitachi General Hospital, Hitachi, Ibaraki, Japan
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20
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Krokidis ME, Hatzidakis AA. Acute hemobilia after bilioplasty due to hepatic artery pseudoaneurysm: treatment with an ePTFE-covered stent. Cardiovasc Intervent Radiol 2008; 32:605-7. [PMID: 19093147 DOI: 10.1007/s00270-008-9486-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 11/19/2008] [Accepted: 11/26/2008] [Indexed: 12/25/2022]
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21
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Won YD, Ku YM, Kim KT, Kim KH, Kim JI. Successful management of a ruptured hepatic artery pseudoaneurysm with a stent-graft. Emerg Radiol 2008; 16:247-9. [PMID: 18401604 DOI: 10.1007/s10140-008-0716-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Accepted: 03/05/2008] [Indexed: 11/24/2022]
Abstract
Hepatic artery pseudoaneurysm is a rare and potentially life-threatening vascular disorder. Careful consideration and early management of this lesion can be life-saving. The authors report a case of a hepatic artery pseudoaneurysm which was successfully controlled by endovascular repair using a covered stent-graft.
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Affiliation(s)
- Yoo Dong Won
- Department of Radiology, Catholic University Medical College, Uijeongbu St. Marys Hospital, Gyeonggi-do, South Korea
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22
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Raad E, Demaria R, Rouvière P, Prudhomme M, Frapier JM, Dauzat M, Albat B. Les anévrismes des artères digestives. À propos d'un cas clinique de localisation anévrismale multiple et revue de la littérature. ACTA ACUST UNITED AC 2007; 32:216-20. [PMID: 17658233 DOI: 10.1016/j.jmv.2007.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2007] [Accepted: 06/13/2007] [Indexed: 11/29/2022]
Abstract
Visceral artery aneurysms constitute a rare vascular disease, with a risk of rupture associated to a high mortality. Often asymptomatic, they are discovered following a routine radiological examination. We present the case of a 71-year-old patient with multiple aneurysms involving the celiac trunk, the splenic artery, and the common hepatic artery. The surgical treatment consisted of an aortohepatic bypass using polytetrafluoroethylene prosthesis, after exclusion of all the aneurysms. The angiography and postoperative angioscan demonstrated the perfect patency of the prosthesis, totally excluding the aneurysms. Given the variety of presentations and the absence of precise predictive factors, there is no therapeutic consensus so far. Surgery is the first therapeutic choice. Endovascular treatment by angioembolization must be reserved for particular conditions. The purpose of this article is to propose the best therapeutic approach on the basis of evidence in the literature.
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Affiliation(s)
- E Raad
- Service de chirurgie cardiovasculaire, hôpital Arnaud-de-Villeneuve, CHU de Montpellier, 371, avenue du Doyen-G.-Giraud, 34295 Montpellier, France
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23
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Elias G, Rastellini C, Nsier H, Nazarey P, Brown M, Pahari M, Shick L, Kim D, Cicalese L. Successful long-term repair of hepatic artery pseudoaneurysm following liver transplantation with primary stent-grafting. Liver Transpl 2007; 13:1346-8. [PMID: 17763391 DOI: 10.1002/lt.21137] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Georg Elias
- Department of Surgery, University of Massachusetts, Worcester, MA 01655-0333, USA
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24
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Moukaddam H, Al-Kutoubi A. Pseudoaneurysms of Hepatic Artery Branches: Treatment with Self-expanding Stent-grafts in Two Cases. J Vasc Interv Radiol 2007; 18:897-901. [PMID: 17609450 DOI: 10.1016/j.jvir.2007.04.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Pseudoaneurysms of the hepatic artery or its branches are rare complications with several potential causes. Herein, the authors report two cases of pseudoaneurysms of hepatic artery branches, one secondary to laparoscopic surgery and the other probably due to malignancy. The pseudoaneurysms were treated with the placement of self-expanding stent-grafts. Complete and prompt occlusion of the pseudoaneurysm was achieved in both patients, with resolution of symptoms and preservation of the blood flow in the parent arterial branch at long-term follow-up.
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Affiliation(s)
- Hicham Moukaddam
- Department of Diagnostic Radiology, the American University of Beirut Medical Center, Beirut, Lebanon
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25
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Hyare H, Desigan S, Brookes JA, Guiney MJ, Lees WR. Endovascular management of major arterial hemorrhage as a complication of inflammatory pancreatic disease. J Vasc Interv Radiol 2007; 18:591-6. [PMID: 17494839 DOI: 10.1016/j.jvir.2007.02.035] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Major arterial hemorrhage is an important complication of inflammatory pancreatic disease, with an overall mortality of 37%. The present study was undertaken to evaluate the experience of a tertiary referral center for pancreaticobiliary disease in the management of major arterial complications of pancreatitis with selective visceral angiography and transcatheter arterial embolization (TAE). MATERIALS AND METHODS A 6-year retrospective analysis of all patients undergoing visceral angiography for major bleeding as a complication of pancreatitis identified 35 patients (26 male, 9 female) with a mean age of 51.2 years (range, 11-73 y). Patient demographics, history, clinical presentation, angiographic findings, angiographic treatment, and follow-up outcomes were retrospectively noted. Technical success was defined as the devascularization of a focal lesion or reduction or cessation of blood flow to a target vascular bed or organ, and clinical success was defined as the resolution of the symptoms and signs that prompted the initial embolization. RESULTS Angiography identified the site of bleeding in 54.3% of patients (n=19) and angiographic intervention was performed in 77.1% of patients (n=27). Technical success was achieved in 81.5% of those 27 patients (n=22), with overall clinical success in 80.0% (n=28). Multiple angiograms were required in 12 patients, with four demonstrating bleeding from new sites. The mortality rate was 20% (7 of 35). CONCLUSIONS In major arterial hemorrhage resulting from pancreatic inflammatory disease, visceral angiography can identify the site of bleeding and hemostasis can be achieved. Repeat angiography is often required with bleeding from new sites. The mortality rate is comparable to that associated with surgery and reflects multisystem involvement in acute severe pancreatitis.
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Affiliation(s)
- Harpreet Hyare
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, United Kingdom.
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26
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Hepatic artery aneurysm involving the proper hepatic and gastroduodenal artery treated using a gastroepiploic artery in situ bypass. J Vasc Surg 2007; 45:1069-71. [DOI: 10.1016/j.jvs.2006.12.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Accepted: 12/13/2006] [Indexed: 11/24/2022]
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27
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Fujii Y, Shimada H, Endo I, Yoshida KI, Matsuo KI, Takeda K, Ueda M, Morioka D, Tanaka K, Togo S. Management of massive arterial hemorrhage after pancreatobiliary surgery: does embolotherapy contribute to successful outcome? J Gastrointest Surg 2007; 11:432-8. [PMID: 17436126 PMCID: PMC1852380 DOI: 10.1007/s11605-006-0076-9] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Massive arterial hemorrhage is, although unusual, a life-threatening complication of major pancreatobiliary surgery. Records of 351 patients who underwent major surgery for malignant pancreatobiliary disease were reviewed in this series. Thirteen patients (3.7%) experienced massive hemorrhage after surgery. Complete hemostasis by transcatheter arterial embolization (TAE) or re-laparotomy was achieved in five patients and one patient, respectively. However, 7 of 13 cases ended in fatality, which is a 54% mortality rate. Among six survivors, one underwent selective TAE for a pseudoaneurysm of the right hepatic artery (RHA). Three patients underwent TAE proximal to the proper hepatic artery (PHA): hepatic inflow was maintained by successful TAE of the gastroduodenal artery in two and via a well-developed subphrenic artery in one. One patient had TAE of the celiac axis for a pseudoaneurysm of the splenic artery (SPA), and hepatic inflow was maintained by the arcades around the pancreatic head. One patient who experienced a pseudoaneurysm of the RHA after left hemihepatectomy successfully underwent re-laparotomy, ligation of RHA, and creation of an ileocolic arterioportal shunt. In contrast, four of seven patients with fatal outcomes experienced hepatic infarction following TAE proximal to the PHA or injury of the common hepatic artery during angiography. One patient who underwent a major hepatectomy for hilar bile duct cancer had a recurrent hemorrhage after TAE of the gastroduodenal artery and experienced hepatic failure. In the two patients with a pseudoaneurysm of the SPA or the superior mesenteric artery, an emergency re-laparotomy was required to obtain hemostasis because of worsening clinical status. Selective TAE distal to PHA or in the SPA is usually successful. TAE proximal to PHA must be restricted to cases where collateral hepatic blood flow exists. Otherwise or for a pseudoaneurysm of the superior mesenteric artery, endovascular stenting, temporary creation of an ileocolic arterioportal shunt, or vascular reconstruction by re-laparotomy is an alternative.
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Affiliation(s)
- Yoshiro Fujii
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan.
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28
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Imaging and Intervention in Acute Pancreatic Conditions. Emerg Radiol 2007. [DOI: 10.1007/978-3-540-68908-9_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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29
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Ichihara T, Sato T, Miyazawa H, Shibata S, Hashimoto M, Ishiyama K, Yamamoto Y. Stent placement is effective on both postoperative hepatic arterial pseudoaneurysm and subsequent portal vein stricture: A case report. World J Gastroenterol 2007; 13:970-2. [PMID: 17352034 PMCID: PMC4065940 DOI: 10.3748/wjg.v13.i6.970] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
To treat postoperative bleeding after hepato-pancreato-biliary surgery, interventional radiology has become essential. We report a case of coincidental pseudoaneurysm and jejunal varices that were both successfully treated by stent-grafts. After a pancreaticoduodenectomy, the patient developed a pseudoaneurysm in the hepatic artery and a stenosis in its periphery. After establishing hepatic arterial flow by placing stent-grafts over both the pseudoaneurysm and the stenosis, the pseudoaneurysm was embolized with microcoils. Nine months later, the patient developed jejunal varices caused by a severe stricture in the main trunk of the portal vein. Percutaneous transhepatic portography was performed and stent-grafts were placed over the stenotic segment. A venoplasty using stent-grafts normalized the portal blood flow and the jejunal varices vanished. Although stenosis occurred due to scarred tissues from leakage after pancreaticoduodenectomy, stent-grafts were useful for managing jejunal bleeding post-operatively.
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Affiliation(s)
- Toshiaki Ichihara
- Department of Gastroenterological Surgery, Akita University School of Medicine, 1-1-1 Hondo, Akita 010-8543, Japan.
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30
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Miller MT, Comerota AJ, Disalle R, Kaufman A, Pigott JP. Endoluminal embolization and revascularization for complicated mesenteric pseudoaneurysms: A report of two cases and a literature review. J Vasc Surg 2007; 45:381-6. [PMID: 17264020 DOI: 10.1016/j.jvs.2006.09.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2006] [Accepted: 09/04/2006] [Indexed: 11/16/2022]
Abstract
Mesenteric artery pseudoaneurysms are a rare and complex complication after abdominal trauma, surgery, or inflammatory disease. These lesions can be associated with compression or erosion into adjacent structures and may result in life-threatening hemorrhage. Traditional management has been open surgical ligation, aneurysm resection with interposition grafts, or resection or partial resection of the end organ involved. We present two cases of endovascular repair of complex mesenteric pseudoaneurysms. One patient presented with a recurrent pseudoaneurysm of the superior mesenteric artery and the second presented as recurrent gastrointestinal bleeding secondary to a traumatic celiac artery pseudoaneurysm-to-pancreatic duct fistula. A systematic review of the literature on endovascular management of mesenteric vascular disease and mesenteric pseudoaneurysms is included in this report to allow these cases to be put into proper perspective.
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31
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Kaw LL, Saeed M, Brunson M, Delaria GA, Dilley RB. Use of a stent graft for bleeding hepatic artery pseudoaneurysm following pancreaticoduodenectomy. Asian J Surg 2006; 29:283-6. [PMID: 17098663 DOI: 10.1016/s1015-9584(09)60103-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Although uncommon, bleeding following pancreaticoduodenectomy is associated with high mortality. Management generally includes surgical reexploration or, alternatively, transarterial embolization. We report the case of a 62-year-old man who presented with massive upper gastrointestinal bleeding 3 weeks after pancreaticoduodenectomy. Selective coeliac angiography revealed a large pseudoaneurysm involving the proper hepatic artery. This was treated successfully with a stent graft. There was no recurrence of bleeding at the 6-month follow-up. To our knowledge, this is the first report of stent graft repair of bleeding hepatic artery pseudoaneurysm following pancreaticoduodenectomy.
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Affiliation(s)
- Leoncio L Kaw
- Division of Cardiothoracic and Vascular Surgery, Scripps Clinic and Scripps Green Hospital, La Jolla, California, USA.
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32
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Singh CS, Giri K, Gupta R, Aladdin M, Sawhney H. Successful management of hepatic artery pseudoaneurysm complicating chronic pancreatitis by stenting. World J Gastroenterol 2006; 12:5733-4. [PMID: 17007032 PMCID: PMC4088180 DOI: 10.3748/wjg.v12.i35.5733] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
A 41-year old alchoholic male with a history of chronic pancreatitis was admitted for nausea, vomiting and weight loss. Angiogram was performed and demonstrated an aneurysmal sac with a narrow neck originating from the inferior aspect of the distal portion of the proper hepatic artery. The origin of the pseudoaneurysm was covered with a 5 mm × 2.5 cm Viabahn cover stent (Gore). A repeat angiogram showed some leak and a second stent (6 mm × 2.3 cm) was deployed and overlapped with the first stent by 3 mm. Contrast was injected and a repeat angiogram demonstrated complete exclusion of the aneurysm. A repeat computerized axial tomography (CAT) scan of the abdomen after 24 h showed successful stenting. The patient had an uneventful post-operative course.
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Affiliation(s)
- Cynthia Sudar Singh
- Wyckoff Heights Medical Center, 374 Stockholm Street, Brooklyn, NY 11237, USA.
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33
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Harvey J, Dardik H, Impeduglia T, Woo D, DeBernardis F. Endovascular management of hepatic artery pseudoaneurysm hemorrhage complicating pancreaticoduodenectomy. J Vasc Surg 2006; 43:613-7. [PMID: 16520182 DOI: 10.1016/j.jvs.2005.11.031] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2005] [Accepted: 11/12/2005] [Indexed: 12/19/2022]
Abstract
Gastrointestinal bleeding is a morbid complication of pancreaticoduodenectomy. Determining its etiology is often a daunting challenge in that both common and unusual mechanisms may be operative. Visceral artery pseudoaneurysms, although rare, must be considered in that minimally invasive means are available for effective therapy. Our recent experience with two cases highlights the importance for both general and vascular surgeons to be aware of the diagnostic and therapeutic role for early angiography and deployment of endovascular techniques to achieve a successful outcome.
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Affiliation(s)
- John Harvey
- Vascular Surgery Service, Englewood Hospital and Medical Center, Englewood, NJ 07631, USA
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34
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Christensen T, Matsuoka L, Heestand G, Palmer S, Mateo R, Genyk Y, Selby R, Sher L. Iatrogenic pseudoaneurysms of the extrahepatic arterial vasculature: management and outcome. HPB (Oxford) 2006; 8:458-64. [PMID: 18333102 PMCID: PMC2020760 DOI: 10.1080/13651820600839993] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pseudoaneurysms of the extrahepatic arterial vasculature are relatively uncommon lesions following surgery and trauma. In this report we analyze the presentation, management and outcomes of these vascular lesions. Of the related surgical procedures, the reported incidence is highest following laparoscopic cholecystectomy. We hereby analyze the literature on this subject and report our experience, specifically with extrahepatic pseudoaneurysms, drawing an important distinction from intrahepatic pseudoaneurysms. METHODS From September 1995 until July 2004, six patients, including three males and three females with a mean age of 67 years, were treated for seven extrahepatic arterial pseudoaneurysms. Patients were evaluated by endoscopy, ultrasound, computerized tomography, and angiography. Management included coil embolization or arterial ligation and/or hepatic resection. RESULTS The mean pseudoaneurysm size was 4.9-cm (range 1.0-11.0-cm) and the locations included the right hepatic artery (n = 5), inferior pancreaticoduodenal artery (n = 1), and gastroduodenal artery (n = 1). All six patients had prior surgical or percutaneous procedures. Median latency period between the original procedure and treatment of pseudoaneurysm was 17 weeks (range one month-16 years). Clinical features ranged from the dramatic presentation of hypotension secondary to intraperitoneal aneurysmal rupture to the subtle presentation of obstructive jaundice secondary to pseudoaneurysm mass effect. The range of patient presentations created diagnostic challenges, proving that accurate diagnosis is made only by early consideration of pseudoaneurysm. Management was ligation of the right hepatic artery (n = 4) and embolization of the pseudoaneurysms (n = 2). Post-treatment sequelae included liver failure requiring liver transplant (n = 1), intrahepatic biloma requiring percutaneous drainage (n = 1) and cholangitis with right hepatic duct strictures requiring right lobectomy and biliary reconstruction (n = 1). These complications followed arterial ligation, with no complications resulting from embolization. All six patients are alive and well after a mean follow-up of 53 months. CONCLUSIONS Our six patients demonstrate the diversity and unpredictability with which a pseudoaneurysm of the extrahepatic arterial vasculature may present in terms of initial symptoms, prior procedures, and the latency period between presentation and prior procedure. Through our experience and an analysis of the literature, we recommend a diagnostic and management approach for these patients.
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Affiliation(s)
- T. Christensen
- Departments of Surgery and Radiology, University of Southern California, Keck School of MedicineLos Angeles California
| | - L. Matsuoka
- Departments of Surgery and Radiology, University of Southern California, Keck School of MedicineLos Angeles California
| | - G. Heestand
- Departments of Surgery and Radiology, University of Southern California, Keck School of MedicineLos Angeles California
| | - S. Palmer
- University of Southern California, Keck School of MedicineLos Angeles California
| | - R. Mateo
- Departments of Surgery and Radiology, University of Southern California, Keck School of MedicineLos Angeles California
| | - Y. Genyk
- Departments of Surgery and Radiology, University of Southern California, Keck School of MedicineLos Angeles California
| | - R. Selby
- Departments of Surgery and Radiology, University of Southern California, Keck School of MedicineLos Angeles California
| | - L. Sher
- Departments of Surgery and Radiology, University of Southern California, Keck School of MedicineLos Angeles California
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35
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Kostro J, Zapaśnik A, Siondalski P, Sledziński Z. Hemorrhage From Ruptured Hepatic Artery Pseudoaneurysm Co-occurring With Pancreatic Head Tumor and Portal Vein Thrombosis. Surg Laparosc Endosc Percutan Tech 2005; 15:256-8. [PMID: 16082320 DOI: 10.1097/01.sle.0000174548.87048.bc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report a case of 50-year-old man with a hepatic artery pseudoaneurysm, pancreatic head tumor, and portal vein thrombosis. The patient was operated on due to acute bleeding into duodenum. The pancreatic tumor was unresectable, which is why the ruptured pseudoaneurysm was only sutured. The second therapeutic step was to protect the hepatic artery against rupture. Therefore, a stent graft and then a wall graft endoprosthesis were placed across the pseudoaneurysm neck. The final angiogram demonstrated total exclusion of the pseudoaneurysm with preservation of the arterial lumen.
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Affiliation(s)
- Justyna Kostro
- Department of General, Endocrine and Transplantation Surgery, Medical University of Gdańsk, Gdańsk, Poland
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36
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Maleux G, Pirenne J, Aerts R, Nevens F. Case report: hepatic artery pseudoaneurysm after liver transplantation: definitive treatment with a stent-graft after failed coil embolisation. Br J Radiol 2005; 78:453-6. [PMID: 15845944 DOI: 10.1259/bjr/12679319] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
A 69-year-old woman presented with massive upper gastrointestinal bleeding owing to a ruptured hepatic pseudoaneurysm located at the surgical arterial anastomosis, 2 months after combined liver and kidney transplantation. Initially the pseudoaneurysm was successfully coiled but 3 weeks later recurrence of her symptoms occurred. Hepatic angiography revealed partial reperfusion of the coiled pseudoaneurysm; definitive treatment was performed by placement of an expanded-polytetrafluoroethylene (e-PTFE) covered coronary stent-graft, completely excluding the pseudoaneurysm. Radiological follow-up studies demonstrate a patent stent-graft functioning normally.
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Affiliation(s)
- G Maleux
- Department of Radiology, University Hospitals Gasthuisberg, Herestraat, Belgium
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37
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Banga NR, Kessel DO, Patel JV, White SA, Pollard SG, Prasad KR, Toogood GJ. Endovascular Management of Arterial Conduit Pseudoaneurysm after Liver Transplantation: A Report of Two Cases. Transplantation 2005; 79:1763-5. [PMID: 15973183 DOI: 10.1097/01.tp.0000163287.14796.45] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We describe two cases of pseudoaneurysms in liver-transplant iliac artery conduits, which were successfully treated with endovascular stent grafting.
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Affiliation(s)
- Neal R Banga
- Department of Hepatobiliary Surgery and Transplantation, Leeds Teaching Hospitals/NHS Trust, St. James' University Hospital, Beckett Street, Leeds LS9 7TF, UK
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38
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Basile A, Saluzzo CM, Lupattelli T, Carbonatto P, Bottari A, Mundo E, Certo A. Nonoperative management of iatrogenic lesions of celiac branches by using transcatheter arterial embolization. Surg Laparosc Endosc Percutan Tech 2005; 14:268-75. [PMID: 15492656 DOI: 10.1097/00129689-200410000-00008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We present our experience in the nonoperative management of iatrogenic lesions of celiac branches by using transcatheter arterial embolization. We treated 6 pseudoaneurysms (5 intrahepatic and 1 of the gastroduodenal artery), 6 vessel lacerations (1 common hepatic artery, 1 right hepatic artery, 1 gastroduodenal artery, 2 pancreatoduodenal, 1 polar intrasplenic artery), 1 arterioportal fistula, and 1 arteriobiliary fistula; all the bleeding lesions were secondary to surgical, endoscopic, or interventional radiologic procedures.
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Affiliation(s)
- Antonio Basile
- Department of Radiology, Ospedale Ferrarotto, Catania, Italy.
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39
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Abstract
Visceral artery aneurysms are an uncommon form of vascular disease, yet are important to the practicing vascular surgeon because of the potential for rupture or erosion into an adjacent viscus, resulting in life-threatening hemorrhage. Many visceral artery aneurysms still present with rupture, which often results in the death of the patient. An aggressive approach to the diagnosis and management of these aneurysms is warranted. The treatment of visceral artery aneurysms has significantly evolved over the past decade. Open surgical repair has been the standard method of treatment, usually by aneurysm resection or simple ligation. Open surgical repair is durable with excellent long-term results, but is accompanied by the morbidity and mortality of a major abdominal operation. Over the past decade, catheter-based treatments with coil embolization and placement of stent grafts have emerged as promising therapies to treat visceral artery aneurysms. These have provided safe and effective short-term results and should be preferentially used in selected patients at high surgical risk.
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Affiliation(s)
- Jade S Hiramoto
- University of California, 400 Parnassus Avenue, A-581, Box 0222, San Francisco, CA 94143-0222, USA.
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40
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Muraoka N, Uematsu H, Kinoshita K, Takeda T, Morita N, Matsunami H, Itoh H. Covered Coronary Stent Graft in the Treatment of Hepatic Artery Pseudoaneurysm after Liver Transplantation. J Vasc Interv Radiol 2005; 16:300-2. [PMID: 15713937 DOI: 10.1097/01.rvi.0000145226.08478.28] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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41
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Tessier DJ, Fowl RJ, Stone WM, McKusick MA, Abbas MA, Sarr MG, Nagorney DM, Cherry KJ, Gloviczki P. Iatrogenic hepatic artery pseudoaneurysms: an uncommon complication after hepatic, biliary, and pancreatic procedures. Ann Vasc Surg 2003; 17:663-9. [PMID: 14564553 DOI: 10.1007/s10016-003-0075-1] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hepatic artery pseudoaneurysms are uncommon but potentially lethal complications of hepatic, biliary, and pancreatic interventions. To enhance our knowledge about these pseudoaneurysms, we reviewed our institution's experience with the management of these lesions. We reviewed the literature on 136 cases of hepatic artery pseudoaneurysms as well as our experience with 17 patients (excluding patients who were post-transplantation or had suffered abdominal trauma). The causes, pathogenesis, and clinical features were analyzed. Ten women and seven men developed hepatic artery pseudoaneurysms after undergoing hepatic (65%), biliary (30%), or pancreatic procedures (5%). The mean time between initial intervention and diagnosis was 5.7 months (range 7 days-38 months). Rupture occurred in 13 patients (76%). Mean pseudoaneurysm size was 1.9 cm (range 0.7-4 cm). Embolization was successful in 12 of 14 patients (86%). Four patients (24%), including the two who failed embolization, required operative intervention. Postoperative mortality was 25% while postembolization mortality was 14%. One patient was observed, and the aneurysm thrombosed at 72 months follow-up. Mean follow-up was 48 months (range 1-184 months) for 13 of the 14 survivors (93%) (1 patient was lost to follow-up) without any clinical sequela. Hepatic artery pseudoaneurysms are rare. Rupture is common and occurred in 76% of patients. For both ruptured and nonruptured cases angiography with embolization of the pseudoaneurysm is safe and effective. Operative intervention should be reserved for patients for whom embolization fails or for whom it is not feasible.
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Affiliation(s)
- Deron J Tessier
- Department of Surgery, Division of Vascular Surgery, Mayo Clinic Scottsdale, Scottsdale, AZ 85259, USA
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42
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Patel JV, Weston MJ, Kessel DO, Prasad R, Toogood GJ, Robertson I. Hepatic artery pseudoaneurysm after liver transplantation: treatment with percutaneous thrombin injection. Transplantation 2003; 75:1755-57. [PMID: 12777870 DOI: 10.1097/01.tp.0000063936.94587.10] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pseudoaneurysms of the hepatic artery are a rare complication of liver transplantation. Early diagnosis and treatment are essential to avoid life-threatening hemorrhage. Conventional treatment consists of surgical resection and vascular reconstruction or transarterial coil embolization. More recently, percutaneous thrombin injection has been successfully used in the treatment of femoral artery pseudoaneurysms. We describe a 70-year-old woman who had a hepatic artery pseudoaneurysm after orthotopic liver transplantation, which was successfully treated by percutaneous thrombin injection.
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Affiliation(s)
- Jai V Patel
- Department of Radiology, The Leeds Teaching Hospitals NHS Trust, St. James's University Hospital, Leeds, UK.
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