Endovascular approach of hepatic artery pseudoaneurysm after Whipple procedure: Case report and literature review

Abstract

Introduction and importance

Pseudoaneurysms after pancreatoduodenectomy are an uncommon complication, but they are associated with life-threatening outcomes in up to 50 % due to the development of postoperative bleeding. They usually result as a consequence of local inflammatory processes, such as pancreatic fistula or intra-abdominal collections. The cornerstones of treatment are thus intraoperative management and early identification of the complication.

Case presentation

We present a 62-year-old female patient in postoperative pancreatoduodenectomy due to a periampullary tumor, that presented upper gastrointestinal bleeding which required multiple transfusions. During hospitalization, the patient presented a refractory hypovolemic shock to conservative measures. It was documented intra-abdominal hemorrhage due to hepatic artery pseudoaneurysm that required endovascular management with common hepatic artery embolization, with successful bleeding control.

Clinical discussion

Pseudoaneurysms are the result of tissue damage after surgery. The usual clinical presentation is upper gastrointestinal bleeding unresponsive to conservative treatment that results in hemodynamic instability due to hypovolemic shock. Prevention is currently based on preoperative and intraoperative measures such as nutritional repletion, vessel protection, adequate hemostasis, and prevention and treatment of pancreatic leak and abdominal infection. Once documented, treatment can be endovascular or surgical.

Conclusion

The formation of pseudoaneurysms after pancreaticoduodenectomy is an uncommon and challenging complication. Early diagnosis, risk factor detection and a combined multidisciplinary approach lead to better outcomes, avoiding open surgical procedures that can increase morbidity and mortality rates.

Highlights

• •Intraoperative factors have been described to reduce the occurrence of postoperative pseudoaneurysms.
• •Endovascular management is currently the management of choice due to the reduction in morbidity and mortality.
• •The multidisciplinary approach, early interventional radiology, and surgical procedures are the cornerstone of management in reducing rates of morbimortality

1. Introduction

Pancreatoduodenectomy (PD) is the standard surgical procedure for treating periampullary tumors [1], it has been historically considered to be the most complex and promising procedure that involves extensive resection, and vascular divestment that could lead to exposure of the vascular wall and increase the risk of tissue irritation [1], [2]. Although the mortality of PD has decreased (0 %–5 %) [3], its morbidity remains high (20 %–40 %) [3], [4]. The most common complications after a PD are delayed gastric emptying, pancreatic fistula, and intra-abdominal abscess [4], [5]. Hemorrhage after PD is a less common complication that can occur in the early or late postoperative curse [6], increasing morbimortality rates.

One of the most common causes of postoperative bleeding is pseudoaneurysms, secondary to the local inflammatory process [2], [3], [5]. The most common locations are in the gastroduodenal artery, followed by the hepatic artery [3], [6]. It usually occurs after acute/chronic severe pancreatitis, blunt abdominal trauma, or surgical treatment [3], [5]. Since pseudoaneurysm may lead to sudden life-threatening hemorrhage, early diagnosis, and active treatment are required, however, there is a high rate of misdiagnosis that leads to late treatment, increased morbidity, and mortality. [4]. Surgical treatment used to be the mainstream approach for managing visceral aneurysms, and in recent years, the endovascular approach has become the preferred treatment for such lesions [4], [5]. In this article, we present a proper hepatic artery pseudoaneurysm treated with endovascular selective catheterization [6]. We present the next case after ethical and institutional approval, previous informed consent filled, and following SCARE guidelines [7].

2. Presentation of the case

After ethical and institutional approval, previous informed consent filled, and following SCARE guidelines [7], we present a 62-year-old female patient diagnosed with an obstructive periampullary tumor. The patient was taken to an open PD. The procedure lasted approximately 300 min, with intraoperative bleeding of 400 cc, a mass with a diameter of 2.5 cm was identified in the ampullary region extending onto the pancreatic tissue. The histopathological report described an ulcerated, moderately differentiated, ampullary adenocarcinoma.

During the postoperative period, the patient presented poorly modulated abdominal pain associated with high debt through Blake's drainage, raising clinical suspicion of a biochemical leak. Therefore, an amylase test of Blake's drainage production was performed, and a positive value was obtained, proving our initial hypothesis.

The patient presented a stationary evolution, with evident signs of a systemic inflammatory response, thus antibiotic management was started and an abdominal CT was requested. A 9-millimeter collection adjacent to the major curvature of the stomach was evidenced and drained, without complications.

20 days after the procedure, the patient presented multiple episodes of upper gastrointestinal bleeding with hematemesis and melenas, with a 2 g/dL decrease in hemoglobin levels. The hypovolemic shock was documented with multiple blood transfusion requirements. An intensive care unit stay was required for initial stabilization, however, the patient remained unstable without evidence of the source of bleeding. The patient was taken to an emergency endoscopy that showed a marginal ulcer of the esophagojejunostomy, Forrest III, where an endoscopic treatment with adrenaline was performed, without success in bleeding control.

Due to the hemodynamic deterioration of the patient, an emergency angiography was performed (Fig. 1), where a pseudoaneurysm of the proper hepatic artery was identified as the source of bleeding. Selective catheterization was performed with two Boston interlock coils, one of 14 × 50 mm and 14 × 30 mm, respectively, completing the occlusion; additionally, cyanoacrylate with lipidol was injected, achieving complete exclusion of the defect, to finally perform a hemostatic seal.

Fig. 1.

Endovascular approach.

After endovascular management, gastrointestinal bleeding was controlled with no evidence of hemorrhage or hemoglobin level decrease after 96 h of the procedure, as well there is no evidence of liver ischemia or post-embolization bacteremia; and the patient recovered successfully and no complications were observed after 30, 60, and 90 days.

3. Discussion

Postoperative PD hemorrhage can be classified as early or late [1], [3]. Early bleeding refers to bleeding <24 h post-PD [2], and delayed post pancreatoduodenectomy bleeding refers to bleeding al >24 h to 7 days post-PD [1], [3], [4], our patient debuted with a late clinical presentation.

The incidence of postoperative PD hemorrhage related to pseudoaneurysm has been estimated to be 4 % to 16 % and the mortality rate is up to 50 % in the following month [5]. Among all complications after PD, postoperative pancreatic fistula (POPF) is the most important risk factor for postoperative hemorrhage, due to the ability to cause arterial rupture and bleeding [6], [7]. The pancreatic fistula in the aforementioned case was considered type B increasing the imminent risk of rupture.

The POPF usually leads to sepsis from intestinal and biliary bacteria. It is the local sepsis that weakens the vessel wall and allows the extravasation of the blood, leading to the formation of a fibrotic capsule, followed by a rupture of the pseudoaneurysm [2], [8]. The gastroduodenal artery is the most often involved, behind the hepatic, splenic, and intestinal branches of the superior mesenteric artery [3], [8], [9].

Other risk factors include age, sex, body mass index (BMI), comorbidities, history of abdominal surgery, operative time, postoperative biliary drainage, lymph node resection, reconstruction of the blood vessels, and the pancreatic anastomosis type [6], [8], [9]. Electrotome and ultrasound scalpel may damage adventitia and result in pseudoaneurysm during lymph node removal [5], [9] also in the tissue dissection, it is inevitable to clamp the tissue, resulting in arterial and venous damage [4], [8].

In our case, the surgery involved a wide dissection, resulting in vascular tissue exposure, associated with a pancreatic fistula diagnosed in the postoperative period, leading to tissue erosion, which is directly related to the development of a pseudoaneurysm.

The usual clinical presentation includes abdominal pain associated with distension and evidence of upper gastrointestinal bleeding such as hematemesis or melenas once the pseudoaneurysm rupture has occurred [6], [9]. Additionally, patients can develop signs of peritoneal irritation as a result of the hemoperitoneum produced by the rupture [8].

Initial studies in patients presenting with gastrointestinal bleeding are endoscopy and colonoscopy. However, they may not demonstrate active bleeding or the source of the bleeding [5], [9] (10). The preferred method for diagnosis is CT angiography, with a sensitivity rate of 95 % [7], [8], however, its performance depends on the patient's clinical condition and hemodynamic stability [6], [9] (10).

Selective celiac angiography is the gold standard for the diagnosis and treatment of bleeding and pseudoaneurysm post-PD [6], [9], as it determines the exact location of the lesion, and its size, allowing immediate treatment [6], [8] (10). It is important to consider that a location far from the main branch, or a slow flow rate of the contrast medium, in addition to the superimposition of intestinal gas, moving artifacts, and other possible interferences may result in a false negative result in the angiography, therefore the multidisciplinary approach is essential [1], [4], [8].

Once the diagnosis is established, an effective treatment should be offered as soon as possible. Management of bleeding and post-PD aneurysms can be either surgical or endovascular [5], [8]. The aim of the surgical procedure is to identify the greater artery and ligate or clamp it (10). If POPF is identified, pancreaticojejunal anastomosis should be performed simultaneously. In endovascular management, embolization, stent-graft implantation, stent-assisted coiling, and balloon remodeling techniques are preferred [9] (10).

The embolization method depends on the location, size, and diameter of the major artery [7], [9], additionally, the presence of collateral branches may determine the choice [8], [9]. Coils are the method of preference and the most used, several techniques involve them [3], [7], [9].

The exclusion technique is recommended for embolization in emergencies [7], [9]; embolization and exclusion with coils reduce the occurrence of adverse events. Proximal embolization is exclusive for the treatment of small-branch pseudoaneurysms; however, the choice depends on medical criteria, intrinsic characteristics of the patient, blood pressure, and the use of vasoconstrictor drugs.

Endovascular management has been shown to reduce patient mortality by up to 30 % [6], [8], [9], and its effectiveness for hemorrhage control reaches up to 95 % [8], [9], however, complications have been documented, including uncontrolled bleeding, failed coil embolization attempts, liver failure following embolization of the hepatic artery, liver abscesses, hepatic infarction without liver failure, and post embolization bacteremia in up to 20 % of cases (10, 11).

In our case, the patient was taken to endovascular management with selective catheterization of the common hepatic artery with interlock coils, with successful management of bleeding and adequate radiological control with the flow to the celiac trunk, superior mesenteric artery, and splenic artery. As well, complications after an embolization were ruled out.

4. Conclusion

Complications after PD can occur in at least 30 % [1], [5], [8] of the patients. Late hemorrhage is an uncommon complication related to pseudoaneurysm, due to the inflammatory local process, therefore in the presence of postoperative upper GI bleeding, the possibility of arterial pseudoaneurysm should be ruled out. [8], [9]. Its early diagnosis and treatment are still challenging. Angiography is the gold standard to determine the localization of the lesion, and endovascular management is the management of preference [6], [9]. The multidisciplinary approach, early interventional radiology, and surgical procedures are the cornerstone of management in reducing rates of morbimortality [9].

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical approval was provided by the authors' institution.

Funding

Authors do not declare any financial conflict.

Author contribution

DA: Manuscript writing, critical revision of the manuscript, data analysis. JFS: Data analysis, manuscript writing. JG: Data analysis, manuscript writing. CR: Manuscript writing, critical revision of the manuscript, data analysis. DC: Manuscript writing, critical revision of the manuscript, data analysis. JCSO: Manuscript writing, critical revision of the manuscript, data analysis.

Guarantor

Daniela Ayala Olaya

Research registration number

Do not apply.

Conflict of interest statement

Authors do not declare any conflict of interest.