J Korean Soc Radiol.  2012 Mar;66(3):247-254. 10.3348/jksr.2012.66.3.247.

Miscellaneous Endovascular Treatment of Ruptured Hepatic Artery Pseudoaneurysms after Pylorus Preserving Pancreaticoduodenectomy

• Kang UR
• Kim YH
• Kim SH
• Ahn EJ
• Lee YH

• KMID: 1439421
• DOI: http://doi.org/10.3348/jksr.2012.66.3.247

Abstract

PURPOSE
To assess the feasibility and safety of the endovascular treatment of ruptured hepatic artery pseudoaneurysms after pylorus preserving pancreaticoduodenectomy (PPPD).
MATERIALS AND METHODS
Thirteen patients with hepatic artery pseudoaneurysm after PPPD were enrolled. Various endovascular techniques were used depending on the sites and morphologies of the pseudoaneurysms. Five cases were treated by coil embolization, five with stent-graft, one by thrombin injection and coil embolization, one with stent-graft and coil embolization, and one with N-butyl cyanoacrylate (NBCA) injection. Computed tomography scans and liver function test were performed after the procedures.
RESULTS
Pseudoaneurysm exclusion and bleeding cessation was achieved in all patients. In four patients that underwent coil or NBCA embolization of the hepatic artery, aspartate transaminase (AST) and alanine transaminase (ALT) were markedly elevated. Two of these four patients with narrowing of the portal vein due to surrounding hematoma died of hepatic infarction or hepatic abscess. In other nine patients, AST and ALT were unchanged. In the 11 surviving patients, normal hepatic function and complete pseudoaneurysm disappearance were achieved during follow-up.
CONCLUSION
Endovascular treatment of ruptured hepatic artery pseudoaneurysms can be considered as a feasible and safe method. However, complete occlusion of the hepatic artery with coils should be avoided in patients with inadequate portal flow.

MeSH Terms

Alanine Transaminase
Aneurysm, False
Aspartate Aminotransferases
Cyanoacrylates
Endovascular Procedures
Hematoma
Hemorrhage
Hepatic Artery
Humans
Infarction
Liver Abscess
Liver Function Tests
Pancreaticoduodenectomy
Portal Vein
Pylorus
Thrombin
Alanine Transaminase
Aspartate Aminotransferases
Cyanoacrylates
Thrombin

Reference

1. Choi SH, Moon HJ, Heo JS, Joh JW, Kim YI. Delayed hemorrhage after pancreaticoduodenectomy. J Am Coll Surg. 2004. 199:186–191.

2. Harvey J, Dardik H, Impeduglia T, Woo D, DeBernardis F. Endovascular management of hepatic artery pseudoaneurysm hemorrhage complicating pancreaticoduodenectomy. J Vasc Surg. 2006. 43:613–617.

3. Laganà D, Carrafiello G, Mangini M, Dionigi G, Caronno R, Castelli P, et al. Multimodal approach to endovascular treatment of visceral artery aneurysms and pseudoaneurysms. Eur J Radiol. 2006. 59:104–111.

4. Makowiec F, Riediger H, Euringer W, Uhl M, Hopt UT, Adam U. Management of delayed visceral arterial bleeding after pancreatic head resection. J Gastrointest Surg. 2005. 9:1293–1299.

5. Santoro R, Carlini M, Carboni F, Nicolas C, Santoro E. Delayed massive arterial hemorrhage after pancreaticoduodenectomy for cancer. Management of a life-threatening complication. Hepatogastroenterology. 2003. 50:2199–2204.

6. Saad NE, Saad WE, Davies MG, Waldman DL, Fultz PJ, Rubens DJ. Pseudoaneurysms and the role of minimally invasive techniques in their management. Radiographics. 2005. 25:Suppl 1. S173–S189.

7. Tessier DJ, Fowl RJ, Stone WM, McKusick MA, Abbas MA, Sarr MG, et al. Iatrogenic hepatic artery pseudoaneurysms: an uncommon complication after hepatic, biliary, and pancreatic procedures. Ann Vasc Surg. 2003. 17:663–669.

8. Otah E, Cushin BJ, Rozenblit GN, Neff R, Otah KE, Cooperman AM. Visceral artery pseudoaneurysms following pancreatoduodenectomy. Arch Surg. 2002. 137:55–59.

9. Kasirajan K, Greenberg RK, Clair D, Ouriel K. Endovascular management of visceral artery aneurysm. J Endovasc Ther. 2001. 8:150–155.

10. Baker KS, Tisnado J, Cho SR, Beachley MC. Splanchnic artery aneurysms and pseudoaneurysms: transcatheter embolization. Radiology. 1987. 163:135–139.

11. Reber PU, Baer HU, Patel AG, Wildi S, Triller J, Büchler MW. Superselective microcoil embolization: treatment of choice in high-risk patients with extrahepatic pseudoaneurysms of the hepatic arteries. J Am Coll Surg. 1998. 186:325–330.

12. Yamakado K, Nakatsuka A, Tanaka N, Takano K, Matsumura K, Takeda K. Transcatheter arterial embolization of ruptured pseudoaneurysms with coils and n-butyl cyanoacrylate. J Vasc Interv Radiol. 2000. 11:66–72.

13. Parildar M, Oran I, Memis A. Embolization of visceral pseudoaneurysms with platinum coils and N-butyl cyanoacrylate. Abdom Imaging. 2003. 28:36–40.

14. Schoder M, Cejna M, Längle F, Hittmaier K, Lammer J. Glue embolization of a ruptured celiac trunk pseudoaneurysm via the gastroduodenal artery. Eur Radiol. 2000. 10:1335–1337.

15. Teramoto K, Kawamura T, Takamatsu S, Noguchi N, Arii S. A case of hepatic artery embolization and partial arterialization of the portal vein for intraperitoneal, hemorrhage after a pancreaticoduodenectomy. Hepatogastroenterology. 2003. 50:1217–1219.

16. Bürger T, Halloul Z, Meyer F, Grote R, Lippert H. Emergency stent-graft repair of a ruptured hepatic artery secondary to local postoperative peritonitis. J Endovasc Ther. 2000. 7:324–327.

17. Larson RA, Solomon J, Carpenter JP. Stent graft repair of visceral artery aneurysms. J Vasc Surg. 2002. 36:1260–1263.

18. Carrafiello G, Laganà D, Recaldini C, Mangini M, Lumia D, Giorgianni A, et al. Combined percutaneous thrombin injection and endovascular treatment of gastroduodenal artery pseudoaneurysm (PAGD): case report. Emerg Radiol. 2007. 14:51–54.

19. Benjaminov O, Atri M. Percutaneous thrombin injection for treatment of an intrarenal pseudoaneurysm. AJR Am J Roentgenol. 2002. 178:364–366.

20. Kang SS, Labropoulos N, Mansour MA, Michelini M, Filliung D, Baubly MP, et al. Expanded indications for ultrasound-guided thrombin injection of pseudoaneurysms. J Vasc Surg. 2000. 31:289–298.