Ann Hepatobiliary Pancreat Surg.  2016 Nov;20(4):204-210. 10.14701/ahbps.2016.20.4.204.

Pseudoaneurysm of the splenic artery - an uncommon cause of delayed hemorrhage after pancreaticoduodenectomy

• Dumitru R
• Carbunaru
• Grasu M
• Toma M
• Ionescu M
• Dumitrascu T

• KMID: 2362473
• DOI: http://doi.org/10.14701/ahbps.2016.20.4.204

Abstract

Delayed post-pancreatectomy hemorrhage (PPH) is a relatively uncommon, but feared, complication after pancreaticoduodenectomy (PD). A splenic artery pseudoaneurysm is a rare cause of delayed PPH after a PD. This paper describes the case of a patient with PD used to treat a distal bile duct cholangiocarcinoma complicated with a clinically significant pancreatic fistula and secondary intraabdominal abscess. Computed tomography-guided drainage of the abscess was performed with an apparently favourable outcome; the patient was discharged on postoperative day (POD) 35 and the abdominal drains were removed on POD 50. On POD 80, the patient was readmitted for a severe digestive hemorrhage. Computed tomography revealed a pseudoaneurysm of the splenic artery with a subsequent hematoma formation. Immediately, an angiography was performed and coils were successfully mounted. This case illustrates the rare possibility of the development of a splenic artery pseudoaneurysm with severe delayed PPH after PD complicated with a clinically significant pancreatic fistula, even after the patient was discharged from the hospital. An interventional radiology approach represents the first treatment option in hemodynamically stable patients with high success rates.

Keyword

Pancreaticoduodenectomy; Pancreatic fistula; Delayed hemorrhage; Splenic artery pseudoaneurysm; Interventional angiography

MeSH Terms

Abscess
Aneurysm, False*
Angiography
Bile Ducts
Cholangiocarcinoma
Drainage
Hematoma
Hemorrhage*
Humans
Pancreatic Fistula
Pancreaticoduodenectomy*
Radiology, Interventional
Splenic Artery*

Figure

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  Fig. 1 Abdominal contrast-enhanced computed tomography in the venous phase performed on post-operative day (POD) 7 (A) frontal slice showing partial thrombosis of the superior mesenteric vein (open white arrow); (B) axial slice showing peripancreatic fluids and minor non-enhancing areas in the remnant pancreas (open white arrow).

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  Fig. 2 Abdominal contrast-enhanced computed tomography axial slice in the venous phase performed on POD 19 showing thrombosis of the proximal splenic vein (open white arrow) and distal peripancreatic fluids (filled white arrow).

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  Fig. 3 Abdominal contrast-enhanced computed tomography axial slice in the venous phase performed on POD 30 showing (A) a large peripancreatic distal collection with gas inside suggesting the formation of a peripancreatic abscess (open white arrow); (B) the percutaneous drainage catheter (filled white arrow) toward the peripancreatic abscess (open white arrow); (C) the drainage catheter (filled white arrow) successfully inserted in the peripancreatic abscess.

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  Fig. 4 Abdominal contrast-enhanced computed tomography axial slice in the arterial phase performed on POD 50 showing complete regression of the peripancreatic abscess (open white arrow - the drainage catheter).

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  Fig. 5 Abdominal contrast-enhanced computed tomography in the arterial phase performed on POD 84 (A) axial slice showing a 3.2 cm×1.8 cm-sized pseudoaneurysm (filled black arrow) of the splenic artery (open black arrow); (B) axial slice showing a high-density lesion indicating a subsequent 9.5 cm×4.3 cm-sized hematoma formation (filled white arrow); (C) frontal slice with reconstruction showing the pseudoaneurysm (filled black arrow) of the splenic artery (open black arrow); (D) axial slice showing extravasations of contrast agent suggesting active bleeding in the distal part of the splenic artery (open black arrow).

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  Fig. 6 (A) Digital subtraction angiogram obtained through the celiac trunk showing the splenic artery (open black arrow) with the pseudoaneurysm (filled black arrow) (C - the catheter positioned at the celiac ostium); (B) angiography showing pushable coils (open black arrow) on either side of a false aneurysm of the splenic artery, with no extravasations of contrast agent (C - the catheter positioned at the proximal part of the splenic artery).

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  Fig. 7 Check-up after embolization with an abdominal contrast-enhanced computed tomography axial slice in the arterial phase showing (A) on day 4 after the interventional radiology procedure the disappearance of the splenic artery pseudoaneurysm, presence of tiny arciform images due to the metal artifacts created by coils (open black arrow), and several ischemic areas within the spleen (filled black arrow); (B) on day 9 after the interventional radiology procedure the presence of tiny arciform images due to the metal artifacts created by coils (open black arrow) and stationary ischemic areas within the spleen (filled black arrow), without tendency of modification or abscesses; (C) on day 9 after the interventional radiology procedure the complete remission of the peripancreatic hematoma (filled white arrow).

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