Ann Hepatobiliary Pancreat Surg.  2020 Feb;24(1):114-118. 10.14701/ahbps.2020.24.1.114.

Successful treatment of visceral pseudoaneurysm after pancreatectomy using flow-diverting stent device

• Giorgakis
• Chong B
• Oklu R
• Jaroszewski DE
• Knuttinen
• Mathur AK

• KMID: 2471200
• DOI: http://doi.org/10.14701/ahbps.2020.24.1.114

Abstract

Aim of the study is the description of the successful management of gastroepiploic artery pseudoaneurysm with preservation of parent vessels using flow-diversion technology. The present report describes the application of a flow-diversion Pipelineâ„¢ Flex device for occlusion of a sidewall bleeding pseudoaneurysm on a patient who was status-post sub-total pancreatectomy and remote esophagectomy with a gastric conduit. The pseudoaneurysm was on the solitary vessel supplying the patient's conduit. Use of flow diversion technology excluded the sidewall pseudoaneurysm while maintaining gastric conduit perfusion. In our case, the application of flow diversion technology allowed the preservation of patency of the main arterial supply to the gastric conduit on a post-esophagectomy patient; loss of the right gastroepiploic artery in that case would had been otherwise catastrophic. Flow-diversion technology can be considered for the treatment of pseudoaneurysms post-pancreatic resections, especially when there is no other surgical or endovascular treatment option.

Keyword

Gastroepiploic artery pseudoaneurysm; Flow diverter therapy; Endovascular repair visceral aneurysm; Post-pancreatectomy pseudoaneurysm

MeSH Terms

Aneurysm, False*
Esophagectomy
Gastroepiploic Artery
Hemorrhage
Humans
Pancreatectomy*
Parents
Perfusion
Stents*

Figure

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  Fig. 1 3-dimensional reconstruction of superior mesenteric artery (SMA) arteriography. The angiogram revealed a sidewall type pseudoaneurysm arising from the 1st segmental artery off of the SMA and the inferior pancreaticoduodenal artery (IPDA) anastomosing with the gastroduodenal artery and the gastroepiploic artery. The pseudoaneurysm dimensions were 5.3×7.4 mm.

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  Fig. 2 Graph representation of the arterial supply of the gastric conduit. The gastric conduit was completely dependent on blood flow from the right gastroepiploic artery. The branch giving rise to the pseudoaneurysm was observed to be the only vessel supplying the gastric conduit.

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  Fig. 3 Superior mesenteric artery angiogram. After catheterization of the SMA, a microcatheter was advanced to the 1st order SMA branch. Injection of contrast revealed the sidewall pseudoaneurysm. This SMA branch appeared to be supplying the only vessel shown to be supplying the gastric conduit.

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  Fig. 4 Control SMA angiography post deployment of flow-diverting devices. Control SMA angiography after positioning of the first device (3 mm×35 mm Pipeline Flex flow diverter) demonstrated optimal device position but persistent vigorous filling of the pseudoaneurysm. Deployment of a second Pipeline device (3 mm×20 mm) inside the first device in a “telescoping” fashion demonstrated excellent stasis of contrast inside the aneurysm.

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