Clinical study
Transcatheter Arterial Embolization of Gastroduodenal Artery Stump Pseudoaneurysms after Pancreaticoduodenectomy: Safety and Efficacy of Two Embolization Techniques

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Purpose

To evaluate the safety and efficacy of two transcatheter arterial embolization (TAE) techniques used to treat pseudoaneurysms of the gastroduodenal artery (GDA) stump after pancreaticoduodenectomy.

Materials and Methods

Between March 2003 and March 2008, 16 patients were treated with TAE for pseudoaneurysms of the GDA stump after pancreaticoduodenectomy. Two embolization techniques were employed: endovascular trapping of the hepatic artery (embolization of the hepatic artery proximal and distal to GDA stump; group A; n = 13) and selective embolization of the GDA stump and/or pseudoaneurysm sparing hepatic arterial flow (group B; n = 3). Technical success, initial hemostasis, recurrence of bleeding, and complications were compared between the two groups retrospectively.

Results

All TAE procedures were technically successful and immediate hemostasis was achieved in all patients. There was no recurrent bleeding in group A; however, all three patients in group B experienced recurrent bleeding after initial hemostasis (P = .002), and these patients required subsequent embolization with the endovascular trapping technique. Two patients died of multiple organ failure (one patient in each group) despite successful hemostasis. Three patients experienced subsegmental (n = 1, group A) and multisegmental (n = 2, group B) liver infarction, which were successfully managed with conservative treatment. There was a higher incidence of major complications in group B (15.4% vs 100%; P = .018).

Conclusions

Endovascular trapping of the hepatic artery is a safe and effective treatment of pseudoaneurysms of the GDA stump after pancreaticoduodenectomy. Hepatic ischemic complications are not rare, but can be conservatively managed. Selective embolization of the GDA stump and/or pseudoaneurysm is frequently associated with recurrence of bleeding, which eventually leads to major complications.

Section snippets

Patients

Between March 2003 and March 2008, a total of 192 patients underwent pancreaticoduodenectomy at a single institution. By searching our surgical database, 20 patients were identified who underwent TAE for treatment of delayed massive hemorrhage (> 24 h after the index operation, decrease of hemoglobin level by > 3 g/dL) (3). The site of bleeding included GDA stump (n = 16), gastrojejunal anastomosis (n = 2), and jejunal artery (n = 2). The 16 patients with GDA stump bleeding were included in

Results

All TAE procedures were technically successful and initial hemostasis was achieved in all patients in both groups. In group A, intrahepatic arterial flow through the common hepatic artery was completely interrupted. However, maintenance of hepatic arterial flow was verified on postembolic angiograms in 10 patients (76.9%). The major collateral routes were the right inferior phrenic artery (n = 2; Fig 1), left gastric artery (n = 3; Fig 2), and both (n = 1). In four patients with hepatic

Discussion

There has been a continued debate in the literature regarding the optimal management of delayed massive hemorrhage after pancreaticoduodenectomy (5, 6, 7). Immediate angiography to identify the site of bleeding with subsequent treatment by radiologic intervention has been the first approach for the past decade (11, 16, 17). However, several recent investigations insisted that surgery should be a primary treatment in massive bleeding and the application of TAE should be limited to patients in

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This work was supported by a Korea Research Foundation Grant funded by the Korean Government (KRF-2005-041-E00302). The abstract of this work was presented at the European Congress of Radiology 2009, in Vienna, Austria. None of the authors have identified a conflict of interest.

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