Clinical Study
Endovascular Treatment of Hepatic Artery Pseudoaneurysm after Pancreaticoduodenectomy: Risk Factors Associated with Mortality and Complications

https://doi.org/10.1016/j.jvir.2016.04.004Get rights and content

Abstract

Purpose

To evaluate risk factors predicting death and complications of primary therapy for hepatic and gastric duodenal artery pseudoaneurysms following endovascular treatment (EVT) after pancreaticoduodenectomy (PD).

Materials and Methods

Between April 2004 and December 2014, 28 patients (mean age, 64.7 y) with post-PD hemorrhage underwent EVT. Prevention of hepatic artery blockage via stents or side-holed catheter grafts was stratified in cases without a replaced hepatic artery. Mortality and major hepatic complications following EVT were evaluated according to age; sex; surgery–EVT interval; presence of portal vein stenosis, shock, and coagulopathy at EVT onset; and post-EVT angiographic findings.

Results

All hemorrhages were successfully treated with microcoils (n = 17; 61%), covered stents (n = 1; 3%), bare stent–assisted coil embolization (n = 5; 18%), or catheter grafts with coil embolization (n = 5; 18%). Hepatic arterial flow was observed after EVT in 18 patients (64%). Mortality and major hepatic complication rates were 28.6% and 32.1%, respectively. Hemorrhagic shock and coagulopathy at EVT onset (n = 8 each; odds ratio [OR], 27; 95% confidence interval [CI], 3.1–235.7; P < .01) were significantly associated with mortality. Coagulopathy at EVT onset (adjusted OR [aOR], 48.1; 95% CI, 3.2–2,931), portal vein stenosis (n = 16; aOR, 16.9; 95% CI, 1.3–721.9), and no visualization of hepatopetal flow through the hepatic arteries (n = 10; aOR, 29.5; 95% CI, 2.1–1,477) were significantly associated with major hepatic complications.

Conclusions

EVT should be performed as soon as possible before the development of shock or coagulopathy. Hepatic arterial flow visualization decreases major hepatic complications.

Section snippets

Patients

Forty consecutive patients who underwent EVT for post-PD hemorrhage or pseudoaneurysm between April 2004 and December 2014 were retrospectively reviewed. This study was approved by the institutional review board, and the need for informed consent from patients was waived. Twenty-eight patients who underwent post-PD EVT of the CHA and its distal arteries were included in the final analysis. Six patients who underwent EVT for other arteries (three for jejunal branches and one each for splenic,

EVT Findings

Bleeding sites included the GDA stump or CHA in 19 patients (68%), proper hepatic artery in four (14%), right hepatic artery in three (11%), and left hepatic artery in two (7%; Table 2). Portal vein stenosis was found in 16 patients (57%). The EVT techniques included coil embolization in 17 patients (61%), covered stent placement in one (3%), bare stent–assisted coil embolization in five (18%), and catheter graft with coil embolization in five (18%). In one patient who underwent coil

Discussion

EVT is widely performed to treat postoperative hemorrhage, and its effectiveness has been reported in previous studies (1,11, 12, 13, 14). However, hepatic artery embolization is occasionally associated with serious hepatic complications caused by hepatic ischemia (13, 31). Development of hepatopetal collateral vessels after EVT is associated with prevention of hepatic ischemia (13, 15, 16, 32), whereas post-EVT portal vein stenosis is associated with the poor prognosis and onset of hepatic

References (35)

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