Efficacy and hepatic complications of three endovascular treatment approaches for delayed postpancreatectomy hemorrhage: evolution over 15 years

Chang et al. CVIR Endovascular (2019) 2:33 https://doi.org/10.1186/s42155-019-0077-x ORIGINAL ARTICLE CVIR Endovascular Open Access Efficacy and hepatic complications of three endovascular treatment approaches for delayed postpancreatectomy hemorrhage: evolution over 15 years Yu-Chien Chang1, Kao-Lang Liu1,2, Yu-Cheng Huang1, Po-Ting Chen1, Yu-Wen Tien3, Yen-Heng Lin1* Yeun-Chung Chang1 and Abstract Background: Delayed postpancreatectomy hemorrhage (PPH) is a fatal complication caused by arterial erosion. This study reports a single-center experience of managing delayed PPH with different endovascular treatment approaches. Methods: We reviewed the data of patients who had delayed PPH due to hepatic artery or gastroduodenal artery stump perforation and underwent endovascular treatment between 2003 and 2018. We categorized endovascular treatment approaches involving hepatic artery sacrifice, superselective pseudoaneurysm embolization with hepatic artery preservation, and covered stent placement. Technical success rates, hemorrhage recurrence rates, major and minor hepatic complication rates, and 30-day and 1-year mortality rates were assessed. Results: A total of 18 patients were reviewed; 11 (61%), 4 (22%), and 3 (17%) delayed PPH cases were managed through hepatic artery sacrifice, superselective pseudoaneurysm embolization, and hepatic artery stenting, respectively. Multidetector computed tomography was performed in 14 (78%) patients. The technical success rate was 100%. The overall hemorrhage recurrence rate was 39%, with superselective pseudoaneurysm embolization having a 100% hemorrhage recurrence rate—much higher than that of hepatic artery sacrifice or stent graft placement. The overall major and minor hepatic complication rates were 56% and 83%, respectively. The overall 30day and 1-year mortality rates were 11% and 25%, respectively. The 30-day and 1-year mortality rates and minor and major hepatic complication rates were similar in each group. Conclusion: Hepatic artery sacrifice is more effective than superselective pseudoaneurysm embolization in the management of delayed PPH. Covered stent placement may be a reasonable alternative treatment to hepatic artery sacrifice. Keywords: Pancreaticoduodenectomy, Delayed postpancreatectomy hemorrhage, Transarterial embolization, Covered stent * Correspondence: 1 Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung-Shan South Rd, Taipei 100, Taiwan, Republic of China Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Chang et al. CVIR Endovascular (2019) 2:33 Background Pancreaticoduodenectomy, a complex surgical procedure for resecting tumors or ameliorating inflammation in the periampullary region, is performed as either a classic pancreaticoduodenectomy (Whipple procedure) or a pyloruspreserving pancreaticoduodenectomy (PPPD). Common complications associated with this procedure include anastomotic leakage, infection, and hemorrhage (Bhosale et al. 2013; Raman et al. 2013; Malleo and Vollmer Jr. 2016). Postpancreatectomy hemorrhage (PPH) is observed in less than 10% of patients but is responsible 11%–38% of the associated deaths (Puppala et al. 2011). PPH can be classified as early or delayed PPH according to the definition of the International Study Group of Pancreatic Surgery (Wente et al. 2007). Delayed PPH is defined as hemorrhage occurring more than 24 h postoperatively, and its etiology is related to postoperative leakage due to anastomotic failure and localized inflammation. Continued inflammation can lead to splanchnic vessel wall erosion, thus explaining delayed PPH (Hasegawa et al. 2017). Relaparotomy, endoscopy, and endovascular treatment (EVT) have been described as treatments used for managing delayed PPH. Endoscopy plays a limited role, and relaparotomy is indicated for conditions of insufficient hemostasis despite endoscopy or EVT (Khalsa et al. 2015). Strategies for managing delayed PPH have shifted from surgery toward EVT over the past decade (Zhang et al. 2011; Adam et al. 2014; Asai et al. 2015; Khalsa et al. 2015; Zhou et al. 2017; Biondetti et al. 2019). The common hepatic artery and gastroduodenal artery (GDA) stump are the most common culprit vessels (Hasegawa et al. 2017). Different EVT approaches, including hepatic artery sacrifice and superselective pseudoaneurysm embolization, have been described (Hur et al. 2011; Stampfl et al. 2012). Recent studies have reported that covered stent grafts are effective for both managing delayed PPH and preserving hepatic artery flow (Hankins et al. 2009; Ching et al. 2016). Despite the various alternatives, the hepatic complication rates of these treatment approaches have been variable in thus far. The mid-to-long-term clinical outcome data of these strategies remain scarce. In the present study, the short- and mid-term clinical outcomes of three EVT approaches, namely hepatic artery sacrifice, superselective pseudoaneurysm embolization with hepatic artery preservation, and covered stent placement, for managing delayed PPH were explored. Materials and methods Patients We retrospectively reviewed the databank at National Taiwan University Hospital for 2003–2018. This study was approved by the institutional review board of the hospital. We searched for electronic medical records of Page 2 of 8 patients who received the Whipple procedure or PPPD. Patients who had delayed PPH and underwent EVT were included. Patients were excluded if (1) the culprit vessel was not branched from the common hepatic artery or (2) the clinical or image data were missing or were insufficient for analysis. In total, 19 patients had delayed PPH and underwent EVT. Because one patient with a splenic artery pseudoaneurysm after the Whipple procedure was excluded, 18 patients were included in the final analysis. Clinical management and data assessment Hemorrhage was detected by the presence of either sentinel bleeding, defined as blood in the abdominal drain, or hematemesis and melena. All patients presented with delayed PPH, defined as hemorrhage occurring more than 24 h postoperatively. Most patients underwent multidetector computed tomography (MDCT) angiography for culprit lesion detection. Clinical data, including age, sex, pathologic diagnosis, coagulation profile, clinical presentation, and onset time of bleeding after surgery, were obtained from the available medical records. On the basis of the International Study Group for Pancreatic Fistula (Bas (...truncated)