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

Ann Hepatobiliary Pancreat Surg 2020;24:114-118 https://doi.org/10.14701/ahbps.2020.24.1.114 Case Report Successful treatment of visceral pseudoaneurysm after pancreatectomy using flow-diverting stent device Emmanouil Giorgakis1,2, Brian Chong3, Rahmi Oklu4, Dawn E. Jaroszewski5, Grace Knuttinen4, and Amit K. Mathur1 1 Division of Transplantation and Hepatopancreatobiliary Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, 2 Department of Solid Organ Transplantation, University of Arkansas for Medical Sciences, Little Rock, AR, 3 Division of Neuroradiology, Department of Radiology, Mayo Clinic, 4 Department of Interventional Radiology, Mayo Clinic, 5 Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA 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 TM Pipeline 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. (Ann Hepatobiliary Pancreat Surg 2020;24:114-118) Key Words: Gastroepiploic artery pseudoaneurysm; Flow diverter therapy; Endovascular repair visceral aneurysm; Post-pancreatectomy pseudoaneurysm INTRODUCTION sanguineous drain output. He subsequently underwent arteriography, which revealed a pseudoaneurysm arising The authors describe the successful treatment of gastro- from the first segmental artery off the superior mesenteric epiploic artery pseudoaneurysm with parent vessels pres- artery (SMA) and the inferior pancreaticoduodenal artery ervation using a Pipeline TM Flex embolization device. anastomosing with the gastroduodenal artery and the gastroepiploic artery. The branch giving rise to the pseudoa- CASE neurysm was the only vessel supplying the gastric conduit. The pseudoaneurysm was a sidewall type associated The patient was a 64-year old man, with remote history with slow extravasation (Fig. 1), and preserved flow to of trans-hiatal esophagectomy for the treatment of esoph- the gastric conduit. Due to its small diameter, the vessel ageal adenocarcinoma. 12 years later, he developed a pan- would not admit stent; vessel embolization would risk creatic adenocarcinoma and was treated with subtotal gastric conduit necrosis. pancreatectomy. His post-resection course was complicat- During esophagectomy, the intrathoracic, distal esoph- ed with pancreatic leak, which precipitated intra-abdomi- agus and proximal stomach had been removed, and the nal infection and left pleural empyema, which were drain- residual stomach mobilized to reach the residual esoph- ed. One-month post-resection, the patient presented with ageal stump in the neck. The gastric conduit was com- Received: September 8, 2019; Revised: December 27, 2019; Accepted: January 19, 2020 Corresponding author: Emmanouil Giorgakis Department of Solid Organ Transplantation, University of Arkansas for Medical Sciences, 4301 W Markham St. Little Rock, AR 72205, USA Tel: +1-501-686-6380, Fax: +1-501-686-5215, E-mail: Copyright Ⓒ 2020 by The Korean Association of Hepato-Biliary-Pancreatic Surgery This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Annals of Hepato-Biliary-Pancreatic Surgery ∙ pISSN: 2508-5778ㆍeISSN: 2508-5859 Emmanouil Giorgakis, et al. Flow-diverting stent application on post-pancreatectomy pseudoaneurysms 115 pletely dependent on blood flow from the right gastro- neurysms can be life threatening. They develop when pan- epiploic artery (Fig. 2). It was, therefore, decided to pur- creatic secretions result in autodigestion of the adjacent sue flow-diverting stent device placement across the pseu- arterial walls. Pancreatitis is the major pancreatic pseu- doaneurysm to preserve gastric conduit flow. The SMA doaneurysm formation cause, with an incidence as high was catheterized (Fig. 3). An intermediate distal access as 10%. Pancreatic pseudoaneurysms may also develop catheter (Navien 5F, Medtronic, Irvine CA) and a Phenom after biliopancreatic resections or after pancreas trans- 027 microcatheter (Medtronic Irvine CA) were advanced plantation. The focal inflammation with or without sepsis over a Synchro 014 microwire (Stryker Neurovascular, triggered by the presence of an anastomotic leak may re- Freemont CA) through the guide catheter. Attempts to ad- sult in vessel erosion with pseudoaneurysm formation and vance this combination to the first order SMA branch sup- delayed rupture and bleed. The splenic artery is the most plying the pseudoaneurysm failed due to marked frequent site of visceral artery pseudoaneurysms, followed tortuosity. Angioplasty was performed and an Enterprise by the hepatic artery. 4 mm×20 mm stent (Codman Neurovascular, Miami Lakes FL) was placed into the affected branch. The patient was brought back to the interventional suite the following day for definitive treatment. Using similar 1 2 Based on the originating artery type, presence of gastrointestinal tract communication and pancreatic juice ex3 posure, Pang et al. developed a management-based classification system for peripancreatic pseudoaneurysms. technique, the SMA branch was catheterized and the mi- Rupture carries a 13-40% mortality risk and is almost cro-catheter was placed distal to the aneurysm after pass- universally fatal if left untreated. Therefore, timely identi- ing through the previously placed stent. In order to pass fication and management is of essence. Owing to inter- the microcatheter distal to the aneurysm, it was necessary ventional radiology advances, the standard of care has to enter it with the guidewire and microcatheter and loop shifted from surgical intervention to endovascular treat- the system inside the aneurysm before passing out well ment.4 Digital subtraction facilitates high resolution map- beyond its neck, in order to deploy the flow diverter. ping of th (...truncated)