Role of interventional endovascular therapy for delayed hemorrhage after pancreaticoduodenectomy

Delayed massive hemorrhage (DMH) after pancreaticoduodenectomy (PD) is a serious complication and one of the most common causes of mortality after PD. Its ideal management remains unclear. This paper is to present our experience in the endovascular treatment of patients with DMH after PD using different techniques and materials.

During a seven years period, 19 patients (fifteen men, four women) with DMH arter PD were treated with endovascular procedures, including transcatheter arterial embolization (TAE) with coils embolization in eight cases, with coils plus N-butyl-2-cyanoacrylate (NBCA)-Lipiodol mixture in six cases, and stent-graft placement in five cases. The mean age of the patients was 58.2 years. Follow-up, including clinical condition, liver function tests, and Doppler ultrasound examinations, was documented.

The immediate technical success rate was 84.2% (16/19). There were no significant procedure-related complications. Hemostasis was not achieved with interventional procedures in three patients: one died of uncontrolled bleeding four days after the second TAE, and two patients required emergency laparotomy without re-angiography because of worsening clinical status. Among the 16 patients with successfully stopped bleeding who became hemodynamically stable after the procedure without evidence of further bleeding, two patients died during the peri-interventional procedure period because of multiple organ failure, and fourteen patients survived to hospital discharge. The mean length of follow-up was 14.6 months. Recurrent bleeding after discharge did not occur in any of these cases. Clinical and laboratory follow-up findings were unremarkable. Doppler ultrasound examination verified patency of the hepatic artery in the four patients with stent-graft placement during the follow-up period (5 months-29 months; mean, 15.3 months).

Interventional endovascular procedure is a safe and technically feasible solution to control DMH. The first-line treatment for the bleeding is TAE. Stent-graft placement with preservation of the organ arterial flow, if technically possible, is a valuable alternative to TAE and surgical intervention for management of DMH.