Interventional Radiology for Delayed Post-Pancreatectomy Hemorrhage: A Case Report and Review of the Literature

Post-pancreatectomy hemorrhage (PPH) is a life-threatening complication of pancreatic surgery associated with high mortality. The International Study Group of Pancreatic Surgery (ISGPS) classifies PPH as early (<24 hours) or delayed (>24 hours), with delayed hemorrhage often resulting from vascular erosion, pseudoaneurysm formation, or anastomotic ulceration. We report a case of a 52-year-old male who underwent a classical pancreaticoduodenectomy (Whipple's procedure) for periampullary adenocarcinoma. The early postoperative course was uneventful until postoperative day (POD) 6, when the patient developed a sentinel bleed, presenting as hematemesis and melena, followed approximately two hours later by hemodynamic instability (BP 80/50 mmHg). Laboratory evaluation revealed a sharp drop in hemoglobin from 11.2 g/dL to 6.4 g/dL, with normal coagulation parameters. Emergency digital subtraction angiography demonstrated a pseudoaneurysm near the gastroduodenal artery (GDA) stump with active contrast extravasation. Selective transcatheter arterial embolization (TAE) using microcoils and embolic agents achieved immediate angiographic success; however, despite aggressive resuscitation and vasopressor support, the patient's condition deteriorated, and he succumbed to massive hemorrhage and its complications. There was no evidence of pancreatic leak or intra-abdominal sepsis. This case highlights the catastrophic potential of delayed PPH, where sentinel bleeding serves as an early warning sign. Prompt recognition, urgent angiography, and a multidisciplinary approach are critical to improving patient outcomes, with interventional radiology offering a minimally invasive, potentially lifesaving alternative to high-risk re-exploratory surgery.