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Percutaneous Transhepatic Stent Graft Placement for Treatment of Hepatic Artery Injury after a Whipple Procedure
LETTERS TO THE EDITOR Percutaneous Transhepatic Stent Graft Placement for Treatment of Hepatic Artery Injury after a Whipple Procedure From: Panteleimon Papadopoulos, MD Pierre Bize, MD Boris Guiu, MD, PhD Alban Denys, MD Department of Diagnostic and Interventional Radiology Centre Hospitalier Universitaire Vaudois (CHUV) Rue du Bugnon 46 1011 Lausanne, Switzerland
Editor: Postoperative hemorrhage after pancreatoduodenectomy is a rare but life-threatening complication (1). The most complex scenario is when the hepatic artery (HA) is involved. HA embolization has a limited risk of complications when the portal vein (PV) is patent and if accessory arterial inflow is maintained through the peribiliary plexus coming from the gastroduodenal artery. However, in patients who have undergone liver transplantation or a Whipple procedure, most of this accessory arterial supply is missing. If possible, hemorrhage should be dealt with while preserving arterial flow to avoid ischemic biliopathy and bilioenteric anastomosis leakage or stenosis. We describe a challenging case treated by an alternative approach. Institutional review board approval was granted for this publication. A 62-year-old woman with a locally confined pancreatic head tumor encasing the superior mesenteric vein (SMV) underwent pancreatoduodenectomy with a 5-cm venous resection and direct end-toend anastomosis between the PV and SMV. She presented on postoperative day 4 with a decrease of the serum hemoglobin from 10 g/dL to 6 g/dL. Contrastenhanced computed tomography revealed a pseudoaneurysm and dissection of the HA extending to its origin as well as stenosis of the anastomosis between the SMV and the PV. Stenosis of the celiac axis secondary to compression by the median arcuate ligament was also noted (Fig 1). No ascites was present. Taking into consideration the complexity of the clinical setting, we decided to treat the HA by a percutaneous transhepatic approach. The arterial branch of segment III was punctured under ultrasound guidance with the 22-gauge Chiba needle of a micropuncture set (Neff Percutaneous Access Set; Cook, Inc, Bloomington, Indiana). A 6-F sheath was introduced, and angiography confirmed the common HA dissection with a flap reaching into the left HA None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.03.020
(Fig 2a). An intraperitoneal extravasation was also shown (Fig 2b). After the administration of 3,000 IU of heparin, a 0.032-inch hydrophilic guide wire (Glidewire; Terumo Corporation, Tokyo, Japan) was advanced with the help of a Berenstein catheter (AngioDynamics, Latham, New York) into the aorta. A 6 mm 22 mm covered stent (Advanta V12, Atrium Medical, Hudson, New Hampshire) subsequently was inserted over the point of rupture. A second noncovered self-expandable 6 mm 40 mm stent (Absolute Pro; Abbott Laboratories, Abbott Park, Illinois) was deployed to treat the dissection of the HA at its origin, and both stents were dilated with a 6 mm 40 mm balloon (Fox Plus; Abbott Laboratories). Final angiography showed a patent HA without evidence of bleeding (Fig 2c). We proceeded with the treatment of the portomesenteric venous stenosis. The portal branch of segment V was accessed under ultrasound guidance using again a micropuncture set, and a 6-F sheath was put in place. The subocclusive stenosis was negotiated with a 0.035inch stiff hydrophilic guide wire (Glidewire), and we reached the SMV, which retained a very slow flow (Fig 3a). The pressure gradient between the SMV and the PV was 7 mm Hg (5 mm Hg in the PV vs 12 mm Hg in the SMV). A self-expandable stent 12 mm in diameter and 60 mm in length (S.M.A.R.T. CONTROL, Cordis Corporation, Bridgewater, New Jersey) was deployed without dilation owing to the recent anastomosis. Angiography demonstrated restored flow in the portal system (Fig 3b), and the pressure gradient decreased to 2 mm Hg. Finally, embolization of the left HA and its parenchymal tract and of the parenchymal tract to the PV branch was performed with coils delivered through the sheath (Tornado Embolization Coils 7-3, 6-3, 5-3, and 4-3 mm, Cook, Inc). Contrast-enhanced computed
Figure 1. Sagittal multiplanar reconstruction showing the origin of the celiac trunk compressed by the median arcuate ligament (arrow). (Available in color online at www.jvir.org.)
978
’
Letters to the Editor
Papadopoulos et al
’
JVIR
Figure 2. (a) Angiography showing the dissection in the common HA (arrow) with a flap reaching into the left HA (arrowhead). (b) On the late arterial phase, intraperitoneal extravasation is seen (arrow). (c) Patent common HA after stent placement (arrowheads). There is still some spasm of the right HA (arrow).
Figure 3. (a) Venography showing stenosis of the portomesenteric anastomosis. Measurement of pressures on both sides revealed a gradient of 7 mm Hg. (b) Venography after stent placement (arrowheads). The pressure gradient is now 2 mm Hg.
tomography performed the next day confirmed patency of both stents. Transaminases, which were normal initially, showed a slight elevation postoperatively (aspartate aminotransferase, 60 U/L; alanine aminotransferase, 70 U/L) and normalized again on day 4 after the intervention. The patient had an uneventful recovery, and no other intervention was needed. Follow-up examination at 3 months showed a patent HA and PV stent and normal parenchymal perfusion of the liver including the left lobe. Liver function tests were normal. The use of stent grafts to treat hepatic arterial hemorrhage, especially in the setting of a compromised PV, is common (2). However, in the presence of a severe stenosis of the celiac axis, stent grafts can be difficult to deliver because of their diameter and relative stiffness. Left brachial artery access and respiratory maneuvers can be helpful, but the presence of a dissection of the HA in the case we report complicated things further. Transhepatic arterial access has been reported for the treatment of hepatic carcinoma and metastases (3,4). In our case, it facilitated entry into the true lumen of the dissection, while avoiding the median arcuate ligament.
Finally, we did not observe any complications at the arterial access site. When the main HA is patent, occlusion of distal branches usually has no consequence because collaterals in the liver hilum revascularize the occluded segments. In our case, normal transaminases and absence of clinical complications concerning the left lobe parenchyma support the hypothesis that this territory was supplied by collaterals.
REFERENCES 1. Puppala S, Patel J, McPherson S, Nicholson A, Kessel D. Hemorrhagic complications after Whipple surgery: imaging and radiologic intervention. AJR Am J Roentgenol 2011; 196:192–197. 2. Wang MQ, Liu FY, Duan F, Wang ZJ, Song P, Fan QS. Stent-grafts placement for treatment of massive hemorrhage from ruptured hepatic artery after pancreaticoduodenectomy. World J Gastroenterol 2010; 16: 3716–3722. 3. Seror O, N’Kontchou G, Haddar D, et al. Large infiltrative hepatocellular carcinomas: treatment with percutaneous intraarterial ethanol injection alone or in combination with conventional percutaneous ethanol injection. Radiology 2005; 234:299–309. 4. Yu M, Lewandowski RJ, Ibrahim S, et al. Direct hepatic artery puncture for transarterial therapy in liver cancer. J Vasc Interv Radiol 2010; 21: 394–399.
Editor: Postoperative hemorrhage after pancreatoduodenectomy is a rare but life-threatening complication (1). The most complex scenario is when the hepatic artery (HA) is involved. HA embolization has a limited risk of complications when the portal vein (PV) is patent and if accessory arterial inflow is maintained through the peribiliary plexus coming from the gastroduodenal artery. However, in patients who have undergone liver transplantation or a Whipple procedure, most of this accessory arterial supply is missing. If possible, hemorrhage should be dealt with while preserving arterial flow to avoid ischemic biliopathy and bilioenteric anastomosis leakage or stenosis. We describe a challenging case treated by an alternative approach. Institutional review board approval was granted for this publication. A 62-year-old woman with a locally confined pancreatic head tumor encasing the superior mesenteric vein (SMV) underwent pancreatoduodenectomy with a 5-cm venous resection and direct end-toend anastomosis between the PV and SMV. She presented on postoperative day 4 with a decrease of the serum hemoglobin from 10 g/dL to 6 g/dL. Contrastenhanced computed tomography revealed a pseudoaneurysm and dissection of the HA extending to its origin as well as stenosis of the anastomosis between the SMV and the PV. Stenosis of the celiac axis secondary to compression by the median arcuate ligament was also noted (Fig 1). No ascites was present. Taking into consideration the complexity of the clinical setting, we decided to treat the HA by a percutaneous transhepatic approach. The arterial branch of segment III was punctured under ultrasound guidance with the 22-gauge Chiba needle of a micropuncture set (Neff Percutaneous Access Set; Cook, Inc, Bloomington, Indiana). A 6-F sheath was introduced, and angiography confirmed the common HA dissection with a flap reaching into the left HA None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.03.020
(Fig 2a). An intraperitoneal extravasation was also shown (Fig 2b). After the administration of 3,000 IU of heparin, a 0.032-inch hydrophilic guide wire (Glidewire; Terumo Corporation, Tokyo, Japan) was advanced with the help of a Berenstein catheter (AngioDynamics, Latham, New York) into the aorta. A 6 mm 22 mm covered stent (Advanta V12, Atrium Medical, Hudson, New Hampshire) subsequently was inserted over the point of rupture. A second noncovered self-expandable 6 mm 40 mm stent (Absolute Pro; Abbott Laboratories, Abbott Park, Illinois) was deployed to treat the dissection of the HA at its origin, and both stents were dilated with a 6 mm 40 mm balloon (Fox Plus; Abbott Laboratories). Final angiography showed a patent HA without evidence of bleeding (Fig 2c). We proceeded with the treatment of the portomesenteric venous stenosis. The portal branch of segment V was accessed under ultrasound guidance using again a micropuncture set, and a 6-F sheath was put in place. The subocclusive stenosis was negotiated with a 0.035inch stiff hydrophilic guide wire (Glidewire), and we reached the SMV, which retained a very slow flow (Fig 3a). The pressure gradient between the SMV and the PV was 7 mm Hg (5 mm Hg in the PV vs 12 mm Hg in the SMV). A self-expandable stent 12 mm in diameter and 60 mm in length (S.M.A.R.T. CONTROL, Cordis Corporation, Bridgewater, New Jersey) was deployed without dilation owing to the recent anastomosis. Angiography demonstrated restored flow in the portal system (Fig 3b), and the pressure gradient decreased to 2 mm Hg. Finally, embolization of the left HA and its parenchymal tract and of the parenchymal tract to the PV branch was performed with coils delivered through the sheath (Tornado Embolization Coils 7-3, 6-3, 5-3, and 4-3 mm, Cook, Inc). Contrast-enhanced computed
Figure 1. Sagittal multiplanar reconstruction showing the origin of the celiac trunk compressed by the median arcuate ligament (arrow). (Available in color online at www.jvir.org.)
978
’
Letters to the Editor
Papadopoulos et al
’
JVIR
Figure 2. (a) Angiography showing the dissection in the common HA (arrow) with a flap reaching into the left HA (arrowhead). (b) On the late arterial phase, intraperitoneal extravasation is seen (arrow). (c) Patent common HA after stent placement (arrowheads). There is still some spasm of the right HA (arrow).
Figure 3. (a) Venography showing stenosis of the portomesenteric anastomosis. Measurement of pressures on both sides revealed a gradient of 7 mm Hg. (b) Venography after stent placement (arrowheads). The pressure gradient is now 2 mm Hg.
tomography performed the next day confirmed patency of both stents. Transaminases, which were normal initially, showed a slight elevation postoperatively (aspartate aminotransferase, 60 U/L; alanine aminotransferase, 70 U/L) and normalized again on day 4 after the intervention. The patient had an uneventful recovery, and no other intervention was needed. Follow-up examination at 3 months showed a patent HA and PV stent and normal parenchymal perfusion of the liver including the left lobe. Liver function tests were normal. The use of stent grafts to treat hepatic arterial hemorrhage, especially in the setting of a compromised PV, is common (2). However, in the presence of a severe stenosis of the celiac axis, stent grafts can be difficult to deliver because of their diameter and relative stiffness. Left brachial artery access and respiratory maneuvers can be helpful, but the presence of a dissection of the HA in the case we report complicated things further. Transhepatic arterial access has been reported for the treatment of hepatic carcinoma and metastases (3,4). In our case, it facilitated entry into the true lumen of the dissection, while avoiding the median arcuate ligament.
Finally, we did not observe any complications at the arterial access site. When the main HA is patent, occlusion of distal branches usually has no consequence because collaterals in the liver hilum revascularize the occluded segments. In our case, normal transaminases and absence of clinical complications concerning the left lobe parenchyma support the hypothesis that this territory was supplied by collaterals.
REFERENCES 1. Puppala S, Patel J, McPherson S, Nicholson A, Kessel D. Hemorrhagic complications after Whipple surgery: imaging and radiologic intervention. AJR Am J Roentgenol 2011; 196:192–197. 2. Wang MQ, Liu FY, Duan F, Wang ZJ, Song P, Fan QS. Stent-grafts placement for treatment of massive hemorrhage from ruptured hepatic artery after pancreaticoduodenectomy. World J Gastroenterol 2010; 16: 3716–3722. 3. Seror O, N’Kontchou G, Haddar D, et al. Large infiltrative hepatocellular carcinomas: treatment with percutaneous intraarterial ethanol injection alone or in combination with conventional percutaneous ethanol injection. Radiology 2005; 234:299–309. 4. Yu M, Lewandowski RJ, Ibrahim S, et al. Direct hepatic artery puncture for transarterial therapy in liver cancer. J Vasc Interv Radiol 2010; 21: 394–399.