Anterior superior pancreaticoduodenal artery pseudoaneurysm after distal pancreatectomy with en bloc celiac axis resection successfully treated with balloon-assisted coil embolization

Abstract

Bleeding is a fatal complication after pancreatectomy. Although coil embolization is a widely accepted treatment option, ischemia of the remaining organs should be prevented. This study reports the successful treatment of intra-abdominal hemorrhage following distal pancreatectomy with en bloc celiac axis resection (DP-CAR) using balloon-assisted coil embolization (BACE). A 59-year-old man was diagnosed with locally advanced pancreatic cancer. The tumor involves the common hepatic artery, splenic artery, and celiac artery. After four cycles of treatment with gemcitabine/nab-paclitaxel, the soft-density masses, surrounding the artery, shrunk. DP-CAR and R0 resections were performed. A minor postoperative pancreatic fistula occurred. Six months postoperatively, the computed tomography showed delayed asymptomatic bleeding from an anterior superior pancreaticoduodenal artery (ASPDA) pseudoaneurysm located near the gastroduodenal artery confluence. BACE was performed by placing a microballoon catheter in the region of confluence of the ASPDA and posterior superior pancreaticoduodenal artery (PSPDA) to prevent coil migration. After inserting the microballoon catheter, coil embolization was performed in the ASPDA. Hepatic blood flow was maintained from the PSPDA. BACE is a useful technique to preserve blood flow to the remnant organs when performing coil embolization for bleeding following a distal pancreatectomy, especially following a DP-CAR.

Successful treatment for pseudoaneurysm following distal pancreatectomy with celiac axis resection without postoperative pancreatic fistula: a case report

“…However, recognizing that this innovative surgical approach has the potential for severe complications owing to its alternations in vascular dynamics is imperative. The rate of Clavien–Dindo classification grade 3a or higher complications in DP–CAR is reported to be 41.3%, including gastric ischemia (28.8%), delayed gastric emptying (25%) [ 2 ], hepatic ischemia [ 4 – 6 ], bleeding [ 4 , 5 , 7 ], and the formation of arterial aneurysms [ 8 , 9 ] related to pancreatic leakage.…”

“…In particular, intraperitoneal bleeding due to pancreatic leakage following DP–CAR is common and is a lethal complication [ 4 , 5 , 7 – 9 ]. In previous reports, there were two cases wherein the patients developed pseudoaneurysm rupture concomitant with pancreatic leakage requiring catheter intervention [ 8 , 9 ].…”

“…In particular, intraperitoneal bleeding due to pancreatic leakage following DP–CAR is common and is a lethal complication [ 4 , 5 , 7 – 9 ]. In previous reports, there were two cases wherein the patients developed pseudoaneurysm rupture concomitant with pancreatic leakage requiring catheter intervention [ 8 , 9 ]. However, to the best of our knowledge, this is the first report regarding pseudoaneurysm development without pancreatic leakage after a long period following DP–CAR.…”

“…The prior confirmation of blood flow from the RGA to the liver enabled successful GDA embolization. As emphasized in previous reports, microembolization that preserves arterial communications is indispensable [ 9 ]. This procedure requires delicate and highly skilled techniques.…”

“…Distal pancreatectomy with celiac axis resection (DP–CAR) represents an innovative surgical procedure for locally advanced pancreatic body cancer, with a goal of achieving complete resection even in cases involving celiac axis invasion [ 1 – 3 ]. However, despite its potential benefits, DP–CAR is associated with perioperative risks, including alterations in vascular dynamics and the development of severe complications, such as arterial aneurysms and organ ischemia [ 2 , 4 – 9 ]. Understanding the associated risks of DP–CAR is crucial for optimizing patient outcomes and guiding treatment decisions.…”