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Cizman Z, Saad W. Transplant Hepatic Artery Complications. Tech Vasc Interv Radiol 2023; 26:100923. [PMID: 38123292 DOI: 10.1016/j.tvir.2023.100923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Hepatic artery complications can be divided into 2 different categories, nonocclusive and steno-occlusive disease. Steno-occlusive disease is a collective term that encompasses hepatic artery thrombosis, hepatic artery stenosis, and hepatic arterial kinks, while nonocclusive arterial disease encompasses less than 5% of complications and is a collective term used to describe arteriovenous fistulae, pseudoaneurysms, arterial rupture and nonocclusive hepatic artery hypoperfusion syndrome. This article details the angiographic techniques and definitions needed to accurately diagnose arterial transplant complications and describes the technical aspects and results of endoluminal management of these arterial complications. In addition, this article discusses the presentation, etiology and indications for treatment, including surgical management of these various complications.
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Affiliation(s)
- Ziga Cizman
- Department of Radiology and Imaging Sciences, University of Utah Hospital/Huntsman Cancer Institute, Salt Lake City, UT.
| | - Wael Saad
- Department of Radiology and Imaging Sciences, University of Utah Hospital/Huntsman Cancer Institute, Salt Lake City, UT
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Arend J, Schütte K, Peglow S, Däberitz T, Popp F, Benedix F, Pech M, Wolff S, Bruns C. [Arterial and portal venous complications after HPB surgical procedures: Interdisciplinary management]. Chirurg 2015; 86:525-32. [PMID: 26016713 DOI: 10.1007/s00104-015-0027-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The surgical treatment of hepatopancreatobiliary (HPB) diseases requires complex operative procedures. Within the last decades the morbidity (36-50 %) and mortality (<5 %) of these procedures could be reduced; nonetheless, postoperative complications still occur in 41.2 % of cases. Compared with hepatobiliary procedures, pancreatic surgery shows an increased rate of complications. Postoperative bleeding has a major effect on the outcome and the incidence is 6.7 % after pancreatic surgery and 3.2 % after hepatobiliary surgery. The major causes of early postoperative hemorrhage are related to technical difficulties in surgery whereas late onset postoperative hemorrhage is linked to anastomosis insufficiency, formation of fistulae or abscesses due to vascular arrosion or formation of pseudoaneurysms. In many cases, delayed hemorrhage is preceded by a self-limiting sentinel bleeding. The treatment is dependent on the point in time, location and severity of the hemorrhage. The majority of early postoperative hemorrhages require surgical treatment. Late onset hemorrhage in hemodynamically stable patients is preferably treated by radiological interventions. After interventional hemostatic therapy 8.2 % of patients require secondary procedures. In the case of hemodynamic instability or development of sepsis, a relaparotomy is necessary. The treatment concept includes surgical or interventional remediation of the underlying cause of the hemorrhage. Other causes of postoperative morbidity and mortality are arterial and portal venous stenosis and thrombosis. Following liver resection, thrombosis of the portal vein occurs in 8.5-9.1 % and in 11.6 % following pancreatic resection with vascular involvement. Interventional surgical procedures or conservative treatment are suitable therapeutic options depending on the time of diagnosis and clinical symptoms. The risk of morbidity and mortality after HPB surgery can be reduced only in close interdisciplinary cooperation, which is particularly true for vascular complications.
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Affiliation(s)
- J Arend
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Magdeburg A. ö. R., Leipziger Straße 44, 39120, Magdeburg, Deutschland,
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Lim SJ, Park KB, Hyun DH, Do YS, Park HS, Shin SW, Cho SK, Choi DW. Stent graft placement for postsurgical hemorrhage from the hepatic artery: clinical outcome and CT findings. J Vasc Interv Radiol 2014; 25:1539-48. [PMID: 25149115 DOI: 10.1016/j.jvir.2014.06.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 06/24/2014] [Accepted: 06/24/2014] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To evaluate the clinical results and imaging follow-up findings of stent grafts placed for hemorrhage from hepatic arteries following surgery. MATERIALS AND METHODS The investigation included 17 patients (14 men and 3 women) who underwent endovascular stent graft placement for hepatic arterial hemorrhage following surgery. Bleeding occurred from the common hepatic artery (n = 1; 6%), right hepatic artery (n = 1; 6%), proper hepatic artery (n = 6; 35%), and gastroduodenal artery stump (n = 9; 53%). Stent graft patency, thrombus at the graft, target hepatic artery diameter, and liver perfusion status were analyzed by comparing computed tomography (CT) scans performed before the procedure with follow-up CT scans. Laboratory data were also analyzed before the procedure and at follow-up intervals. RESULTS There were 17 stent grafts placed in 17 patients. The mean follow-up period was 356 days (range, 1-2,119 d). The stent graft primary patency rate was 79.5% at 1 month, 69.6% at 6 months, and 69.6% at 1 year. The clinical success rate was 82% (14 of 17 patients), and the technical success rate was 94% (16 of 17 patients). Mortality related to the stent graft was 12% (2 of 17 patients). Occlusion occurred in 4 of 16 stent grafts (25%). There was one technical failure. The mean stent graft diameter was 6.2 mm (range, 3.5-8.0 mm), and the degree of stent graft oversizing was 38% of the hepatic artery diameter on CT scans and 58% on angiography. Hepatic parenchymal perfusion was preserved in 80% of patients (12 of 15). CONCLUSIONS Hepatic artery hemorrhage following surgery can be treated effectively with stent graft placement.
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Affiliation(s)
- Seong Joo Lim
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
| | - Kwang Bo Park
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea.
| | - Dong Ho Hyun
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
| | - Young Soo Do
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
| | - Hong Suk Park
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
| | - Sung Wook Shin
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
| | - Sung Ki Cho
- Department of Radiology, Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
| | - Dong Wook Choi
- Division of Hepato-Biliary and Pancreas, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, 135-710, Irwon-Dong, Gangnam Gu, Seoul, Korea
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Pang TCY, Maher R, Gananadha S, Hugh TJ, Samra JS. Peripancreatic pseudoaneurysms: a management-based classification system. Surg Endosc 2014; 28:2027-38. [PMID: 24519028 PMCID: PMC4065337 DOI: 10.1007/s00464-014-3434-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 01/09/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Peripancreatic pseudoaneurysms can arise in a number of different clinical settings but are associated mostly with pancreatitis and pancreatobiliary surgery. The aim of this study is to review the current literature and to propose a management classification system based on the pathophysiological processes and the exact anatomical site of peripancreatic pseudoaneurysms. METHODS A systematic review of the literature from 1995 to 2012 was performed. Articles on studies describing peripancreatic pseudoaneurysms in the setting of pancreatitis or major hepatic or pancreatic surgery with more than ten patients were included. Seventeen eligible studies were identified and reviewed. RESULTS The demographic characteristics of the patients in all studies were similar with a predominance of males and a mean age of 55 years. The overall mortality rate varied greatly among the studies, ranging from 0 to 60%. Embolisation was the first line of management in the majority of the studies, with surgery reserved for failed embolisation or for haemodynamically unstable cases. Embolisation of the hepatic artery or its branches was associated with high rates of morbidity (56%) and hepatic failure (19%). More recent studies show that stents are used increasingly for vessels that cannot be embolised safely. Late bleeding, a major cause of mortality and morbidity, is generally underreported. The proposed classification system is based on three factors: (1) the type of artery from which the pseudoaneurysm arises, (2) whether communication with the gastrointestinal tract is present, and (3) whether there is high concentration of pancreatic juice at the bleeding site. CONCLUSION The management of peripancreatic pseudoaneurysms usually comprises a combination of interventional radiology and surgery and this may be assisted by a logical classification system.
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Affiliation(s)
- Tony C Y Pang
- Upper GI Surgical Unit, Royal North Shore Hospital and North Shore Private Hospitals, University of Sydney, St Leonards, NSW, 2065, Australia
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Endovascular Management of Severe Bleeding After Major Abdominal Surgery. Ann Vasc Surg 2013; 27:1098-104. [DOI: 10.1016/j.avsg.2012.10.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 10/12/2012] [Accepted: 10/17/2012] [Indexed: 12/19/2022]
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Lee JH, Hwang DW, Lee SY, Hwang JW, Song DK, Gwon DI, Shin JH, Ko GY, Park KM, Lee YJ. Clinical features and management of pseudoaneurysmal bleeding after pancreatoduodenectomy. Am Surg 2012. [PMID: 22524769 DOI: 10.1177/000313481207800339] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A ruptured pseudoaneurysm is the most serious and life-threatening cause of postpancreatoduodenectomy (PD) hemorrhages. We have evaluated the clinical course and management of pseudoaneurysms after PD. Of 586 patients who underwent PD for periampullary tumors in Asan Medical Center between March 2003 and March 2011, 27 experienced pseudoaneurysmal bleeding. Bleeding developed at a median of 21 days (range, 8 to 45 days) after surgery, including 9 patients who developed bleeding more than 4 weeks after surgery. Before development of bleeding, 26 patients showed pancreatic fistula. Bleeding was developed from the gastroduodenal artery stump in 12 patients, the common hepatic artery in eight, the proper hepatic artery in five, and the left hepatic artery in two. Of the angiographic group, 21 patients underwent with microcoil embolization, four underwent stent insertion, and one experienced technical failure. Only one patient required emergent laparotomy without angiography. Of 25 patients with angiographic procedures, all patients achieved hemostasis. The mortality rate was 22.2 per cent (6 patients). Delayed hemorrhage after PD is closely associated with pancreatic fistula and carried a significantly higher mortality rate. The patients with pancreatic fistula should be carefully monitored, even more than 4 weeks after surgery. Selective microcoil embolization or stent graft is effective for pseudoaneurysmal bleeding.
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Affiliation(s)
- Jae Hoon Lee
- Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Semiz-Oysu A, Keussen I, Cwikiel W. Stent-graft placement for urgent treatment or prevention of bleeding. Acta Radiol 2012; 53:28-33. [PMID: 22067208 DOI: 10.1258/ar.2011.110141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Stent-graft treatment of the patients with ongoing bleeding may be beneficial in specific situations, especially when preservation of blood flow to the distant organs is important. PURPOSE To present the results of stent-graft placement for urgent treatment or prevention of the bleeding. MATERIAL AND METHODS Stent-graft placement was performed urgently for the treatment of active bleeding and/or pseudoaneurysm/aneurysm in 17 patients. Diagnoses were based on clinical findings and/or imaging studies. The etiology was previous major surgery and/or percutaneous intervention in 13, malignancy in one, pancreatitis and pseudocyst in one, multitrauma due to traffic accident in one and unknown cause in one patient. RESULTS A total of 23 stent-grafts were placed. Angiograms obtained after placement revealed patent stent-graft with no further active extravasation or filling of pseudoaneurysm in 14 patients. Due to persistent bleeding, embolization was performed in two patients. In three patients, the stent-grafts were found to be thrombosed either immediately after placement (n = 1) or at follow-up (n = 2). Stent-grafts were patent in six of nine patients that could be followed (between 3 months and 6 years). CONCLUSION Urgent stent-graft placement may be an alternative to endovascular embolization or surgery. It may be preferred when embolization is technically difficult or impossible and/or when preservation of blood supply to distal organs is essential such as in liver transplant grafts or extremity salvage.
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Affiliation(s)
- Aslihan Semiz-Oysu
- Department of Radiology, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Inger Keussen
- Center for Medical Imaging and Physiology, University Hospital,Lund, Sweden
| | - Wojciech Cwikiel
- Department of Radiology, University of Michigan Hospital, Ann Arbor, MI, USA
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Cho SK, Kim SS, Do YS, Park KB, Shin SW, Park HS, Choo SW, Choo IW. Ischemic liver injuries after hepatic artery embolization in patients with delayed postoperative hemorrhage following hepatobiliary pancreatic surgery. Acta Radiol 2011; 52:393-400. [PMID: 21498292 DOI: 10.1258/ar.2011.100414] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Many collateral pathways to the liver are dissected during hepatobiliary pancreatic surgery and, if the arterial bleeding is massive and a hematoma becomes larger, the adjacent portal vein can be compressed with impairment of the portal venous flow. PURPOSE To evaluate the frequency and severity of ischemic liver injuries after hepatic artery embolization in patients with delayed postoperative arterial hemorrhage after hepatobiliary pancreatic surgery. MATERIAL AND METHODS Eighteen patients undergoing proper or common hepatic artery embolization for delayed postoperative arterial hemorrhage after hepatobiliary pancreatic surgery achieved hemostasis. To evaluate the frequency and severity of ischemic liver injuries, the liver enzyme levels and CT findings before and after hepatic artery embolization were retrospectively compared and the clinical outcomes after hepatic artery embolization were analyzed. Angiographic findings were also analyzed to reveal any association with development of ischemic liver injuries after hepatic artery embolization. RESULTS Ischemic liver injuries were observed in 15 (83%) of 18 patients undergoing hepatic artery embolization for postoperative hemorrhage. Injuries included hepatic infarction combined with abscess in one (5%) patient, hepatic infarction in 12 (67%) patients, and transient hepatic ischemia/dysfunction in two (11%). As for the extent of hepatic infarction, lobar infarction developed in two patients and subsegmental infarction in 11. One patient with right hepatic lobar infarction died of hepatic failure 11 days after hepatic artery embolization. In the other 14 patients with ischemic liver injuries, the elevated liver enzymes returned to baseline levels within two weeks. All of the four patients with portal vein stenosis, four patients with no hepatic arterial flow on post-embolization angiogram, and one patient with both had hepatic infarction after hepatic artery embolization. No ischemic liver injuries developed after hepatic artery embolization in three patients with no portal vein stenosis and bilobar hepatic arterial flow via the left hepatic artery aberrantly arising from the left gastric artery or from the common hepatic artery. CONCLUSION Ischemic liver injuries can develop in most patients undergoing hepatic artery embolization for postoperative arterial hemorrhage after hepatobiliary pancreatic surgery; hepatic infarction appears to be the most frequent type of ischemic liver injury. Hepatic artery embolization for postoperative arterial hemorrhage after hepatobiliary pancreatic surgery may carry a great risk of ischemic liver injury if a patient has portal vein stenosis or no aberrant hepatic artery.
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Affiliation(s)
- Sung Ki Cho
- Department of Radiology, Kangwon National University College of Medicine, Kangwon-do
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sam Soo Kim
- Department of Radiology, Kangwon National University College of Medicine, Kangwon-do
| | - Young Soo Do
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Bo Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Wook Shin
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Suk Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Wook Choo
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - In Wook Choo
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Herzog T, Suelberg D, Belyaev O, Uhl W, Seemann M, Seelig MH. Treatment of acute delayed visceral hemorrhage after pancreatic surgery from hepatic arteries with covered stents. J Gastrointest Surg 2011; 15:496-502. [PMID: 21240640 DOI: 10.1007/s11605-010-1260-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Accepted: 06/07/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed visceral hemorrhage following pancreatic surgery is a rare but life-threatening complication. Usually hemorrhage originates from pseudoaneurysms secondary to pancreatic or biliary fistula. Re-laparotomy is often associated with high morbidity and mortality. Endovascular occlusion with metallic coils can stop pseudoaneurysmatic bleeding, but hepatic artery occlusion can result in severe organ damage. Interventional treatment with covered stents is an alternative providing persistent organ perfusion. RESULTS In our department endovascular stenting for visceral hemorrhage was introduced in November 2008. From November 2008 until October 2009, 303 patients underwent pancreatic surgery at our institution. Among those, four patients were successfully treated with covered stents for delayed visceral hemorrhage. In all four patients bleeding originated from hepatic arteries. Mean onset of hemorrhage was 24 days after surgery. Endovascular stenting was successful in all four patients. None of these patients required re-operation or died during the study. CONCLUSION Treatment of delayed visceral hemorrhage from hepatic arteries after pancreatic surgery with covered stents is safe and effective. Endovascular stenting is associated with a lower morbidity than re-laparotomy or coil embolisation. Emergency angiography with endovascular stenting should be considered for all patients with delayed hemorrhage from hepatic arteries after pancreatic surgery.
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Affiliation(s)
- Torsten Herzog
- Department of Surgery, St. Josef Hospital, Ruhr-University of Bochum, School of Medicine, Bochum, Germany
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Philippou P, Moraitis K, El-Husseiny T, Wazait H, Masood J, Buchholz N. Endovascular covered stenting for the management of post-percutaneous nephrolithotomy renal pseudoaneurysm: a case report. J Med Case Rep 2010; 4:316. [PMID: 20863388 PMCID: PMC2955059 DOI: 10.1186/1752-1947-4-316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 09/23/2010] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Intrarenal pseudoaneurysm is a rare, yet clinically significant, complication of percutaneous nephrolithotomy. A high index of clinical suspicion is necessary in order to recognize pseudoaneurysm as the cause of delayed bleeding after percutaneous nephrolithotomy and angiography confirms the diagnosis which allows endovascular management. CASE PRESENTATION We present a case of a 65-year old Caucasian woman who underwent percutaneous nephrolithotomy in the supine position for a two centimetre renal calculus. The postoperative course was complicated by persistent bleeding due to a renal pseudoaneurysm. The vascular lesion was successfully managed by endovascular exclusion through the use of a covered stent graft. We report the first successful use of this method for the management of iatrogenic pseudoaneurysm in a branch of the left renal artery and we focus on the imaging findings, technical details, advantages and limitations of this technique. CONCLUSION As a result of its high efficacy, interventional radiology has largely replaced open surgery for the management of renal pseudoaneurysm related to percutaneous nephrolithotomy. Recent technical advancements have allowed the use of covered stent grafts as an alternative to embolisation for the angiographic management of visceral artery pseudoaneurysm located in other organs. This novel technique allows the endovascular exclusion of the pseudoaneurysm, without compromising arterial supply to the end-structures - an advantage of critical importance in organs supplied by segmental arteries - in the absence of collateral vasculature, such as the kidney.
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Affiliation(s)
- Prodromos Philippou
- Department of Urology, Barts and The London NHS Trust, Smithfield, London EC1A 7BE, UK
| | - Konstantinos Moraitis
- Department of Urology, Barts and The London NHS Trust, Smithfield, London EC1A 7BE, UK
| | - Tamer El-Husseiny
- Department of Urology, Barts and The London NHS Trust, Smithfield, London EC1A 7BE, UK
| | - Hassan Wazait
- Department of Urology, Barts and The London NHS Trust, Smithfield, London EC1A 7BE, UK
| | - Junaid Masood
- Department of Urology, Barts and The London NHS Trust, Smithfield, London EC1A 7BE, UK
| | - Noor Buchholz
- Department of Urology, Barts and The London NHS Trust, Smithfield, London EC1A 7BE, UK
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Flum AS, Geiger JD, Gemmete JJ, Williams DM, Teitelbaum DH. Management of a traumatic hepatic artery pseudoaneurysm and arterioportal fistula with a combination of a stent graft and coil embolization using flow control with balloon remodeling. J Pediatr Surg 2009; 44:e31-6. [PMID: 19853737 DOI: 10.1016/j.jpedsurg.2009.07.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Revised: 07/15/2009] [Accepted: 07/16/2009] [Indexed: 12/26/2022]
Abstract
We describe a child who presented with a traumatic hepatic artery pseudoaneurysm and arterioportal fistula, which were subsequently managed with an endovascular stent graft and coil embolization using flow control with balloon remodeling. This case demonstrates a rarely seen condition in the pediatric population and a novel management strategy, which should be considered in the management of this complex injury.
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Affiliation(s)
- Andrew S Flum
- Section of Pediatric Surgery, CS Mott Children's Hospital, University of Michigan, Ann Arbor, MI 48109, USA
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Ginat DT, Saad WEA, Waldman DL, Davies MG. Stent-Graft Placement for Management of Iatrogenic Hepatic Artery Branch Pseudoaneurysm After Liver Transplantation. Vasc Endovascular Surg 2009; 43:513-7. [DOI: 10.1177/1538574409334831] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pseudoaneurysm of the hepatic arteries is uncommon following liver transplantation and is usually iatrogenic. We describe a case of balloon angioplasty of a left hepatic artery stenosis complicated by an iatrogenic pseudoaneurysm. Resolution of the stenosis and the pseudoaneurysm was achieved through a combination of a bare stent and a balloon-expandable covered stent. The completion angiogram demonstrated excellent appearance of the patent hepatic arteries with exclusion of the pseudoaneurysm. No surgery was required. The graft and the patient did well for the following 6 months. Doppler ultrasound examination at 2 and 6 months postintervention revealed patent hepatic arteries and no evidence of the pseudoaneurysm.
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Affiliation(s)
- Daniel T. Ginat
- Department of Imaging Science and Interventional Radiology, University of Rochester Medical Center, Rochester, New York,
| | - Wael E. A. Saad
- Department of Imaging Science and Interventional Radiology, University of Rochester Medical Center, Rochester, New York
| | - David L. Waldman
- Department of Imaging Science and Interventional Radiology, University of Rochester Medical Center, Rochester, New York
| | - Mark G. Davies
- Department of Imaging Science and Interventional Radiology, University of Rochester Medical Center, Rochester, New York
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Results of non-operative therapy for delayed hemorrhage after pancreaticoduodenectomy. J Gastrointest Surg 2009; 13:922-8. [PMID: 19224299 DOI: 10.1007/s11605-009-0818-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Accepted: 01/28/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Hemorrhage after pancreaticoduodenectomy is a life-threatening complication, which occurs in 4% to 16% of cases, even in experienced centers. Many diagnostic and therapeutic options exist but no one has yet established management guidelines. This study aimed to determine the role of conservative management in delayed hemorrhage. PATIENTS AND METHODS From January 2005 to August 2008, 87 patients underwent pancreaticoduodenectomy at our center. We reviewed, retrospectively, the medical charts of all patients who had experienced postoperative hemorrhage. RESULTS AND DISCUSSION Early hemorrhage occurred in one patient, who underwent successful reoperation. Nine patients presented with delayed hemorrhage (10.3%), including three with sentinel bleeding. Mean onset was 20 days post-surgery. We used the same initial management for each patient: all had an urgent contrast computed tomography scan. In every case, the bleeding site was arterial. Conservative treatment (embolization or covered stent) was successful in every case. We reoperated on two patients for gastrointestinal perforation, at 9 days and 2 months after embolization, respectively. We transferred seven patients to an intensive care unit, with an average stay of 8 days. Mean hospital stay was 43 days (33-60). All patients survived. CONCLUSION Conservative management, combining endovascular procedures and aggressive resuscitation, is appropriate for most cases of delayed hemorrhage after pancreaticoduodenectomy.
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Miura F, Asano T, Amano H, Yoshida M, Toyota N, Wada K, Kato K, Yamazaki E, Kadowaki S, Shibuya M, Maeno S, Furui S, Takeshita K, Kotake Y, Takada T. Management of postoperative arterial hemorrhage after pancreato-biliary surgery according to the site of bleeding: re-laparotomy or interventional radiology. ACTA ACUST UNITED AC 2008; 16:56-63. [PMID: 19110653 DOI: 10.1007/s00534-008-0012-3] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Accepted: 01/16/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND/PURPOSE Intra-abdominal arterial hemorrhage is still one of the most serious complications after pancreato-biliary surgery. We retrospectively analyzed our experiences with 15 patients in order to establish a therapeutic strategy for postoperative arterial hemorrhage following pancreato-biliary surgery. METHODS Between August 1981 and November 2007, 15 patients developed massive intra-abdominal arterial bleeding after pancreato-biliary surgery. The initial surgery of these 15 patients were pylorus-preserving pancreatoduodenectomy (PPPD) (7 patients), hemihepatectomy and caudate lobectomy with extrahepatic bile duct resection or PPPD (4 patients), Whipple's pancreatoduodenectomy (PD) (3 patients), and total pancreatectomy (1 patient). Twelve patients were managed by transcatheter arterial embolization and three patients underwent re-laparotomy. RESULTS Patients were divided into two groups according to the site of bleeding: SMA group, superior mesenteric artery (4 patients); HA group, stump of gastroduodenal artery, right hepatic artery, common hepatic artery, or proper hepatic artery (11 patients). In the SMA group, re-laparotomy and coil embolization for pseudoaneurysm were performed in three and one patients, respectively, but none of the patients survived. In the HA group, all 11 patients were managed by transcatheter arterial embolization. None of four patients who had major hepatectomy with extrahepatic bile duct resection survived. Six of seven patients (85.7%) who had pancreatectomy survived, although hepatic infarction occurred in four. CONCLUSIONS Management of postoperative arterial hemorrhage after pancreato-biliary surgery should be done according to the site of bleeding and the initial operative procedure. Careful consideration is required for indication of interventional radiology for bleeding from SMA after pancreatectomy and hepatic artery after major hepatectomy with bilioenteric anastomosis.
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Affiliation(s)
- Fumihiko Miura
- Department of Surgery, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
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Briceño J, Naranjo &A, Ciria R, Sánchez-Hidalgo JM, Zurera L, López-Cillero P. Late hepatic artery pseudoaneurysm: A rare complication after resection of hilar cholangiocarcinoma. World J Gastroenterol 2008; 14:5920-3. [PMID: 18855995 PMCID: PMC2751906 DOI: 10.3748/wjg.14.5920] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We report an unusual pathological entity of a pseudoaneurysm of the right hepatic artery, which developed two years after the resection of a type II hilar cholangiocarcinoma and secondary to an excessive skeletonization for regional lymphadenectomy and neoadjuvant external-beam radiotherapy. After a sudden and massive hematemesis, a multidetector computed tomographic angiography (MDCTA) showed a hepatic artery pseudoaneurysm. Angiography with embolization of the pseudoaneurysm was attempted using microcoils with adequate patency of the hepatic artery and the occlusion of the pseudoaneurysm. A new episode of hematemesis 3 wk later revealed a partial revascularization of the pseudoaneurysm. A definitive interventional radiological treatment consisting of transarterial embolization (TAE) of the right hepatic artery with stainless steel coils and polyvinyl alcohol particles was effective and well-tolerated with normal liver function tests and without signs of liver infarction.
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16
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Pasklinsky G, Gasparis AP, Labropoulos N, Pagan J, Tassiopoulos AK, Ferretti J, Ricotta JJ. Endovascular covered stenting for visceral artery pseudoaneurysm rupture: report of 2 cases and a summary of the disease process and treatment options. Vasc Endovascular Surg 2008; 42:601-6. [PMID: 18583306 DOI: 10.1177/1538574408318478] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We present 2 cases of hemorrhage from a visceral artery pseudoaneurysm, managed successfully with endovascular covered stent placement. The first case was a 59-year-old man, 3 months after a laparoscopic distal pancreatectomy for adenoma, presenting with diffuse abdominal pain. The patient was evaluated with a computed tomography scan revealing a splenic artery pseudoaneurysm (PA) bleeding into a pancreatic pseudocyst. He was emergently taken to the angiography suite where a covered stent was deployed at the level of splenic artery PA. The second case was a 52-year-old woman with recurrent left retroperitoneal mass 5 years after distal pancreatectomy and splenectomy for a nonfunctional neuroendocrine tumor. She underwent resection of the mass in the left upper quadrant. Postoperative course was complicated by hematoma, abscess formation, reexploration, and repair of the duodenotomy and the portal vein. Subsequently, she was noted to have intermittent gastrointestinal hemorrhage, which prompted an angiogram revealing a hepatic artery PA that was repaired with a covered balloon-expandable stent. A completion angiogram was obtained in each case demonstrating exclusion of the PA. Our experience with these 2 cases supports the notion that endovascular covered stenting is a safe and effective therapy for exclusion of visceral artery aneurysm.
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Affiliation(s)
- Garri Pasklinsky
- Division of Vascular Surgery, Stony Brook University Medical Center, Stony Brook, New York 11794-8191, USA
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17
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Tien YW, Wu YM, Liu KL, Ho CM, Lee PH. Angiography is indicated for every sentinel bleed after pancreaticoduodenectomy. Ann Surg Oncol 2008; 15:1855-61. [PMID: 18415651 DOI: 10.1245/s10434-008-9894-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Revised: 02/20/2008] [Accepted: 02/20/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND Delayed massive bleeding is one of the leading causes of mortality after pancreaticoduodenectomy (PD) and is often preceded by sentinel bleed. Immediate and accurate diagnosis of sentinel bleed is essential to save patients from a delayed massive hemorrhage. Angiography is probably the procedure of choice for patients with sentinel bleed after PD, as it will localize the bleeding point and provide interventional embolization. The purpose of this study is to test the efficiency of angiography as the initial management for patients with sentinel bleed after pancreaticoduodenectomy. METHODS The study group consisted of 283 patients who underwent PD from July 2002 to June 2007. Angiography and arterial embolization were performed for every sentinel bleed and detected pseudoaneurysm. Patients (n = 311) from a previous study (July 1996-June 2002) were used as a historical control group. RESULTS Sentinel bleed was detected in 20 patients in study group. Of these, angiography-detected pseudoaneurysm was evident in seven (35%); all were successfully embolized. Delayed massive hemorrhage occurred in three of 13 patients with sentinel bleed but negative angiography. All three were operated on; one died of uncontrolled bleeding. The number of hemodynamically unstable patients before transfusion, units of transfused packed cells, and bleeding related mortalities were significantly less in study group than the control group. CONCLUSIONS Institution of angiography for every detected sentinel bleed after PD enabled us to embolize seven pseudoaneurysms before massive hemorrhage. Most importantly, bleeding-related mortality was significantly less than in the absence of angiography.
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Affiliation(s)
- Yu-Wen Tien
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, Republic of China.
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18
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Saad WEA. Management of nonocclusive hepatic artery complications after liver transplantation. Tech Vasc Interv Radiol 2008; 10:221-32. [PMID: 18086427 DOI: 10.1053/j.tvir.2007.09.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Nonocclusive arterial disease represents less than 5% of posttransplant arterial complications. Nonocclusive arterial complications are classified into (1) nonocclusive diminished flow in the hepatic artery, (2) arteriovenous fistulae, (3) pseudoaneurysms, and (4) arterial rupture. Due to the rarity of these complications, particularly when considering them individually, many of the opinions and managements of these complications are anecdotal. Transcatheter embolization is the main mode of minimal invasive management of these uncommon complications. Other minimal invasive methods have been described such as stent placement or direct percutaneous embolization/thrombosis. The article discusses the presentation, etiology, types, treatment indications, and various modes of minimal invasive therapy used to manage these complications.
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Affiliation(s)
- Wael E A Saad
- Vascular Interventional Radiology Section, Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY 14618, USA.
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19
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Moukaddam H, Al-Kutoubi A. Pseudoaneurysms of Hepatic Artery Branches: Treatment with Self-expanding Stent-grafts in Two Cases. J Vasc Interv Radiol 2007; 18:897-901. [PMID: 17609450 DOI: 10.1016/j.jvir.2007.04.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Pseudoaneurysms of the hepatic artery or its branches are rare complications with several potential causes. Herein, the authors report two cases of pseudoaneurysms of hepatic artery branches, one secondary to laparoscopic surgery and the other probably due to malignancy. The pseudoaneurysms were treated with the placement of self-expanding stent-grafts. Complete and prompt occlusion of the pseudoaneurysm was achieved in both patients, with resolution of symptoms and preservation of the blood flow in the parent arterial branch at long-term follow-up.
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Affiliation(s)
- Hicham Moukaddam
- Department of Diagnostic Radiology, the American University of Beirut Medical Center, Beirut, Lebanon
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20
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Fujii Y, Shimada H, Endo I, Yoshida KI, Matsuo KI, Takeda K, Ueda M, Morioka D, Tanaka K, Togo S. Management of massive arterial hemorrhage after pancreatobiliary surgery: does embolotherapy contribute to successful outcome? J Gastrointest Surg 2007; 11:432-8. [PMID: 17436126 PMCID: PMC1852380 DOI: 10.1007/s11605-006-0076-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Massive arterial hemorrhage is, although unusual, a life-threatening complication of major pancreatobiliary surgery. Records of 351 patients who underwent major surgery for malignant pancreatobiliary disease were reviewed in this series. Thirteen patients (3.7%) experienced massive hemorrhage after surgery. Complete hemostasis by transcatheter arterial embolization (TAE) or re-laparotomy was achieved in five patients and one patient, respectively. However, 7 of 13 cases ended in fatality, which is a 54% mortality rate. Among six survivors, one underwent selective TAE for a pseudoaneurysm of the right hepatic artery (RHA). Three patients underwent TAE proximal to the proper hepatic artery (PHA): hepatic inflow was maintained by successful TAE of the gastroduodenal artery in two and via a well-developed subphrenic artery in one. One patient had TAE of the celiac axis for a pseudoaneurysm of the splenic artery (SPA), and hepatic inflow was maintained by the arcades around the pancreatic head. One patient who experienced a pseudoaneurysm of the RHA after left hemihepatectomy successfully underwent re-laparotomy, ligation of RHA, and creation of an ileocolic arterioportal shunt. In contrast, four of seven patients with fatal outcomes experienced hepatic infarction following TAE proximal to the PHA or injury of the common hepatic artery during angiography. One patient who underwent a major hepatectomy for hilar bile duct cancer had a recurrent hemorrhage after TAE of the gastroduodenal artery and experienced hepatic failure. In the two patients with a pseudoaneurysm of the SPA or the superior mesenteric artery, an emergency re-laparotomy was required to obtain hemostasis because of worsening clinical status. Selective TAE distal to PHA or in the SPA is usually successful. TAE proximal to PHA must be restricted to cases where collateral hepatic blood flow exists. Otherwise or for a pseudoaneurysm of the superior mesenteric artery, endovascular stenting, temporary creation of an ileocolic arterioportal shunt, or vascular reconstruction by re-laparotomy is an alternative.
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Affiliation(s)
- Yoshiro Fujii
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan.
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21
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Jenssen GL, Wirsching J, Pedersen G, Amundsen SR, Aune S, Dregelid E, Jonung T, Daryapeyma A, Laxdal E. Treatment of a Hepatic Artery Aneurysm by Endovascular Stent-Grafting. Cardiovasc Intervent Radiol 2007; 30:523-5. [PMID: 17205358 DOI: 10.1007/s00270-006-0089-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Aneurysms of the visceral arteries are rare. Traditional treatment has been surgical or endovascular with coil embolization. Recently, however, reports on endovascular therapy with stent-grafts have been published. We report the case of a 61-year-old man who was successfully treated with a stent-graft for a symptomatic combined celiac/hepatic artery aneurysm.
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Affiliation(s)
- Guttorm L Jenssen
- Department of Radiology, Haukeland University Hospital, 5021 Bergen, Norway.
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22
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Sachdev U, Baril DT, Ellozy SH, Lookstein RA, Silverberg D, Jacobs TS, Carroccio A, Teodorescu VJ, Marin ML. Management of aneurysms involving branches of the celiac and superior mesenteric arteries: a comparison of surgical and endovascular therapy. J Vasc Surg 2006; 44:718-24. [PMID: 17011997 DOI: 10.1016/j.jvs.2006.06.027] [Citation(s) in RCA: 150] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2006] [Accepted: 06/25/2006] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Aneurysms involving branches of the superior mesenteric and celiac arteries are uncommon and require proper management to prevent rupture and death. This study compares surgical and endovascular treatment of these aneurysms and analyzes outcome. METHODS Patients at the Mount Sinai Medical Center in New York who were treated for aneurysms in the branches of the celiac artery and superior mesenteric artery were identified through a search of the institution's medical records and endovascular database. Patient demographics, history, clinical presentation, aneurysm characteristics, treatments, and follow-up outcome were retrospectively recorded. Significant differences between patients treated by surgical or endovascular therapy were determined by using Student's t test and chi2 analysis. RESULTS Between January 1, 1991, and July 1, 2005, 59 patients with 61 aneurysms were treated at a single institution. Twenty-four patients had surgical repair, and 35 underwent endovascular treatment, which included coil embolization and stent-graft therapy. Splenic (28) and hepatic (22) artery aneurysms predominated. Eighty-nine percent of splenic artery aneurysms were true aneurysms and were treated by endovascular and surgical procedures in near equal numbers (14 and 11, respectively). Pseudoaneurysms were significantly more likely to be treated by endovascular means (P < .01). The technical success rate of endovascular treatment for aneurysms was 89%, and failures were successfully treated by repeat coil embolization in all patients who presented for retreatment. Patients treated by endovascular techniques had a significantly higher incidence of malignancy than patients treated with open surgical techniques (P = .03). Furthermore, patients treated by endovascular means had a shorter in-hospital length of stay (2.4 vs 6.6 days, P < .001). CONCLUSION Endovascular management of visceral aneurysms is an effective means of treating aneurysms involving branches of the celiac and superior mesenteric arteries and is particularly useful in patients with comorbidities, including cancer. It is associated with a decreased length of stay in the elective setting, and failure of primary treatment can often be successfully managed percutaneously.
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Affiliation(s)
- Ulka Sachdev
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Medical Center, New York, NY 10029, USA.
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Abstract
A porto-biliary fistula causing hemobilia is a known complication of percutaneous transhepatic biliary drainage (PTBD). We present two patients with hemobilia secondary to porto-biliary fistula, treated successfully by percutaneous placement of stent-grafts. In one case, the stent-graft was placed in the bile duct, and in the other case, it was placed in the intrahepatic portal vein branch. Hemobilia stopped and there were no complications except a small area of hepatic infarction, distal to the stent-graft in the portal vein.
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Affiliation(s)
- Bora Peynircioglu
- Department of Radiology, University of Michigan Hospital, Ann Arbor, MI, USA
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24
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Zealley IA, Tait IS, Polignano FM. Delayed massive hemorrhage after pancreatic and biliary surgery: embolization or surgery? Ann Surg 2006; 243:138-9; author reply 139. [PMID: 16371750 PMCID: PMC1449978 DOI: 10.1097/01.sla.0000195020.02707.a0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Cimsit B, Ozden I, Emre AS. A rare intraabdominal tumor: giant hepatic artery aneurysm. THE JOURNAL OF MEDICAL INVESTIGATION 2006; 53:174-6. [PMID: 16538012 DOI: 10.2152/jmi.53.174] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
A 55-year-old man was investigated for right upper abdominal quadrant pain. He had no history of abdominal trauma or surgery. Imaging studies showed a common hepatic artery aneurysm involving the gastroduodenal artery. Following aneurysmectomy, examination with a hand Doppler apparatus yielded clear arterial signals from the liver surface. Therefore, vascular reconstruction was not performed. He had an uneventful postoperative course.
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Affiliation(s)
- Bayindir Cimsit
- Department of General Surgery, Hepatopancreatobiliary Unit, Istanbul University, Istanbul Faculty of Medicine, Turkey
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