Pseudoaneurysmal Rupture of the Common

Spiridon Vernadakis, Evangelos Christodoulou, Jürgen Treckmann,
Fuat Saner, Andreas Paul, Zoltan Mathe
Department of General, Visceral and Transplantation Surgery, University Hospital.
Essen, Germany
ABSTRACT
Context Pseudoaneurysm of the hepatic artery after a pancreaticoduodenectomy is a serious complication, which should always be
considered in the differential diagnosis when late bleeding has occurred. Case report We report a case of pseudoaneurysmal rupture
of the common hepatic artery into the biliodigestive anastomosis. A 55 year old female patient with a history of pancreatic head
cancer underwent a pylorus preserving pancreaticoduodenectomy at our hospital in September 2008. Six days postoperatively the
patient underwent surgery because of sentinel bleeding of a portal vein branch. On the 40th postoperative day she presented melena.
Upper gastrointestinal endoscopy indicated bleeding near the biliodigestive anastomosis. An emergency angiography demonstrated a
pseudoaneurysm of the common hepatic artery. Transcatheter arterial embolization was performed and a hemodynamic stabilization
of the patient was achieved. Six days after the embolization the patient developed hemorrhagic shock and an urgent relaparotomy
was carried out. The explorative laparotomy revealed bleeding of the common hepatic artery into the biliodigestive anastomosis in
the form of an arteriointestinal fistula. The anastomosis was opened, the ruptured pseudoaneurysm was sutured, and a new
biliodigestive anastomosis was made. The patient has been well for two months with good liver function, without rebleeding.
Conclusion This case illustrates the occurrence of a rare complication (rupture of a hepatic artery pseudoaneurysm) inside the
biliodigestive anastomosis after pancreaticoduodenectomy, appearing as upper gastrointestinal bleeding. Different modalities such as
transarterial embolization and the use of stents give promising results, but ligation of the pseudoaneurysm and repair of the intestinal
communication is also an effective modality of treatment.
INTRODUCTION
Almost 50% of hepatic artery aneurysms are
pseudoaneurysms and are mainly associated with
interventional procedures of the biliary tract and are
diagnosed with greater frequency nowadays thanks to
the increased use of CT-scan after blunt abdominal
trauma [1, 2]. Bleeding from a pseudoaneurysm of the
major visceral arteries is an uncommon but important
complication which can occur postoperatively. Delayed
massive hemorrhage complicated by fistula formation
is a common cause of death after pancreatico-
duodenectomy. The observation of sentinel bleeding
should lead to emergency angiography, and depending
on the result, to emergency relaparotomy to increase
the likelihood of survival [3]. Hepatic artery
pseudoaneurysm can result in hemorrhage into the
gastrointestinal tract when an abnormal communication
is established between the vessel and the enteric part
involve. We report the case of a ruptured aneurysm of
the common hepatic artery into the biliodigestive
anastomosis.
CASE REPORT
A 55-year-old Caucasian woman with a history of
pancreatic head cancer underwent a pylorus preserving
pancreaticoduodenectomy operation at our hospital in
September 2008. The patient had no history of
abdominal trauma, liver surgery or percutaneous
interventions. The intraoperative course was
uneventful. Postoperatively the patient displayed
anxiety with a low hemoglobin concentration (6.5
g/dL; reference range: 12.0-15.2 g/dL). The patient was
immediately re-operated, however the laparotomy did
not reveal an obvious bleeding source. After 48 hours
of intensive care monitoring and an additional 72-hour
stay in the clinic with no further hemodynamic
instability, the symptoms reappeared. Moreover she
had sentinel bleeding from her abdominal drains. She
was resuscitated with intravenous fluids and blood
transfusions. The patient was operated on once again.
Received April 5th, 2009 - Accepted June 4th, 2009
Key words
Aneurysm, Ruptured; Hepatic Artery;
Pancreaticoduodenectomy
Correspondence Spiridon Vernadakis
Department of General, Visceral and Transplantation Surgery,
University Essen, Hufelandstrasse, 55, 45122 Essen, Germany
Phone: +49-201.723.85857; Fax: +49-201.723.5631
E-mail: spiridon.vernadakis@uk-essen.de
Document URL http://www.joplink.net/prev/200907/15.html

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JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 10, No. 4 - July 2009. [ISSN 1590-8577]
442
This time the laparotomy showed a bleeding portal
vein branch under the biliodigestive anastomosis. The
leakage was sutured and the bleeding was stopped.
After a short stay in the intensive care unit, the patient
showed no further symptoms and was released. Thirty-
three days later the patient was readmitted with melena
as the dominant symptom. An initial diagnosis was
made through an upper gastrointestinal endoscopy
which indicated bleeding in the anastomotic area. The
selective hepatic artery angiogram confirmed the
existence of a pseudoaneurysm of the right hepatic
artery deriving from the superior mesenteric artery, in
relation to the biliodigestive anastomosis. An
embolization of the pseudoaneurysm was planned.
After super selective catheterization of the hepatic
artery, the aneurysm was embolized using gel foam and
micro coils (Figures 1, 2, and 3). The patient was
monitored in the intensive care unit where she
remained stable hemodynamically and did not have any
further episode of upper gastrointestinal bleeding. Six
days after this last intervention, there was suddenly
another reduction of the hemoglobin concentration (6.0
g/dL) together with abdominal pain and the appearance
of peritoneal signs. The clinical features suggested the
possibility of intra-abdominal bleeding, so the patient
immediately underwent another laparotomy. The
explorative laparotomy proved the existence of new
acute bleeding, this time inside the biliodigestive
anastomosis. The pseudoaneurysm of the common
hepatic artery had ruptured inside the anastomosis in
the form of an arteriointestinal fistula. The anastomosis
was opened and the ruptured pseudoaneurysm was
sutured. A new connection to the intestinal track was
effectuated..
Post-operatively the patient remained in the intensive
care unit for two days and an additional 14 days in the
clinic for observation. Two months later on a follow-up
she was doing well.
DISCUSSION
Pseudoaneurysms arise as a consequence of visceral
inflammation adjacent to the arterial wall, which
damages to the adventitia and leads to thrombosis of
the vasa vasorum resulting in localized weakness of the
vessel wall. Digestion of the hepatic arterial wall due to
infectious bile from anastomotic leakage, arterial
irritation due to a localized abscess in the inferior
hepatic space and mechanical injury of the artery
during the operation (mainly due to lymph node
dissection for malignancy), are the three predisposing
factors for pseudoaneurysmatic formation after
surgery. These are prone to rupture [4, 5].
Figure 1. Selective hepatic artery angiogram showing a
pseudoaneurysm of the common hepatic artery.
Figure 2. Angio-embolization of the pseudoaneurysm.
Figure 3. Post- embolization image showing non-filling of the
pseudoaneurysm

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Pseudoaneurysm of the hepatic artery is a rare and
potentially life threatening entity [6]. Among the
visceral artery pseudoaneurysms, pseudoaneurysms of
the hepatic artery are the second most common [7].
Causes include blunt or penetrating abdominal trauma,
liver surgery, and less commonly, percutaneous
interventional procedures involving the liver (biopsy or
biliary stent placement) [8, 9]. Pancreatitis may also
cause pseudoaneurysms of the hepatic artery but more
frequently it affects other branches of the celiac axis,
most commonly the splenic branch [10, 11]. Hepatic
artery pseudoaneurysms related to a pancreatico-
duodenectomy are rare complications. Postoperative
bleeding complications are reported in 5-16% of
patients after pancreaticoduodenectomy and are
associated with a high morbidity and mortality. Late
bleeding after pancreaticoduodenectomy is usually
massive with peripheral circulatory impairment. It
occurs suddenly, after the second or third post-
operative weeks in hemodynamically stable patients,
sometimes after an apparently uneventful postoperative
course [3]. However, to our knowledge, in addition to
the cases currently reported in the literature, it is the
first time an arteriointestinal fistula has been reported
to have developed inside the biliodigestive
anastomosis. In most cases the hemorrhage developed
from pseudoaneurysms of the major arteries around the
pancreaticojejunostomy [12]. Visceral pseudo-
aneurysms usually present abdominal pain but there are
patients having ruptured pseudoaneurysms without any
clinical symptoms [13]. Other unusual presentations
include upper gastrointestinal hemorrhage or
obstructive jaundice. Our patient presented both
abdominal pain and upper gastrointestinal hemorrhage
but no jaundice. The initial investigation for a patient
having such symptoms is ultrasonography with color
Doppler. However, the fact that most patients
experience sentinel bleeding 0-6 days before massive
bleeding, indicates the need for immediate assessment
by contrast CT or angiography. A multidetector row
CT scanner can depict both hepatic artery anatomy and
pathology efficiently and accurately and it has proved
useful in detecting extrahepatic hepatic artery
complications such as pseudoaneurysm or dissection
[14, 15]. An upper gastrointestinal endoscopy, in most
cases, does not reveal any lesions in the stomach and
duodenum. In our case, it was helpful in that it revealed
the source of bleeding as being the biliodigestive
anastomosis. A selective hepatic artery angiography is
the diagnostic modality of choice when a
pseudoaneurysm is suspected. It helps in making the
diagnosis, provides anatomical details of the visceral
arteries important for the preoperative planning and it
can help to avoid the need to operate. Moreover,
together with embolization, it can stabilize the patient
and convert an emergency situation into a semi-elective
one. Transarterial embolization seems to be a treatment
option for preventing major hemorrhage if any
anomaly is detected, as shown in recent case reports
and studies, but the clinical relevance has not yet been
evaluated in larger studies. Sato et al. [16] and Yoshida
et al. [17] have both shown that transarterial
embolization allows for temporary control of major
hemorrhaging providing hemodynamic stabilization of
most patients and a low recurrence rate of about 14%.
Nonetheless, in their series, it did not seem to be an
alternative to exploration; given the fact that the
mortality rate was 57% due to systemic sepsis and
multi-organ failure. Based on the latest studies,
interventional radiology with selective embolization of
pseudoaneurysm is a safe and a definitive treatment in
most cases. Angiographic embolization should be
performed proximal and distal to the origin of the
pseudoaneurysm rather than proceeding with
embolization in the pseudoaneurysmal cavity [5].
Various methods have been used for successful
embolization; intravascular coils, gelatine foam,
cyanoacrylate glue, ethanol sclerosant, and detachable
balloons [18]. Percutaneous transcatheter embolization
with metallic coils has an 85% success rate of [2].
However, because of the fewer collaterals than normal
after the Whipple procedure, embolization of the
hepatic artery may result in liver abscess, cholangitis or
even in fatal liver failure in the case of disruption of the
hepatic arterial flow. Thus, the implantation of a
covered stent may be better than transarterial
embolization for preserving hepatic arterial blood flow.
However, no evidence is available concerning the
safety and long-term patency of the covered stent for
pseudoaneurysms after the Whipple procedure [14].
The surgical approach involving ligation of the hepatic
artery distal to the celiac axis remains the most
promising treatment of late intra-abdominal
hemorrhage due to the fact that hemostasis, subsequent
to suturing, could stop arterial bleeding without
blocking blood flow [19, 20]. In our case the
arteriointestinal fistula was sutured and a new
biliodigestive anastomosis was realized.. Proximal
control of the hepatic artery should always be
attempted first. Post-operatively, liver function should
also be controlled via blood-tests, as well as
sonographically by checking the perfusion of the
hepatic vessels.
CONCLUSION
Pseudoaneurysm of the hepatic artery after a
pancreaticoduodenectomy is a rare but serious
complication. Early diagnosis can be difficult even in
symptomatic patients. Angiography and transarterial
embolization are the means used for diagnosis and
hemostasis, respectively, and are necessary to bring the
patient out of hemorrhagic shock thus bridging the time
until the patient can be operated upon .Some studies
have provided promising results regarding the
placement of covered stents in order to bridge the
pseudoaneurysm of the visceral artery, but no sufficient
follow-ups exist as yet. Operative ligation of the
pseudoaneurysm remains, in some cases, the treatment
of choice. Finally the existence of an arteriovisceral

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JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 10, No. 4 - July 2009. [ISSN 1590-8577]
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fistula and bleeding inside the anastomosis should also
be part of the differential diagnosis.
Conflict of interest The authors have no potential
conflict of interest
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