Interventional Radiology for Management of Celiac Trunk Bleeding after Pancreatic Surgery

Abstract

A 58-year-old woman had massive abdominal bleeding from the splenic artery and the celiac trunk (A) 1 month after pyloruspreserving pancreaticoduodenectomy for duodenal adenoma with high-grade intraepithelial neoplasia. The bleeding was successfully controlled by interventional radiology. The splenic artery was occluded completely with 12 microcoils (A-E; large arrows), and a covered stent was placed into the left gastric artery (A, E, small arrows) by superselective catheterization. The liver received sufficient arterial blood supply from an abberant left liver artery (A, asterisk) arising from the left gastric artery, instead of the usual right liver artery. CT scan shows sufficient perfusion of the liver 9 days after the intervention (F, black asterisks), and shows the gastric artery stent (F, small arrows) and the microcoils (F, large arrows) in the splenic artery. Initially, the arterial perfusion of the liver and stomach appeared sufficient, but the splenic artery was at risk for splenic infarction. Later a 5 5-cm gastric ulcer developed at the lesser curvature, and was managed conservatively. Because of sufficient blood supply through the stented gastric artery, the ulcer healed without perforation. Splenic infarction (F, white asterisk) did occur from the compromised perfusion after occlusion of the splenic artery. The excess fluid surrounding the spleen was managed with interventional CT-controlled drainage (G). Perfusion of the left liver lobe segments II and III appeared diminished (H, asterisk), while the right liver lobe had sufficient blood supply from the portal vein. These complications were negligible compared with the life-threatening bleeding complications, which were successfully controlled. If surgical reintervention had been necessary, gastrectomy and splenectomy would have been the consequence. After full recovery the patient was discharged home from the hospital in fine condition. Six weeks after the procedure, repeat CT-angiography showed good blood flow in the stented left gastric artery and left liver artery. Bleeding from eroded vessels is a frequent complication after pancreatic surgery, especially after radical resection for pancreatic cancer, 8.6% in a series by Rumstadt and coworkers. Vessels in the immediate area are at risk of septic complications, for example the branches of the celiac trunk, which are dissected free during lymphadenectomy. Intestinal contents and pancreatic fluids from anastomotic leakage may cause erosion of vessels or A