We report a 74-year-old man with rebleeding following stent grafting for the celiac artery bleeding which developed after extended pancreaticoduodenectomy for cancers of the bile duct and stomach. The site of rebleeding seemed to be different from the site of the first bleeding, so it was considered not an endoleak but a new bleeding. It was successfully treated by placement of another stent graft

Junichi Honda

Kengo Ohta

Masahiro Muto

Masashi Shimohira

Takuya Hashizume

Tatsuya Kawai

Yuta Shibamoto

PubMed

Crossref

Hindawi Publishing CorporationCase Reports in Vascular MedicineVolume 2013, Article ID 781698, 3 pageshttp://dx.doi.org/10.1155/2013/781698Case ReportRebleeding after Stent Grafting for the Celiac Artery Bleedingfollowing Extended PancreaticoduodenectomyKengo Ohta, Masashi Shimohira, Takuya Hashizume, Tatsuya Kawai, Masahiro Muto,Junichi Honda, and Yuta ShibamotoDepartment of Radiology, Graduate School of Medical Sciences, Nagoya City University, Nagoya 467-8601, JapanCorrespondence should be addressed to Kengo Ohta; rug by no8@yahoo.co.jpReceived 20 August 2013; Accepted 14 November 2013Academic Editors: W.-Y. Chung and S. YamashiroCopyright © 2013 Kengo Ohta et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.We report a 74-year-old man with rebleeding following stent grafting for the celiac artery bleeding which developed after extendedpancreaticoduodenectomy for cancers of the bile duct and stomach. The site of rebleeding seemed to be different from the site ofthe first bleeding, so it was considered not an endoleak but a new bleeding. It was successfully treated by placement of another stentgraft.1. IntroductionBleeding after pancreaticoduodenectomy is a fatal compli-cation, and endovascular treatment is widely performed.Recently it has been reported that stent grafting is especiallyan appropriate treatment [1]. Here, we present a rare com-plication of rebleeding developing 40 days after stent graftplacement in the celiac artery.2. Case ReportA 74-year-old man with distal bile duct cancer and gas-tric cancer underwent extended pancreaticoduodenectomy.Thereafter, leakage of pancreatic juice occurred, for whichdrainage treatment was performed. At 12 days after surgery, ableeding from the drainage tube and low blood pressure wereobserved, so an emergency angiography was performed. Ableeding from the celiac artery was observed on angiography(Figure 1), and a 5 Fr balloon catheter was inflated in theceliac artery for temporary hemostasis, because we neededsome time to discuss with surgeons and to prepare a stentgraft. Then, a stent graft (Niti-S; Century Medical, Tokyo,Japan) with a diameter of 10mm and a length of 5 cm wasplaced at the celiac artery to the common hepatic arterysuccessfully (Figure 2). Resection of the residual stomach,residual pancreas, and spleen was immediately performedfollowing the stent grafting. After that, wound infectionand insufficient anastomosis of the esophagus and jejunumwere observed; leukocyte count was 5,400/𝜇L and C-reactiveprotein level was 5.4mg/mL. So, drainage treatment wasperformed. At 40 days after this stent grafting and surgery,melena and reduction of blood pressure were observed.Therefore, emergency angiography was performed, whichrevealed a bleeding from the celiac artery (Figure 3). Itseemed to be from a distal site apart from the site of thefirst bleeding, and it was considered not a leakage but anew bleeding. Under fluoroscopy, it was confirmed that thestent graft was not broken. Temporary balloon hemostasiswas performed again. Then, we discussed with our surgeonand decided to perform the stent grafting, because it seemedreally difficult to reach the celiac artery under laparotomydue to strong adhesion caused by the previous operation.Thereafter, the stent graft (Niti-S) with a diameter of 10mmand a length of 6 cm was placed at the inside of the initialstent graft to the distal site successfully (Figure 4). There wasno recurrence of bleeding during a 3-month followup period.No antithrombotic therapy was given during follow-up.3. DiscussionDelayed arterial bleeding after pancreaticoduodenectomy isnot common, but a potentially fatal complication [2–4].2 Case Reports in Vascular MedicineFigure 1: Angiography shows bleeding from celiac artery (arrow).Figure 2: Angiography shows successful placement of the stentgraft.Massive arterial bleeding occurs as a result of inflammatoryvascular erosion related to pancreatic juice or bile leakingfrom an insufficient anastomosis or local infection. Surgicalexploration and identification may be difficult in acute situa-tions and hazardous because of adhesions and surroundingpostsurgical tissue friability [5, 6]. Thus, the endovasculartreatment such as transcatheter arterial embolization (TAE)or stent grafting is widely performed. Gwon et al. [1]compared TAE and stent grafting for extrahepatic arterybleeding after pancreatobiliary surgery. They reported thattwo patients in the TAE group died of hepatic failureand multiorgan failure within 7 days. Furthermore, hepaticischemia and infarction were observed in six (33%, 6/18) andeight (44%, 8/18) patients, respectively, and hepatic abscesswith hepatic infarction was observed in one patient (5.6%,1/18). On the other hand, early stent thrombosis with bileduct necrosis was observed in one patient in the stent graftinggroup (14%, 1/7). They concluded that stent grafting is betterthan TAE for preserving intrahepatic arterial flow.In this case, therefore, we did not perform TAE butperformed stent graft placement after the first angiography.At second angiography, however, it was not easy to decidetreatment strategy, because the bleeding seemed to haveoccurred at a distal site apart from the first bleeding site. So,Figure 3: Angiography shows rebleeding from a distal site apartfrom the first bleeding site (arrow).Figure 4: Angiography shows successful placement of the stent graftat the inside of the initial stent graft to the distal site.we thought it was caused by abdominal infection followingintestinal insufficient anastomosis. Thus, at that time, weconsideredTAE instead of stent grafting because the commonhepatic arterymight have been involved by inflammation andfragility. However, as a result of discussion with the surgeon,we decided to perform stent grafting to protect the liver, andif rebleeding occurs again, we will perform TAE.A few complications after stent graft treatment werereported [1–3]. Rebleedings due to the dislodgment of stentgrafts have been reported but most of them occurred withina day [2]. We experienced delayed bleeding at 40 days afterstent graft treatment. Thus, one should be aware of thiscomplication, and careful observation after stent graftingwith infection is recommended.Conflict of InterestsThe authors declare that they have no conflict of interests.References[1] D. I. Gwon, G. Y. Ko, K. B. Sung, J. H. Shin, J. H. Kim, andH. K. Yoon, “Endovascular management of extrahepatic arteryCase Reports in Vascular Medicine 3hemorrhage after pancreatobiliary surgery: clinical features andoutcomes of transcatheter arterial embolization and stent-graftplacement,”TheAmerican Journal of Roentgenology, vol. 196, no.5, pp. W627–W634, 2011.[2] M.Q.Wang, F. Y. Liu, F. Duan, Z. J.Wang, P. Song, andQ. S. Fan,“Stent-grafts placement for treatment of massive hemorrhagefrom ruptured hepatic artery after pancreaticoduodenectomy,”World Journal of Gastroenterology, vol. 16, no. 29, pp. 3716–3722,2010.[3] C. Stoupis, K. Ludwig,D. Inderbitzin,D.Do, and J. Triller, “Stentgrafting of acute hepatic artery bleeding following pancreatichead resection,” European Radiology, vol. 17, no. 2, pp. 401–408,2007.[4] B. W. Miedema, M. G. Sarr, J. A. van Heerden, D. M. Nagor-ney, D. C. McIlrath, and D. Ilstrup, “Complications followingpancreaticoduodenectomy: current management,” Archives ofSurgery, vol. 127, no. 8, pp. 945–950, 1992.[5] S. M. M. de Castro, K. F. D. Kuhlmann, O. R. C. Busch etal., “Delayed massive hemorrhage after pancreatic and biliarysurgery: embolization or surgery?” Annals of Surgery, vol. 241,no. 1, pp. 85–91, 2005.[6] F. Miura, T. Asano, H. Amano et al., “Management of post-operative arterial hemorrhage after pancreato-biliary surgeryaccording to the site of bleeding: re-laparotomy or interven-tional radiology,” Journal of Hepato-Biliary-Pancreatic Surgery,vol. 16, no. 1, pp. 56–63, 2009.Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and TreatmentAIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

Case Reports in Vascular Medicine

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Rebleeding after Stent Grafting for the Celiac Artery Bleeding following Extended Pancreaticoduodenectomy

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Hindawi Publishing CorporationCase Reports in Vascular MedicineVolume 2013, Article ID 781698, 3 pageshttp://dx.doi.org/10.1155/2013/781698Case ReportRebleeding after Stent Grafting for the Celiac Artery Bleedingfollowing Extended PancreaticoduodenectomyKengo Ohta, Masashi Shimohira, Takuya Hashizume, Tatsuya Kawai, Masahiro Muto,Junichi Honda, and Yuta ShibamotoDepartment of Radiology, Graduate School of Medical Sciences, Nagoya City University, Nagoya 467-8601, JapanCorrespondence should be addressed to Kengo Ohta; rug by no8@yahoo.co.jpReceived 20 August 2013; Accepted 14 November 2013Academic Editors: W.-Y. Chung and S. YamashiroCopyright © 2013 Kengo Ohta et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.We report a 74-year-old man with rebleeding following stent grafting for the celiac artery bleeding which developed after extendedpancreaticoduodenectomy for cancers of the bile duct and stomach. The site of rebleeding seemed to be different from the site ofthefirstbleeding,soitwasconsiderednotanendoleakbutanewbleeding.Itwassuccessfullytreatedbyplacementofanotherstentgraft.1. IntroductionBleeding after pancreaticoduodenectomy is a fatal compli-cation, and endovascular treatment is widely performed.Recently it has been reported that stent grafting is especiallyan appropriate treatment [1] .H e r e ,w ep r e s e n tar a r ec o m -plication of rebleeding developing 40 days after stent graftplacement in the celiac artery.2. Case ReportA 74-year-old man with distal bile duct cancer and gas-tric cancer underwent extended pancreaticoduodenectomy.Thereafter, leakage of pancreatic juice occurred, for whichdrainage treatment was performed. At 12 days after surgery, ableeding from the drainage tube and low blood pressure wereo b s e r v e d ,s oa ne m e r g e n c ya n g i o g r a p h yw a sp e r f o r m e d .Ableeding from the celiac artery was observed on angiography(Figure 1), and a 5Fr balloon catheter was inflated in theceliac artery for temporary hemostasis, because we neededsome time to discuss with surgeons and to prepare a stentgraft. Then, a stent graft (Niti-S; Century Medical, Tokyo,J a p a n )w i t had i a m e t e ro f1 0m ma n dal e n g t ho f5c mw a splaced at the celiac artery to the common hepatic arterysuccessfully (Figure 2). Resection of the residual stomach,residual pancreas, and spleen was immediately performedfollowing the stent grafting. After that, wound infectionand insufficient anastomosis of the esophagus and jejunumwere observed; leukocyte count was 5,400/𝜇L and C-reactiveprotein level was 5.4mg/mL. So, drainage treatment wasperformed. At 40 days after this stent grafting and surgery,melena and reduction of blood pressure were observed.Therefore, emergency angiography was performed, whichrevealed a bleeding from the celiac artery (Figure 3). Its e e m e dt ob ef r o mad i s t a ls i t ea p a r tf r o mt h es i t eo ft h efirst bleeding, and it was considered not a leakage but anew bleeding. Under fluoroscopy, it was confirmed that thestent graft was not broken. Temporary balloon hemostasiswas performed again. Then, we discussed with our surgeonand decided to perform the stent grafting, because it seemedreally difficult to reach the celiac artery under laparotomydue to strong adhesion caused by the previous operation.Thereafter, the stent graft (Niti-S) with a diameter of 10mmand a length of 6cm was placed at the inside of the initialstent graft to the distal site successfully (Figure 4). There wasnorecurrenceofbleedingduringa3-monthfollowupperiod.No antithrombotic therapy was given during follow-up.3. DiscussionDelayed arterial bleeding after pancreaticoduodenectomy isnot common, but a potentially fatal complication [2–4].2 Case Reports in Vascular MedicineFigure 1: Angiography shows bleeding from celiac artery (arrow).Figure 2: Angiography shows successful placement of the stentgraft.Massive arterial bleeding occurs as a result of inflammatoryvascular erosion related to pancreatic juice or bile leakingfrom an insufficient anastomosis or local infection. Surgicalexploration and identification may be difficult in acute situa-tions and hazardous because of adhesions and surroundingpostsurgical tissue friability [5, 6]. Thus, the endovasculartreatment such as transcatheter arterial embolization (TAE)or stent grafting is widely performed. Gwon et al. [1]compared TAE and stent grafting for extrahepatic arterybleeding after pancreatobiliary surgery. They reported thattwo patients in the TAE group died of hepatic failureand multiorgan failure within 7 days. Furthermore, hepaticischemia and infarction were observed in six (33%, 6/18) andeight (44%, 8/18) patients, respectively, and hepatic abscesswith hepatic infarction was observed in one patient (5.6%,1/18). On the other hand, early stent thrombosis with bileductnecrosiswasobservedinonepatientinthestentgraftinggroup (14%, 1/7). They concluded that stent grafting is betterthan TAE for preserving intrahepatic arterial flow.In this case, therefore, we did not perform TAE butperformed stent graft placement after the first angiography.At second angiography, however, it was not easy to decidetreatment strategy, because the bleeding seemed to haveoccurred at a distal site apart from the first bleeding site. So,Figure 3: Angiography shows rebleeding from a distal site apartfrom the first bleeding site (arrow).Figure4:Angiographyshowssuccessfulplacementofthestentgraftat the inside of the initial stent graft to the distal site.we thought it was caused by abdominal infection followingintestinal insufficient anastomosis. Thus, at that time, weconsideredTAEinsteadofstentgraftingbecausethecommonhepaticarterymighthavebeeninvolvedbyinflammationandf r a g i l i t y .H o w e v e r ,a sar e s u l to fd i s c u s s i o nw i t ht h es u r g e o n ,we decided to perform stent grafting to protect the liver, andif rebleeding occurs again, we will perform TAE.A few complications after stent graft treatment werereported [1–3]. Rebleedings due to the dislodgment of stentg r a ft sh a v eb e e nr e p o r t e db u tm o s to ft h e mo c c u r r e dw i t h i nad a y[ 2]. We experienced delayed bleeding at 40 days afterstent graft treatment. Thus, one should be aware of thiscomplication, and careful observation after stent graftingwith infection is recommended.Conflict of InterestsThe authors declare that they have no conflict of interests.References[1] D. I. Gwon, G. Y. Ko, K. B. Sung, J. H. Shin, J. H. Kim, andH. K. Yoon, “Endovascular management of extrahepatic arteryCase Reports in Vascular Medicine 3hemorrhageafterpancreatobiliarysurgery:clinicalfeaturesandoutcomes of transcatheter arterial embolization and stent-graftplacement,”TheA mericanJournalofRoentgenology,vol.196,no.5, pp. W627–W634, 2011.[2] M.Q .W ang,F .Y .Liu,F .Duan,Z.J .W ang,P .Song,andQ .S.Fan,“Stent-grafts placement for treatment of massive hemorrhagefrom ruptured hepatic artery after pancreaticoduodenectomy,”World Journal of Gastroenterology,vol.16,no .29 ,pp .3716–3722,2010.[3] C.Stoupis,K.Ludwig,D.Inderbitzin,D.Do,andJ.T riller ,“Stentgrafting of acute hepatic artery bleeding following pancreatichead resection,” European Radiology,v o l .1 7 ,n o .2 ,p p .4 0 1 – 4 0 8 ,2007.[ 4 ]B .W .M i e d e m a ,M .G .S a r r ,J .A .v a nH e e r d e n ,D .M .N a g o r -ney, D. C. McIlrath, and D. Ilstrup, “Complications followingpancreaticoduodenectomy: current management,” Archives ofSurgery,v o l .1 2 7 ,n o .8 ,p p .9 4 5 – 9 5 0 ,1 9 9 2 .[ 5 ]S .M .M .d eC a s t r o ,K .F .D .K u h l m a n n ,O .R .C .B u s c he ta l . ,“ D e l a y e dm a s s i v eh e m o r r h a g ea ft e rp a n c r e a t i ca n db i l i a r ysurgery: embolization or surgery?” Annals of Surgery,v o l .2 4 1 ,no. 1, pp. 85–91, 2005.[ 6 ]F .M i u r a ,T .A s a n o ,H .A m a n oe ta l . ,“ M a n a g e m e n to fp o s t -operative arterial hemorrhage after pancreato-biliary surgeryaccording to the site of bleeding: re-laparotomy or interven-tional radiology,” Journal of Hepato-Biliary-Pancreatic Surgery,v o l .1 6 ,n o .1 ,p p .5 6 – 6 3 ,2 0 0 9 .Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and Treatment AIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

C.Stoupis,K.Ludwig,D.Inderbitzin,D.Do,andJ.T riller ,“Stent grafting of acute hepatic artery bleeding following pancreatic head resection,”

Endovascular management of extrahepatic arteryCase Reports in Vascular Medicine 3 hemorrhageafterpancreatobiliarysurgery:clinicalfeaturesand outcomes of transcatheter arterial embolization and stent-graft placement,”TheA

i u r a ,T .A s a n o ,H .A m a n oe ta l . ,“ M a n a g e m e n to fp o s t -operative arterial hemorrhage after pancreato-biliary surgery according to the site of bleeding: re-laparotomy or interventional radiology,”

M .d eC a s t r o ,K .F .D .K u h l m a n n ,O .R .C .B u s c he t a l . ,“ D e l a y e dm a s s i v eh e m o r r h a g ea ft e rp a n c r e a t i ca n db i l i a r y surgery: embolization or surgery?”

M i e d e m a ,M .G .S a r r ,J .A .v a nH e e r d e n ,D .M .N a g o r

S.Fan, “Stent-grafts placement for treatment of massive hemorrhage from ruptured hepatic artery after pancreaticoduodenectomy,”

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Rebleeding after Stent Grafting for the Celiac Artery Bleeding following Extended Pancreaticoduodenectomy

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