Postpancreatectomy Hemorrhage: Imaging and Interventional Radiological Treatment

Transcription

1 Postpancreatectomy Hemorrhage: Imaging and Interventional Radiological Treatment Poster No.: C-1422 Congress: ECR 2014 Type: Educational Exhibit Authors: T. Matsuura, K. Takase, T. Hasegawa, H. Ota, K. Seiji, R. Tamura, S. Takahashi; Sendai/JP Keywords: Haemorrhage, Stents, Embolisation, Catheters, CT, Catheter arteriography, Pancreas, Interventional vascular DOI: /ecr2014/C-1422 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 28

2 Learning objectives The aim of this educational exhibit is to 1) Describe the clinical features of postpancreatectomy hemorrhage (PPH) 2) Illustrate the emergency role of CT angiography in the evaluation and localization of active PPH 3) Discuss vascular interventional techniques used in the management of PPH Page 2 of 28

3 Background Postpancreatectomy Hemorrhage The most frequent postoperative complications after pancreatic surgery include delayed gastric emptying, postoperative pancreatic fistula, intraabdominal abscess, and postpancreatectomy hemorrhage (PPH). PPH occurs between 1-8% of pancreatic resections but accounts for 11-38% of mortality. The clinical significance of PPH, therefore, is of critical importance. The International Study Group of Pancreatic Surgery (ISGPS) categorized PPH into three grades: A, B, and C. The grading scheme is based on three parameters: time of onset, location, and severity of hemorrhage (Fig. 1). Patients with grade B PPH have 3-6% of mortality. In the patients with grade C PPH, the mortality rate is 16-34%. Page 3 of 28

4 Fig. 1: International Study Group of Pancreatic Surgery (ISGPS) definition of PPH References: Diagnostic Radiology - Sendai/JP Time of onset In the early PPH, hemorrhage is usually caused by technical failure or coagulopathy and requires repeat laparotomy and surgical hemostasis. In the late PPH, hemorrhage can result from vessel erosion in the case of pancreatic leakage, intraabdominal infection with vessel involvement, or vascular injury during resection and pseudoaneurysm formation in the postoperative interval. Sentinel bleeding often occurs before the onset of late hemorrhage. Location (Fig. 2) Page 4 of 28

5 Postoperative hemorrhage can be either intraluminal (within the bowel) or extraluminal. Intraluminal hemorrhage will usually present with hematemesis or melena, whereas extraluminal hemorrhage often comes to clinical attention as a result of blood in abdominal drains or a dropping hematocrit. Fig. 2: Location of hemorrhage References: Diagnostic Radiology - Sendai/JP Page 5 of 28

6 Images for this section: Fig. 1: International Study Group of Pancreatic Surgery (ISGPS) definition of PPH Page 6 of 28

7 Fig. 2: Location of hemorrhage Page 7 of 28

8 Findings and procedure details Diagnostic Imaging Computed tomography Computed tomography (CT) has generally proven helpful for diagnosis of hemorrhage. Multiphase CT examination (unenhanced, arterial, venous and/or delayed phase images) is used to detect bleeding site, evaluate of cause and vascular anatomy, and make preintervention planning (Fig. 3). Unenhanced scan shows acute hematoma as an area of high density. Arterial phase depicts contrast extravasation, pseudoaneurysm, and anatomy of the artery such as aberrant hepatic artery. Venous and delayed phase shows contrast pooling. In addition to multi-planar reconstruction, images are reviewed with maximum intensityprojection (MIP), which is advantageous way to evaluate vascular anatomy and create vascular map. It is important to remember postoperative anatomic changes in the preintervention planning (Fig. 4). Diagnostic angiography If bleeding site is not detected on CT scan, angiography should be performed. Diagnostic angiography with selective catheter position can be useful for detecting arterial hemorrhage. Gastroduodenal artery stump The gastroduodenal artery (GDA) stump is the most common site of bleeding after pancreaticoduodenectomy (PD) (Fig. 5). On the other hand, normal GDA stump can be radiographically similar in appearance to pseudoaneurysm (Fig. 6). Interventional Radiological Treatment Page 8 of 28

9 Interventional radiology has the effect of controlling late PPH in haemodynamically stable patients. Embolization can be performed by coils, glue, or a combination of coils and glue depending on the vascular anatomy, territory, and type of hemorrhage (Fig. 7). Coils are commonly used. It is essential to embolize with coils both the proximal and distal side of the lesion, or bleeding will recur. Glue is suitable for small vessels that cannot be directly catheterized or patient with coagulopathic condition. In cases of pancreaticoduodenectomy hemorrhage In the patients after PD, important nonhepatic collaterals in the hepatic hilum such as the pancreaticoduodenal arcade and periportal route have been ligated. In case of acute occlusion of the common hepatic artery (CHA) or proper hepatic artery (PHA), it would be crucial to preserve the hepatic arterial flow whether hepatic collaterals such as aberrant hepatic arteries are present (Fig. 8). Remaining nonhepatic collaterals arising from such artery as the inferior phrenic and left gastric artery alone cannot provide sufficient arterial supply to the liver, especially when the patients are complicated with unfavorable status such as shock, coagulopathy, and portal vein stenosis. If the bleeding site is the PHA, CHA or the stump of the GDA, stent grafting has the benefit of preserving distal perfusion to the liver and preventing hepatic failure especially for patients without aberrant hepatic artery (Fig. 9). In tortuous vessels, stent grafting can be impossible; therefore, side-hole catheter placement can be useful for preserving distal perfusion to the liver (Fig.10). The arterial flow enters the catheter through side-hole placed in the aorta and exits through the tip of the catheter. CLINICAL CASES: State after pancreaticoduodenectomy Page 9 of 28

10 CASE 1: Right Gastric Artery Stump (Fig. 11) CASE 2: Right Hepatic Artery (Fig. 12) CASE 3: Middle Colic Artery (Fig. 13) State after distal pancreatectomy CASE 4: GDA (Fig. 14) CASE 5: CHA (Fig. 15) CASE 6: Splenic Artery (Fig. 16) Page 10 of 28

11 Images for this section: Fig. 3: Multiphase CT examination Page 11 of 28

12 Fig. 4: Postoperative Anatomic Changes Page 12 of 28

13 Fig. 5: Gastroduodenal Artery Stump Page 13 of 28

14 Fig. 6: Normal Gastroduodenal Artery Stump Page 14 of 28

15 Fig. 7: Embolic Materials Page 15 of 28

16 Fig. 8: Aberrant Hepatic Arteries Page 16 of 28

17 Fig. 9: Stent Graft Page 17 of 28

18 Fig. 10: Side-hole Catheter Page 18 of 28

19 Fig. 11: Right Gastric Artery Stump Page 19 of 28

20 Fig. 12: Right Hepatic Artery Page 20 of 28

21 Fig. 13: Middle Colic Artery Page 21 of 28

22 Fig. 14: Gastroduodenal Artery Page 22 of 28

23 Fig. 15: Common Hepatic Artery Page 23 of 28

24 Fig. 16: Splenic Artery Page 24 of 28

25 Conclusion Preoperative knowledge of the active bleeding site and vascular anatomy is extremely useful for preintervention planning and choice of the most effective device such as coils, glue and stent graft leads to a successful intervention for the management of postpancreatectomy hemorrhage. Page 25 of 28

26 Personal information Tomonori Matsuura, MD, PhD, Department of Diagnostic Radiology, Tohoku University Hospital 1-1 Seiryo Aoba, Sendai, Miyagi, Japan Page 26 of 28

27 Images for this section: Fig. 17: Tohoku University Tohoku University Page 27 of 28

28 References Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007; 142:20-5. Grützmann R, Rückert F, Hippe-Davies N, et al. Evaluation of the International Study Group of Pancreatic Surgery definition of postpancreatectomy hemorrhage in a high-volume center. Surgery. 2012; 151: Welsch T, Eisele H, Zschäbitz S, et al. Critical appraisal of the International Study Group of Pancreatic Surgery (ISGPS) consensus definition of postoperative hemorrhage after pancreatoduodenectomy. Arch Surg. 2011; 396: Stampfl U, Hackert T, Sommer CM, et al. Superselective embolization for the management of postpancreatectomy hemorrhage: a single-center experience in 25 patients. J Vasc Interv Radiol. 2012; 23: Raman SP, Horton KM, Cameron JL, et al. CT after pancreaticoduodenectomy: spectrum of normal findings and complications. AJR Am J Roentgenol. 2013; 201:2-13. Puppala S, Patel J, McPherson S, et al. Hemorrhagic complications after Whipple surgery: imaging and radiologic intervention. AJR Am J Roentgenol. 2011; 196: Raman SP, Horton KM, Cameron JL, et al. CT after pancreaticoduodenectomy: spectrum of normal findings and complications. AJR Am J Roentgenol. 2013; 201:2-13. Sato A, Yamada T, Takase K, et al. The fatal risk in hepatic artery embolization for hemostasis after pancreatic and hepatic surgery: importance of collateral arterial pathways. J Vasc Interv Radiol. 2011; 22: Page 28 of 28