Commonly, complications develop after PD; there is no doubt that PPH is dangerous and fatal. Furthermore, a ruptured pseudoaneurysm is the most severe and fatal cause of PPH [8]. The formation of the pseudoaneurysm is associated with the damage to the vascular wall. Although adequate lymph node dissection and skeletonization of the vessels in surgery may significantly improve the patient’s prognosis, the dissection and skeletonization make the arterial wall weak and vulnerable, which is susceptible to erosion by trypsin and elastase from the digestive juice [9].
We made a systematic review of the literature over the 20 years. This descriptive systematic review formulated its research question based on PICO: P –, Participants, I – Intervention, C – Comparator, O – Outcomes. The inclusion criteria were P: Patients with pseudoaneurysm after pancreaticoduodenectomy (including laparoscopic assisted), I: Common hepatic artery embolization under DSA, C: Surgery, O: Stop bleeding. Type of article: Multicenter clinical trial, RCT,and Original article. The exclusion criteria were: i, Not all conditions are met (only one or more of the search conditions are met). ii, Full text not retrieved. iii, The type of article is case report or review. The search strategy was “(((embolization) AND (common hepatic artery)) AND (pseudoaneurysm)) AND (pancreaticoduodenectomy)”. We systematically searched the following databases: PubMed, Coherane, Elsevier, Science Direct (SDOS), Springer Link, Online library Wiley, EBSCO and OvidEmbase. The initial literature search identified 623 articles and the remaining 25 after reweighting. No relevant text was retrieved from the bibliography. After screening and data extraction, 8 articles were eligible, we added 2 articles by searching citations, and 10 were finally included in this systematic review. Figure 4 is the flowchart of study selection. The information of all articles included is shown in Table 1. Unfortunately, we were unable to retrieve meaningful reports related to laparoscopic pancreatic surgery. From these 10 articles [17-26], A total of 389 postoperative patients has been included. Only 38.5% of patients with pseudoaneurysms occurred in CHA. The average time from postoperative to diagnosis of pseudoaneurysm was 18.05 ± 1.22 days. Coil embolization was used in about 50% of patients. Combining all articles, we found that the use of coil embolization and covered stent are the two most common treatment methods. However, it is still inconclusive which of the two methods is better or worse. Coil embolization is one of the most common treatment methods, which can effectively block the blood supply of pseudoaneurysm, but it is easy to lead to hepatic artery ischemia. However, the covered stent can take good care of the blood supply of the liver, but the cost is high, and it also needs technology and well anesthesia conditions [10].
Then, we analyzed the pathogenesis of this case, which may be related to laparoscopic instrument operation. Especially, the dissociation of vessels and dissection of the lymph nodes caused excessive skeletonization, and then the Hem-o-lock ligation damaged the arterial wall, which may lead to the formation of the pseudoaneurysm in the stump of the ligated artery.
In this case, intraperitoneal hemorrhage occurred after surgery, and the measured drainage liquid amylase was 1480u/L; thus, it was considered that the digestive fluid leak caused by the pancreatic fistula, corroded the blood vessels and eventually led to bleeding. After conservative treatment, there is a possibility of hemodynamic instability that would require emergency DSA examination; the formation of a pseudoaneurysm of the CHA and arterial embolism are also considered. Microcoil was chosen given the hemodynamic instability of the patient; while the liver has a double blood supply, a simple embolism is not likely to cause liver ischemia necrosis. Microcoil and histoacryl embolization were chosen given.
A recent meta-analysis revealed that endovascular treatment of a ruptured pseudoaneurysm had low mortality and morbidity and high success rate than surgical intervention [11,12]. endovascular treatment is considered the first choice in the treatment of pseudoaneurysm recently. Endovascular treatment consists of Transcatheter Arterial Embolization (TAE) and stent-graft placement. Coil embolization as a TAE is an effective approach for the treatment of a pseudoaneurysm [13,14].
In this case, we summarized several experiences for the iatrogenic traumatic pseudoaneurysm. Based on these experiences, we give some possible suggestions on how to avoid and reduce this complication. First, excessive skeletonization of the blood vessels should be avoided, which leads to the injury of the endangium. In addition, when dealing with the stump of the gastroduodenal artery, the lymph node should be proper to avert excessive skeletonization. Second, compression, avulsion, clamping, or stretching of the skeletonization vessels in the laparoscopic operation increases the risk of bleeding and may cause injury of the endangium. Therefore, accurate vascular localization is the key to a successful operation, and improper operation should be avoided especially when ligating the arteries. Third, when using the Hem-o-lock to ligate the artery, it should be closed slowly, which avoids the shearing action to vessels in the closure process, and damage to the arterial stump. Finally, the vessels and lymph nodes should be skeletonized with laparoscopic instruments by blunt dissection. According to our experience, the skeletonization of the blood vessels tends to be covered with an omental flap to prevent hemorrhage after the PD. Several studies [15,16] revealed that the omental flap or falciform ligament placement over a skeletonization of blood vessels could be an effective measure for the prevention of pseudoaneurysm formation after PD.
In conclusion, this case demonstrated the successful experience for the treatment of delayed PPH by TAE. Endovascular treatment is the first choice for the diagnosis and treatment of a ruptured pseudoaneurysm after PD. Although a stent-graft placement is considered a first-line treatment in the endovascular treatment, coil embolization is a reliable, safe, and effective method particularly when unstable hemodynamics of the patient was observed. In a word, when making the treatment plan, the patient’s condition, presentation, and clinical history should be taken into consideration.