Fujioka Shuichi, Suzuki Fumitake, Funamizu Naotake, Okamoto Tomoyoshi, Munakata Koji, Ashida Hirokazu, Yanaga Katsuhiko
Department of Surgery, The Jikei University Daisan Hospital, 4-11-1, Izumi-honcho, Komae City, 201-0003 Tokyo Japan.
Department of Radiology, The Jikei Daisan Hospital, Tokyo, 201-0003 Japan.
Surg Case Rep. 2015;1(1):60. doi: 10.1186/s40792-015-0060-2. Epub 2015 Jul 22.
Hemorrhage from ruptured pseudoaneurysm is a rapidly progressing and potentially fatal complication after pancreaticoduodenectomy (PD). Stent graft placement for hepatic artery pseudoaneurysm has recently been reported as a valid alternative to transcatheter arterial embolization (TAE). We report a case of pseudoaneurysm of the common hepatic artery (CHA) with distal arterial stenosis treated by stent graft placement for pseudoaneurysm and balloon dilation for arterial stenosis due to pancreatic fistula after PD. A 67-year-old man underwent PD for intraductal papillary mucinous neoplasm with concomitant early gastric cancer. After the operation, pancreatic fistula developed, for which conservative management by drainage was continued. On the postoperative day 30, melena started. Emergency abdominal angiography revealed a pseudoaneurysm in the CHA, as well as distal arterial stenosis extending from the proper hepatic artery (PHA) to bilateral hepatic arteries. The portal vein was also stenotic due to pancreatic fistula, for which TAE was not judged suitable because of the risk of liver failure. Therefore, stent graft placement and balloon dilation were chosen. Three pieces of coronary covered stent were placed in a coaxial overlapping manner followed by balloon dilation of the proper and left hepatic arteries. Balloon dilation of the right hepatic artery failed by technical reasons. Completion arteriography confirmed the patency from the CHA to the left hepatic artery as well as the exclusion of the pseudoaneurysm. A liver abscess that developed in the right hepatic lobe after intervention was successfully treated by percutaneous drainage, and the patient discharged on day 27 after stent graft placement. Non-embolic management with preservation of the liver arterial flow may be an option for complicated pseudoaneurysm after PD.
胰十二指肠切除术后（PD），假性动脉瘤破裂出血是一种进展迅速且可能致命的并发症。最近有报道称，肝动脉假性动脉瘤置入支架移植物是经导管动脉栓塞术（TAE）的一种有效替代方法。我们报告一例肝总动脉（CHA）假性动脉瘤合并远端动脉狭窄的病例，该患者在PD术后因胰瘘导致假性动脉瘤采用支架移植物置入治疗，动脉狭窄采用球囊扩张治疗。一名67岁男性因导管内乳头状黏液性肿瘤合并早期胃癌接受了PD手术。术后出现胰瘘，持续进行引流保守治疗。术后第30天，患者开始出现黑便。急诊腹部血管造影显示CHA有假性动脉瘤，以及从肝固有动脉（PHA）延伸至双侧肝动脉的远端动脉狭窄。由于胰瘘，门静脉也有狭窄，因有肝衰竭风险，TAE被认为不合适。因此，选择了支架移植物置入和球囊扩张。以同轴重叠方式放置了3枚冠状动脉覆膜支架，随后对肝固有动脉和左肝动脉进行球囊扩张。右肝动脉因技术原因球囊扩张失败。完成血管造影证实了从CHA到左肝动脉的通畅以及假性动脉瘤的排除。干预后右肝叶出现的肝脓肿经皮穿刺引流成功治疗，患者在支架移植物置入后第27天出院。对于PD术后复杂的假性动脉瘤，保留肝动脉血流的非栓塞治疗可能是一种选择。
