Endovascular Stent Graft Management of Delayed Post-pancreaticoduodenectomy Hemorrhage: Initial Hemostasis and Rescue Strategy

Pancreaticoduodenectomy (PD) is one of the most complex abdominal surgeries performed. Delayed post-pancreaticoduodenectomy hemorrhage carries a high mortality rate and needs prompt diagnosis with immediate management to prevent a catastrophic outcome. We report endovascular stent graft management of post-pancreaticoduodenectomy hemorrhage that can be treated with a covered stent to achieve immediate hemostasis. We analyzed patients with delayed post-pancreaticoduodenectomy hemorrhage on historical patient records from March 2012 to September 2019. A total of seven patients aged 41 to 69 years were enrolled. Patients were diagnosed using either a computed tomography scan or angiography. During an emergency, all patients were sent to the operation room and received stent graft placement after angiographic diagnosis. Patients were followed up for three months for subsequent clinical conditions. All patients achieved immediate hemostasis after stent graft placement with or without partial coverage of hepatic branches. A patient developed a complication from the initial endovascular attempt and was rescued by a combined surgical and endovascular approach. All complications of post-pancreaticoduodenectomy hemorrhage were treated with surgical intervention, drainage, or conservative management. Subsequent follow-ups showed that all the patients were free of recurrent hemorrhage, stent occlusion, or hepatic failure. Covered stent placement exhibits low mortality and morbidity and is a safe and effective alternative for treating patients with post-pancreaticoduodenectomy hemorrhage under adequate drainage. It facilitates subsequent management with prompt initial hemostasis with preservation of hepatic circulation and may not cause hepatic ischemia even in case of partial coverage of the hepatic artery.