Endovascular approach of hepatic artery pseudoaneurysm after Whipple procedure: Case report and literature review

Introduction and importance: Pseudoaneurysms after pancreatoduodenectomy are an uncommon complication, but they are associated with life-threatening outcomes in up to 50 % due to the development of postoperative bleeding. They usually result as a consequence of local inflammatory processes, such as pancreatic fistula or intra-abdominal collections. The cornerstones of treatment are thus intraoperative management and early identification of the complication.

Case presentation: We present a 62-year-old female patient in postoperative pancreatoduodenectomy due to a periampullary tumor, that presented upper gastrointestinal bleeding which required multiple transfusions. During hospitalization, the patient presented a refractory hypovolemic shock to conservative measures. It was documented intra-abdominal hemorrhage due to hepatic artery pseudoaneurysm that required endovascular management with common hepatic artery embolization, with successful bleeding control.

Clinical discussion: Pseudoaneurysms are the result of tissue damage after surgery. The usual clinical presentation is upper gastrointestinal bleeding unresponsive to conservative treatment that results in hemodynamic instability due to hypovolemic shock. Prevention is currently based on preoperative and intraoperative measures such as nutritional repletion, vessel protection, adequate hemostasis, and prevention and treatment of pancreatic leak and abdominal infection. Once documented, treatment can be endovascular or surgical.

Conclusion: The formation of pseudoaneurysms after pancreaticoduodenectomy is an uncommon and challenging complication. Early diagnosis, risk factor detection and a combined multidisciplinary approach lead to better outcomes, avoiding open surgical procedures that can increase morbidity and mortality rates.