Urgent completion pancreatectomy with non-standard arterial reconstruction in a patient after pancreatoduodenectomy complicated by common hepatic artery pseudoaneurysm: a case report

Postoperative pancreatic fistula is the most frequent complication after pancreatoduodenectomy and the principal trigger of erosive haemorrhage with subsequent formation of arterial pseudoaneurysms in the celiac–mesenteric basin. The vast majority of such pseudoaneurysms arise on a background of an incompetent pancreatoenteric anastomosis through direct exposure of the arterial wall to activated pancreatic juice; formation of an arterial pseudoaneurysm in the absence of fistula and with an intact pancreatoenteric anastomosis is poorly described, and the management of such patients is not standardised. We report a successful management of this rare complication. A 52-year-old female with ductal adenocarcinoma of the pancreatic head (cT3N0M0) underwent gastropancreatoduodenectomy after 8 cycles of neoadjuvant mFOLFIRINOX with achieved disease stabilization; intraoperatively a marked post-chemotherapy desmoplastic reaction was noted in the area of the common and proper hepatic arteries. On postoperative day 5, with an intact pancreatoenteric anastomosis (no rise in drain amylase), the patient developed clinical and CT signs of a common hepatic artery (CHA) pseudoaneurysm. Endovascular implantation of a 7×18 mm stent-graft initially resulted in angiographic haemostasis; however, rebleeding occurred 3 days later and was not amenable to repeat endovascular treatment. Relaparotomy, completion pancreatectomy, splenectomy, resection of the CHA with the pseudoaneurysm and extra-anatomical autovenous bypass from the right common iliac artery to the proper hepatic artery were performed. The postoperative course was uneventful, and follow-up CT confirmed graft patency with preserved hepatic arterial inflow. The case illustrates that arterial pseudoaneurysm after pancreatoduodenectomy may result not only from pancreatic-juice erosion but also from intimal injury during technically demanding peri-arterial dissection. Timely CT angiography at the first signs of an atypical postoperative course and availability of a multidisciplinary team experienced in elective arterial resections are key prerequisites for safe management of such rare complications.