A case of successful treatment of ruptured pseudoaneurysm using transcatheter arterial embolization following pancreaticoduodenectomy

今回われわれは膵頭十二指腸切除(PD)後の胃十二指腸動脈の仮性動脈瘤からの出血に対して肝動脈塞栓術(TAE)によって救命し得た1例を経験したので報告する.症例は58歳,男性.膵頭部癌(T3N1M0Stage II B)にてPDを施行し,Child変法で再建された.術後第21病日に突然,腹痛を来し血圧が60mmHg台まで低下した.緊急内視鏡検査を施行したが出血点の同定は困難であった.CTで腹腔内および消化管内に大量の血種･凝血塊が認められた.造影CTおよび腹部血管造影で胃十二指腸動脈断端に仮性動脈瘤が認められたが,明らかな血管漏出像は認められなかった.総肝動脈をマイクロコイルにて塞栓したところ血圧は安定し,塞栓後20病日目に軽快退院した.本症例では上腸間膜動脈から右肝動脈が起始していたため,総肝動脈塞栓後も肝膿瘍や肝梗塞を来すことはなかった.本症例では予兆出血は認められなかったが,未破裂の動脈瘤を早期診断･早期治療するためには術後の比較的早期にCTを行う必要がある.またPD術後の急性腹症では腹腔動脈域での仮性動脈瘤の発生を念頭に置き,瘤破裂に対しては外科･内科･放射線科の緊密な連携が不可欠である.

We experienced a case of postoperative ruptured pseudoaneurysm of the gastroduodenal artery, which could be successfully managed by means of transcatheter arterial embolization.A 58-year-old man underwent pancreaticoduo-denectomy with a modified Child’s reconst-ruction for advanced pancreas head carcinoma(T4N1M0StageIV A).On the 21th day after the operation, suddenly he had an abdominal pain and had a rapid decrease in blood pressure to 60mmHg mark. Emergency endoscopy faild to reveal any sources of bleeding. CT revealed a large amount of hematomas and coagulations in the abdominal cavity and the gastrointestinal tract. Contrastenhanced CT and angiography also showed a pseudoaneurysm on the stump of the gastroduodenal artery, which had no extravasation and was successfully embolized using microcoils. Thereafter his clinical course was uneventful and was discharged on 20 days after TAE. A right hepatic artery branched off from SMA in this case, so there were no appearance of liver abscess or liver infarction after TAE. This case had no clinical symptom of postoperative ruptured pseudoaneurysm. So we probably should perform CT examination at short interval after PD for early diagnosis and early treatment of unruptured pseudoaneurysm. An acute abdomen after PD should be considered possibly due to rupture of the pseudoaneurysm of the celiac artery branches. The cooperation closely among surgery and internal medicine and interventional radiology should be necessary to treat ruptured pseudoaneurysm.

膵頭十二指腸切除術　

仮性動脈瘤破裂　

消化管穿破　

動脈塞栓術　

膵液漏