Portal Vein Arterialization: A Therapeutic Option for Hepatic Artery Interruption in Pancreaticoduodenectomy
Keywords:
General Surgery, Portal Vein, PancreaticoduodenectomyAbstract
Commonly known as the Whipple’s procedure, a pancreaticoduodenectomy is a surgical operation for aggressive pancreatic cancer with a 10% five-year survival rate, which can potentially provide clearance or control of patient symptomatology. In pancreaticoduodenectomy, injury to major vascular structures such as the hepatic artery can occur, with subsequent high morbidity and mortality related to hepatic complications. This paper describes two cases where damage to major vasculature occurred during a pancreaticoduodenectomy, and portal vein arterialization (PVA) was used as a revascularization option. The first case describes a 69-year-old female who sustained an injury to the common hepatic artery during the procedure. Initial revascularization via direct primary end-to-end anastomosis and a saphenous vein graft were unsuccessful, so PVA was established with success. The second case describes a 52-year-old male who had a segment of the right hepatic artery resected en bloc with the tumor. Initial attempts at end-to-end arterial reconstruction proved futile, and intraoperatively ischemic changes were noted by the surgeon who opted to perform PVA to establish arterial flow. Although multiple options for revascularization of the hepatic artery exist, here we describe two cases where portal vein arterialization is used as a straightforward and successful salvage technique, especially when other options have proved futile.
References
Landen S, Ursaru D, Delugeau V, Landen C. How to deal with hepatic artery injury during pancreaticoduodenectomy. A systematic review. Journal of Visceral Surgery 2017;154:261–8. https://doi.org/10.1016/j.jviscsurg.2017.05.013.
Gaujoux S, Sauvanet A, Vullierme M-P, Cortes A, Dokmak S, Sibert A, et al. Ischemic complications after pancreaticoduodenectomy. Annals of Surgery 2009;249:111–7. https://doi.org/10.1097/sla.0b013e3181930249.
Qiu J, Chen S, Pankaj P, Wu H. Portal vein arterialization as a bridge procedure against acute liver failure after extended hepatectomy for hilar cholangiocarcinoma. Surgical Innovation 2013;21:372–5. https://doi.org/10.1177/1553350613507146.
Shimizu Y, Miyazaki M, Shimizu H, Ito H, Nakagawa K, Ambiru S, et al. Beneficial effects of arterialization of the portal vein on extended hepatectomy. British Journal of Surgery 2000;87:784–9. https://doi.org/10.1046/j.1365-2168.2000.01382.x.
Suzuki O, Takahashi T, Kitagami H, Manase H, Watanabe S, Kondo S, et al. Appropriate blood flow for arterio-portal shunt in acute hypoxic liver failure. European Surgical Research 1999;31:324–32. https://doi.org/10.1159/000008709.
Young AL, Prasad RK, Adair R, Abu Hilal M, Guthrie AJ, Lodge PAJ. Portal vein arterialization as a salvage procedure during left hepatic trisectionectomy for hilar cholangiocarcinoma. Journal of the American College of Surgeons 2008;207:e1–6. https://doi.org/10.1016/j.jamcollsurg.2008.07.019.
Iseki J, Tamaki N, Touyama K, Nakagami K, Takagi M, Toshiyuki O, et al. Mesenteric arterioportal shunt after hepatic artery interruption. Surgery 1998;123:58–66. https://doi.org/10.1016/s0039-6060(98)70229-6.
Otte J-B, Reynaert M, Hemptinne BD, Geubel A, Carlier M, Jamart J, et al. Arterialization of the Portal Vein in Conjunction with a Therapeutic Portacaval Shunt Hemodynamic Investigations and Results in 75 Patients. Annals of Surgery 1982;196:656–63. https://doi.org/10.1097/00000658-198212001-00007.
Kondo S, Hirano S, Ambo Y, Tanaka E, Kubota T, Katoh H. Arterioportal shunting as an alternative to microvascular reconstruction after hepatic artery resection. British Journal of Surgery 2003;91:248–51. https://doi.org/10.1002/bjs.4428.
Lautt WW, Greenway CV. Conceptual review of the hepatic vascular bed. Hepatology 1987;7:952–63. https://doi.org/10.1002/hep.1840070527.
Kim AW, McCarthy WJ, Maxhimer JB, Quiros RM, Hollinger EF, Doolas A, et al. Vascular complications associated with pancreaticoduodenectomy adversely affect clinical outcome. Surgery 2002;132:738–47. https://doi.org/10.1067/msy.2002.127688.
Bhangui P, Salloum C, Lim C, Andreani P, Ariche A, Adam R, et al. Portal vein arterialization: a salvage procedure for a totally de-arterialized liver. The Paul Brousse Hospital experience. HPB 2014;16:723–38. https://doi.org/10.1111/hpb.12200.
Li J, Cai C, Guo H, Guan X, Yang L, Li Y, et al. Portal vein arterialization promotes liver regeneration after extended partial hepatectomy in a rat model. Journal of Biomedical Research 2015;29:69–75. https://doi.org/10.7555/JBR.29.20140054.
Nardo B, Caraceni P, Montalti R, Puviani L, Bertelli R, Beltempo P, et al. Portal vein arterialization: A new surgical option against acute liver failure? Transplantation Proceedings 2005;37:2544–6. https://doi.org/10.1016/j.transproceed.2005.06.093.
Tsuge H, Mimura H, Hamazaki K, Mori M, Kawata N, Orita K. Interruption of hepatic arterial blood flow after resection of pancreaticobiliary carcinoma. Hepatogastroenterology 1995;42.
Miyazaki M, Ito H, Nakagawa K, Ambiru S, Shimizu H, Yoshidome H, et al. Unilateral hepatic artery reconstruction is unnecessary in biliary tract carcinomas involving lobar hepatic artery: implications of interlobar hepatic artery and its preservation. Hepatogastroenterology 2000;47:1526–30.
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Copyright (c) 2024 Madeleine Kelly, Pranavan Palamuthusingam, Peter Lodge
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