Coil-assisted N-butyl cyanoacrylate embolization vs covered stent implantation for delayed hemorrhage in hepatobiliary and pancreatic surgery

Figure 1 Study flowchart. CSI: Covered stent implantation; NBCA: N-butyl cyanoacrylate.

Figure 2 Coil-assisted N-butyl cyanoacrylate embolization for the embolization of the bleeding site (black arrow) after confirming the infeasibility of superselective arterial embolization and covered stent implantation. A: A 3-F microcatheter (light blue) was inserted and advanced through the parent artery (black upward-pointing arrow) distal to the origin of the bleeding artery (black right arrow); B: A detachable coil was placed in the parent artery distal to the origin of the bleeding artery; C and D: An N-butyl cyanoacrylate-lipiodol mixture was gradually injected, with the microcatheter retreating from the coil site up to the parent artery proximal to the origin of the bleeding artery.

Figure 3 Hemorrhage occurring 19 days after pancreaticoduodenectomy for cholangiocarcinoma in a 68-year-old male patient. A: Superior mesenteric artery angiography was performed, and extravasation of the contrast agent (black down arrow) was detected. Subsequently, covered stent implantation was performed; B: The patient experienced rebleeding 5 days after the initial endovascular treatment. Splenic artery angiography was performed, and extravasation of the contrast agent (black right arrow) was detected. Because of the tortuous origin of the splenic and bleeding arteries, superselective arterial embolization and covered stent implantation could not be performed successfully; C: Coil-assisted N-butyl cyanoacrylate (NBCA) embolization was performed successfully; D: NBCA deposits in the targeted bleeding lesion (green arrow) and target- and non-target-organ embolization (blue arrow) were observed in the subsequent imagological examination. Pancreatic and splenic small partial low-density regions (purple arrow) were asymptomatic and self-limited. The patient did not experience rebleeding.