(1691) Post-Whipple Gastroduodenal Artery Stump Bleeding Presenting as Inferior STEMI

Introduction: Pancreatoduodenectomy (Whipple procedure) involves ligation of the gastroduodenal artery (GDA) to allow for resection of the pancreatic head, distal common bile duct, and parts of the stomach, duodenum, and jejunum. Despite improvements in outcomes, there remains a mortality risk, such as from pancreatic leak or postoperative hemorrhage. Hemorrhagic complications can occur in the early or late postoperative period (first 24 hours versus afterward) and may manifest as intraluminal or extraluminal hemorrhage due to erosion or pseudoaneurysm formation of a vessel, most commonly the gastroduodenal artery stump.

Description: An 84 year old male with duodenal adenocarcinoma invading the head of the pancreas underwent standard pancreaticoduodenectomy. Postoperative course was complicated by delayed gastric emptying and low output pancreatic leak. On postoperative day 13 the patient complained of chest pain with associated diaphoresis and hypotension. Electrocardiogram showed new ST segment elevations in leads II, III, and aVF with ST segment depressions in leads aVL, V1, and V2. He was taken for left heart catheterization however no obstructive coronary artery disease was found. His abdominal drains were later noted to have new bloody output. Given clinical concern for GDA stump hemorrhage, patient was taken for angiography with interventional radiology, confirming active extravasation from a GDA pseudoaneurysm which was successfully stented. Despite hemorrhage control and resuscitation with blood products, the patient developed multi-organ dysfunction and was ultimately transitioned to comfort care. He passed away on postoperative day 16.

Discussion: This patient experienced type II myocardial infarction from hemorrhagic shock, as opposed to a primary cardiac event. Unfortunately heparinization during heart catheterization likely worsened the bleeding. While post pancreatectomy hemorrhage is uncommon, associated mortality is relatively high. A herald bleed, such as blood from an abdominal drain, may suggest impending hemorrhage. GDA stump pseudoaneurysm may be caused by pancreatic leak, and more commonly manifests as massive upper GI bleed. Hemorrhage is usually managed with embolization, as the location posterior to the pancreas anastomosis makes operative control difficult.