1 6 7 9 8 18 9 11 19 22 Patients and Methods n n n n n n Massive postoperative arterial hemorrhage was defined as bleeding requiring a transfusion of 2 or more units of packed red blood cells, an invasive intervention such as laparotomy or TAE and monitoring in the surgical intensive care unit within 24 h of the onset of hemorrhage. The medical records of these patients were analyzed retrospectively. Results 1 Table 1 Baseline Characteristics of Patients Case Disease Origin of bleed Surgery a Site of TAE Re-laparotomy Cause of bleed Outcome 1 Ampullary cancer RHA PPPD 10 RHA No Pancreatic leak Alive 2 Gallbladder cancer  RHA and RHA HPD 8 and 12 RHA and PHA No Minor injury Hepatic failure died 3 Hilar bile duct cancer RHA Extended left hepatectomy 9 None No Unsuccessful reconstruction Cancer recurrence, died 4 Gallbladder cancer GDA HPD 10 GDA No Pancreatic leak Alive 5 Distal bile duct cancer GDA PD 11 GDA Yes Minor injury Alive 6 Distal bile duct cancer CHA PPPD 24 CHA No Pancreatic leak Alive 7 Distal bile duct cancer PHA PD 7 None No Pancreatic leak Sepsis, died 8 Hilar bile duct cancer GDA Right hepatectomy 7 CHA Yes Minor injury Hepatic failure died 9 Gallbladder cancer MHA and GDA Right hepatectomy 13 and 27 MHA and CHA No Pancreatic leak Hepatic failure died 10 Gallbladder cancer GDA Right hepatectomy 7 GDA Yes Pancreatic leak Hepatic failure died 11 Pancreatic cancer SPA DP 17 CA Yes Pancreatic leak Alive 12 Intrahepatic cholangiocarcinoma SPA HPD 9 None Yes Minor injury Hepatic failure died 13 Pancreatic cancer SMA PPPD 34 None Yes Pancreatic leak MOF, died TAE RHA PHA GDA CHA MHA SPA CA SMA PPPD HPD DP PD MOF a After restoration of hemodynamic stability by volume loading, 10 of 13 patients underwent emergency pan-abdominal angiography visualizing the celiac axis (CA) and superior mesenteric artery (SMA) by standard Seldinger technique. The other three patients required emergency laparotomy without angiography because their clinical status was deteriorating. 1 1 Of the three patients with a pseudoaneurysm distal to the PHA, one received selective TAE of the RHA with a successful outcome (patient 1). A second patient had recurrent hemorrhage after TAE of the RHA and second TAE of the PHA was required. Unfortunately, the cluster of coils compressed the portal vein and portal flow was disrupted after the second TAE. This patient died of hepatic failure secondary to hepatic hypoperfusion (patient 2). The third patient had undergone extended left hepatectomy with resection of the RHA and had bleeding from the site of the RHA reconstruction (patient 3). If TAE had been performed at the RHA, inflow to the small remnant liver would be completely interrupted, and fatal hepatic failure would have been the most likely outcome. Instead, we re-operated, ligated the RHA, and created an ileocolic arterioportal shunt to supply the hepatic remnant. The patient survived without hepatic failure. However, portal hypertension developed because this shunt remained patent 6 months after reoperation, and the patient died of spinal metastasis 11 months after the initial operation. 1 2 Figure 1 arrow A B LHA SPA  Figure 2 arrow) A B LHA SPA  3 Figure 3 arrow A B RHA LHA GDA  One patient with a pseudoaneurysm of the SMA underwent surgical resection with vascular reconstruction. However, the patient died of recurrent pancreatic cancer and multiple organ failure during the hospital stay (patient 13). Seven of 13 patients died in the hospital; thus, the mortality rate for massive arterial hemorrhage was 54%, and the overall mortality rate was 2.0%. 1 2 3 Discussion 1 6 4 6 11 12 23 1 4 10 12 10 14 1 3 4 17 3 24 1 2 9 13 2 11 25 15 10 24 6 13 14 16 9 17 10 19 22 21 26 27 28 When the origin of a pseudoaneurysm is the SMA, it may be extremely difficult or even impossible to preserve mesenteric arterial flow. Hence, resection of the pseudoaneurysm with vascular reconstruction is indicated (patient 11). Endovascular stenting may be an alternative deserving further study. 6 1 6 29 33 1 6 29 31 4 Figure 4 MHA LHA SPA GDA CHA CA SMA TAE