pancreatic resection is a surgical procedure associated with significant morbidity and mortality even at specialised high - volume centres [ 13 ] . although in recent years refinements in surgical technique and perioperative management have led to a reduction in perioperative mortality , the incidence of postoperative complications ( including intra - abdominal abscesses and leakages [ 49 ] , biliary complications [ 1014 ] and vascular complications [ 1518 ] ) still remains high . moreover , in case of complications , surgical re - operation is associated with a high mortality rate [ 13 ] . in a large series of 650 patients , yeo et al . reported an overall mortality of 1.4  % and a morbidity of 41  % , with a mean length of hospital stay of 13  days . they reported re - operation in 26/650 patients ( 4  % ) and identified the absence of reoperation as an independent predictor of prolonged survival . interventional radiology ( ir ) provides a minimally invasive alternative for managing post - surgical complications [ 19 , 20 ] . several different ir procedures , such as percutaneous drainage , aspiration of abscesses or fluid collections [ 4 , 5 ] , percutaneous transhepatic biliary drainage , and arterial embolisation [ 2123 ] have been introduced in clinical practice to treat post - surgical complications . ir procedures are an alternative approach to manage post - surgical complications less invasive than surgical re - intervention , and may lead to a reduction in hospital stay and re - operation rate [ 10 , 11 ] . in the present pictorial review , we offer an overview on the ir procedures that can be performed to treat different types of complications after pancreatic resection . intra - abdominal collections and abscesses represent the most common complication following pancreatic surgery [ 13 ] . once an intra - abdominal collection is identified , in most cases it is possible to place a percutaneous drainage under image guidance . when the collection is well visible using ultrasound ( us ) , us - guided percutaneous drainage placement is generally the preferred choice , as us is widely available , easy to handle and allows for real - time monitoring of the drainage placement , being also free from ionising radiation . when the collection is located deep in the abdomen and is not well seen at us , computed tomography ( ct ) generally offers good anatomical definition to guide the safe placement of a percutaneous drainage . drainage placement can be performed using the trocar or seldinger technique . in the trocar technique , the trocar technique provides a fast deployment of the drainage that can be extremely helpful in critically ill or agitated patients . the seldinger technique implies multiple steps : the collection is punctured with a small calibre needle , different calibre guidewires are inserted and the drainage is then advanced up to the collection over the guidewire . the seldinger technique is particularly helpful when there is a small window to reach the collection , as typically happens when a retroperitoneal collection has to be drained through an anterior approach . the main disadvantage of this technique is that it may require considerably longer time than the trocar technique . the correct location of the needle or drainage can be confirmed by aspiration of a small amount of material . furthermore , a small amount of iodinated contrast may be injected through the catheter to identify the presence of an underlying fistula . in a series of 373 subjects who underwent pancreaticoduodenectomy reported by zink et al . they report an immediate technical and overall success rate of 97.6 and 79.6  % , respectively . a case of a patient with fluid collection after pancreaticoduodenectomy successfully managed with percutaneous ct guided drainage b the fluid collection ( asterisks ) is punctured with a small needle under ct guidance . c a percutaneous drainage ( arrow ) is inserted into the collection ( asterisks ) using the seldinger technique . d at the end of the treatment complete resolution of the collection is obtained use of a percutaneous drainage to treat a post - pancreaticoduodenectomy fluid collection . a ct scan shows post - pancreaticoduodenectomy retroperitoneal fluid collection ( asterisks ) . b the fluid collection ( asterisks ) is punctured with a small needle under ct guidance . c a percutaneous drainage ( arrow ) is inserted into the collection ( asterisks ) using the seldinger technique . in patients treated by pancreaticoduodenectomy with roux - en - y bilio - enteric reconstruction , endoscopical access to the biliary tree is not feasible . thus , in this kind of patient , a percutaneous transhepatic route is the only approach to the biliary system in case of biliary complications . the access to the biliary system is obtained by puncturing a peripheral bile duct under us and/or fluoroscopic guidance . they have been reported in about 34  % of cases after pancreatic surgery [ 13 ] . these complications are often associated with others , in particular with pancreatic fistula and fluid collections . in patients who develop such complication after surgery , percutaneous transhepatic biliary drainage  by allowing for a bile diversion from the site of the fistula  has been proven to be feasible and effective in the majority of cases [ 6 , 20 , 21 ] . the positioning of an occlusion balloon to obstruct the biliary duct above the site of the fistula , by allowing for complete external drainage of the bile , may represent a valuable option to treat post - surgical biliary leaks [ 7 , 10 ] . a different and more recent technique is to use a covered stent that can close the bile leak and subsequently be retrieved percutaneously . used this approach successfully in 11 patients with postoperative bile leak , with no recurrence in the 1-year follow - up . a case of a patient with post - surgical biliary leak successfully treated with percutaneous transhepatic biliary drainage is shown in fig . 2use of a percutaneous transhepatic biliary drainage to treat a post - surgical biliary leak . a percutaneous colangiography demonstrates a biliary leak ( arrow ) and a biliary drainage ( white arrows ) is inserted via segment iii left lobe approach ; rbt right biliary tree , lbt left biliary tree , sb small bowel . b final result with complete healing of the leak and absence of contrast leakage ; rbt right biliary tree , lbt left biliary tree , sb bowel use of a percutaneous transhepatic biliary drainage to treat a post - surgical biliary leak . a percutaneous colangiography demonstrates a biliary leak ( arrow ) and a biliary drainage ( white arrows ) is inserted via segment iii left lobe approach ; rbt right biliary tree , lbt left biliary tree , sb small bowel . b final result with complete healing of the leak and absence of contrast leakage ; rbt right biliary tree , lbt left biliary tree , sb bowel after bilio - pancreatic surgery , stricture of a biliary duct may represent a serious complication , . surgical re - intervention is associated with morbidity and mortality rates as high as 28 and 2.6  % respectively . percutaneous treatments represent an effective alternative to surgery in the treatment of such complication [ 2729 ] . to achieve resolution of the stenosis , subsequent larger biliary drainage catheter may be inserted and left in place and balloon dilation can be performed . however , recurrence of stenosis may occur in up to 2958  % of cases [ 2729 ] , and multiple treatment sessions may be required . stents are rarely used in the treatment of benign strictures , as they have to be removed after a period because the tube itself may stimulate inflammatory reaction , fibrosis and stone formation . a novel option may be represented by the use of biodegradable biliary stents , which may improve the long - term patency rate , without requiring a subsequent procedure for removal . a case of a patient with a post - surgical biliary stricture successfully treated with balloon dilation and placement of a biodegradable biliary stent is shown in fig . 3percutaneous treatment of a benign stricture of the common bile duct by a bioabsorbable biliary stent . radiopaque contrast agent can be detected in the bowel ( b ) ; asterisks dilated bile ducts . the stent is radiolucent , but two platinum , radiopaque markers can be seen ( black arrowheads ) ; asterisks dilated bile ducts , b bowel . d the stent is fully expanded and radiopaque bile can be seen flowing through the patent common bile duct ( white arrowheads ) ; black arrows radiopaque stent markers ; b bowel . e us follow - up at 3  months demonstrating good visibility of the stent ( arrowheads ) that was correctly expanded , and no dilation of the intrahepatic biliary ducts ; l liver percutaneous treatment of a benign stricture of the common bile duct by a bioabsorbable biliary stent . radiopaque contrast agent can be detected in the bowel ( b ) ; asterisks dilated bile ducts . the stent is radiolucent , but two platinum , radiopaque markers can be seen ( black arrowheads ) ; asterisks dilated bile ducts , b bowel . d the stent is fully expanded and radiopaque bile can be seen flowing through the patent common bile duct ( white arrowheads ) ; black arrows radiopaque stent markers ; b bowel . e us follow - up at 3  months demonstrating good visibility of the stent ( arrowheads ) that was correctly expanded , and no dilation of the intrahepatic biliary ducts ; l liver postoperative intra - abdominal arterial haemorrhage is still one of the most serious complications , with a reported incidence between 1.5 and 15  % , and a reported mortality rate of 2050  % [ 1517 ] . early haemorrhage requires immediate laparotomy , as it is generally caused by a technical failure or underlying coagulopathy , while the most appropriate management of delayed haemorrhage still remains controversial . in haemodynamically stable patients , ct is crucial to address the suspicion of a delayed haemorrhage and is extremely useful prior to angiography as it may avoid it or guide it . in unstable patients , direct visceral angiography has been suggested as the best method to elucidate the site of bleeding , with the advantage of sparing time for a subsequent immediate intra - arterial treatment . transcatheter arterial embolisation has been reported to be safe and effective , with a reported success rate of 50100  % , gaining acceptance for the treatment of intra - abdominal bleeding [ 1517 ] . once the site of bleeding has been identified , several different techniques may be used to stop bleeding and achieve haemostasis . in case of terminal vascularisation , a proximal embolisation of the bleeding vessel may be enough to achieve the haemostasis , while in the presence of collaterals , it is crucial to embolise both the inflow and outflow vessels in order to avoid re - bleeding (  isolation technique  ) . different materials are nowadays available to obtain vascular occlusion , and have to be chosen according to the desired type of vascular occlusion ( transient or permanent ) . transient embolisation , generally required due to a traumatic haemorrhage , is reached by resorbable materials , which allows for restoring the blood flow in a variable window of time ( inter alia : autologous blood clot , gelatine or fibrin sponge ) . the main advantage of such materials is to avoid definitive occlusion of the treated vessel . however , a non - negligible risk of re - bleeding has to be considered once the material has been absorbed . permanent embolisation is reached using non - resorbable materials ( polyvynilic alcohol , bucrilate , metallic coils or detachable balloons ) that induce a permanent vessel occlusion . at the present , an ideal material does not exist , thus the choice of the most appropriate embolic material and technique for embolisation , crucial to minimise failure and complications , requires the presence of a ir team with high experience and the availability of several different materials . stent grafting of the artery at the site of bleeding has been proposed as an alternative or in addition to embolisation , with the advantage of maintaining the patency of the end organ , thus minimising the risk of ischaemia deriving from embolisation . a recent meta - analyisis comparing laparotomy and transarterial embolisation for the management of delayed postoperative haemorrhage found a reduction in mortality ( 43  % vs 20  % ) and morbidity ( 77  % vs 35  % ) in the ir group , even if not reaching the statistical significance . authors conclude that the appropriate treatment pathway for late haemorrhage ultimately will be decided by the clinical status of the patient and the institution preference . a case of transcatheter arterial embolisation for a post - surgical haemorrhage 4arterial embolisation of a post - surgical haemorrhage . a ct scan showing contrast extravasation ( arrow ) from the celiac trunk at the level of the bifurcation between hepatic and splenic artery ; b angiographic appearance of the active bleeding with contrast extravasation ( arrows ) ; asterisk celiac trunk , black arrowhead splenic artery , white arrowhead hepatic artery . c angiography after embolisation with coils ( arrows ) demonstrating absence of contrast extravasation at the level of previous bleeding . d ct scan at 2  years , demonstrating absence of contrast extravasation at the level of previous bleeding and preserved patency of proper hepatic artery ( white arrow ) , even in the presence of part of a coil in its lumen ( arrowhead ) ; black arrow clustered metallic coils in the focus of arterial lesion properly embolised arterial embolisation of a post - surgical haemorrhage . a ct scan showing contrast extravasation ( arrow ) from the celiac trunk at the level of the bifurcation between hepatic and splenic artery ; v inferior vena cava , a abdominal aorta . b angiographic appearance of the active bleeding with contrast extravasation ( arrows ) ; asterisk celiac trunk , black arrowhead splenic artery , white arrowhead hepatic artery . c angiography after embolisation with coils ( arrows ) demonstrating absence of contrast extravasation at the level of previous bleeding . d ct scan at 2  years , demonstrating absence of contrast extravasation at the level of previous bleeding and preserved patency of proper hepatic artery ( white arrow ) , even in the presence of part of a coil in its lumen ( arrowhead ) ; black arrow clustered metallic coils in the focus of arterial lesion properly embolised in some cases , post - surgical complications may involve the portal and mesenteric veins , which may develop stenosis or thrombosis after surgical treatment . moreover , with the recent advancement of vascular reconstruction with polytetrafluoroethylene graft , this occurrence may happen more frequently in the future . percutaneous endovascular treatment , such as transjugular portosystemic shunt , direct and indirect thrombolysis , stenting and mechanical thrombectomy , described mainly in liver - transplant patients , may represent a valuable option in the management of these conditions after pancreatic surgery [ 2 , 5 , 18 ] . the access to the portal system may be achieved through a transhepatic route , with the direct image guided puncture of a peripheral portal branch , or through a transjugular approach , by puncturing the portal system from the hepatic veins . transhepatic access is generally easier than transjugular access and represents the first choice strategy in patients with normal coagulation parameters . in patients with thrombosis of the portal or mesenteric vein , in which anticoagulation treatment has been undertaken , the best choice is represented by the transjugular approach , in order to minimise the risk of peritoneal haemorrhage correlated with direct liver puncture . once the access to the portal system has been achieved , it is possible to perform balloon dilation and stenting of post - surgical strictures using the several different commercially available devices . in case of thrombosis , direct trombo - aspiration through a catheter or infusion of trombolitic agents has been reported as a feasible and effective treatment . a case of post - surgical mesenteric vein stenosis and thrombosis treated percutaneously 5treatment of a patient with postoperative mesenteric vein stenosis and thrombosis by percutaneous transhepatic stenting , thromboaspiration , and thrombolysis through a transjugular approach ( the case has been partially previously reported ) . a maximum intensity projection reconstruction of abdominal mdct shows surgical vascular graft ( black arrow ) at the level of the superior mesenteric vein and ascitic fluid ( asterisks ) b percutaneous transhepatic angiography demonstrates stenosis at the level of proximal ( black arrow ) and distal ( white arrow ) anastomoses of the ptfe graft . c angiography after stent placement ( black arrow proximal stent , white arrow distal stent ) demonstrating resolution of the stenosis . d mdct mip reconstruction and e axial image showing intra - stent thrombosis ( white arrow ) and ascitic fluid ( asterisks ) . h complete resolution and calibre restoration after direct thrombolysis with rt - pa treatment of a patient with postoperative mesenteric vein stenosis and thrombosis by percutaneous transhepatic stenting , thromboaspiration , and thrombolysis through a transjugular approach ( the case has been partially previously reported ) . a maximum intensity projection reconstruction of abdominal mdct shows surgical vascular graft ( black arrow ) at the level of the superior mesenteric vein and ascitic fluid ( asterisks ) b percutaneous transhepatic angiography demonstrates stenosis at the level of proximal ( black arrow ) and distal ( white arrow ) anastomoses of the ptfe graft . c angiography after stent placement ( black arrow proximal stent , white arrow distal stent ) demonstrating resolution of the stenosis . d mdct mip reconstruction and e axial image showing intra - stent thrombosis ( white arrow ) and ascitic fluid ( asterisks ) . fistulas are the most common complication following pancreatic surgery after presence of fluid collections [ 13 ] . the most frequent type is pancreatic fistula , followed by enteric and biliary fistulas [ 13 ] . this kind of complication is frequently associated with others , in particular the presence of an intra - abdominal fluid collection . recent reports highlighted how this kind of complication can be successfully managed without surgery in over 90  % of patients . in the non - operative management of such complications , ir plays a crucial role . in presence of a fluid collection , a percutaneously placed drainage may be enough to treat the collection , and in several cases to allow for the spontaneous closure of the fistula [ 4 , 5 ] . if the main component of a fistula is biliary material , the transhepatic insertion of a biliary drainage , by diverting the bile from the site of the fistula , may be enough to determine the fistula closure . in cases with persisting biliary leak , the placement of an occlusion balloon above the fistula , by interrupting completely the bile flow towards the site of the fistula , has been reported as an effective tool [ 710 ] . some authors reported the direct embolisation of the site of the fistula as a feasible and effective procedure . this can be done through a previously placed surgical drainage , through an image - guided percutaneously placed drainage , or even through a transhepatic approach . once the site of the fistula has been reached , several different materials can be used to perform embolisation , including ethanol , particles or different kind of glues [ 3133 ] . inter alia , cyanoacrilic glues seem to represent optimal materials for fistula percutaneous treatment , due to their high adhesive and haemostatic properties and fast polymerisation . a case of embolisation of a fistula with cyanoacrilic glue a , b contrast injection through a previously placed percutaneous drainage ( white arrowhead ) at the level of a fluid collection ( asterisk ) demonstrating a fistula ( black arrow ) with a communication ( small black arrowhead ) with the biliary system and bowel ( b ) ; large black arrowhead percutaneous transhepatic biliary drainage . c a guidewire ( small white arrowhead ) is advanced through the percutaneous drainage ( large white arrowhead ) into the fistula ( black arrow ) ; asterisk fluid collection , black arrowhead percutaneous transhepatic biliary drainage , b bowel . d a microcatheter ( white arrowhead ) is advanced over the wire at the level of the fistula ( black arrow ) , and glue is injected ( white arrow ) ; asterisk fluid collection , black arrowhead percutaneous transhepatic biliary drainage , b bowel successful percutaneous embolisation with cyanoacrilic glue of a postoperative fistula . a , b contrast injection through a previously placed percutaneous drainage ( white arrowhead ) at the level of a fluid collection ( asterisk ) demonstrating a fistula ( black arrow ) with a communication ( small black arrowhead ) with the biliary system and bowel ( b ) ; large black arrowhead percutaneous transhepatic biliary drainage . c a guidewire ( small white arrowhead ) is advanced through the percutaneous drainage ( large white arrowhead ) into the fistula ( black arrow ) ; asterisk fluid collection , black arrowhead percutaneous transhepatic biliary drainage , b bowel . d a microcatheter ( white arrowhead ) is advanced over the wire at the level of the fistula ( black arrow ) , and glue is injected ( white arrow ) ; asterisk fluid collection , black arrowhead percutaneous transhepatic biliary drainage , b bowel ir plays an increasing , crucial role in the multidisciplinary management of complications after pancreatic surgery , providing a minimally invasive therapy also in critical patients , reducing recovery times and avoiding re - operation morbidity . ir procedures such as percutaneous drainage of fluid collections , percutaneous transhepatic biliary procedures , arterial embolisation , venous interventions and fistula embolisation are viable treatment options and have been reported as feasible , safe and effective techniques with fewer complications compared with re - look surgery , with a shorter hospital stay and faster recovery in the management of complications after pancreatic surgery .