One visceral artery may be enough; successful pancreatectomy in a patient with total occlusion of the celiac and superior mesenteric arteries
The anatomic variations of the visceral arteries are not uncommon. The liver arterial blood supply shows 50% variability between humans, with the most common anatomy being one hepatic artery arising from the celiac trunk and one pancreatico-duodenal arcade between the celiac trunk and the superior mesenteric artery. Occlusion of one artery are mostly asymptomatic but may become clinically relevant when surgery of the liver, bile duct or the pancreas is required. If these pathologies are not reversible, an oncologic pancreatic head resection cannot be performed.
We report the case of a 64-year-old Caucasian female patient with a locally advanced, resectable adenocarcinoma of the pancreas with complete atherosclerotic occlusion of the celiac trunk and the superior mesenteric artery. This vascular anomaly was missed on the preoperative imaging and became known postoperatively. A collateral circulation from a hypertrophic inferior mesenteric artery to the celiac trunk and the superior mesenteric artery compensated the blood supply to the visceral organs. The postoperative course was complicated by an elevation of the transaminases AST/ALT, which normalized under conservative treatment with alprostadil (prostavasin™) and anticoagulation, since angiographic recanalization failed. The patient recovered fully and was discharged at the 14th postoperative day. Two years later, she required endovascular repair of an aortic rupture during which the inferior mesenteric artery was preserved.
This case underlines the natural potential of the human body to adapt to chronic arterial malperfusion by creating a collateral circulation and supports the need for adequate preoperative imaging, including a proper arterial phase before upper abdominal surgery.
KeywordsPancreaticoduodenectomy Mesenteric arteries Occlusion Celiac trunk
Endoscopic retrograde cholangiopancreatography
Endovascular aneurysm repair
Inferior mesenteric artery
Magnetic resonance imaging
Superior mesenteric artery
Superior mesenteric vein
The blood supply of the liver is variable and only 50% of humans present with a standard vascular anatomy of one hepatic artery arising from the celiac trunk and a pancreatico-duodenal arcade between the hepatic and the superior mesenteric arteries (SMA) . Chronic occlusion of one artery exists in approximately 10–20% of patients, but can often be compensated and therefore usually remains asymptomatic due to the dual blood supply [2, 3, 4, 5]. The most frequent compensation is the hypertrophy of the pancreatico-duodenal arcade .
Asymptomatic occlusion may become clinically relevant when surgery of the liver, bile duct or the pancreas is required; the oncologic resection of the pancreatic head (e.g. Whipple procedure) requires the ligation of the gastroduodenal (GDA), and the pancreatico-duodenal arteries (PDA). Gastrointestinal and biliary anastomoses require adequate arterial flow. Therefore, a celiac trunk stenosis is critical and a complete occlusion is considered a contraindication for many of these procedures.
We report the case of a patient with a locally advanced, resectable adenocarcinoma of the pancreas with complete atherosclerotic occlusion of the celiac trunk and the SMA.
The patient underwent a classic Whipple procedure (partial duodenopancreatectomy) with regional lymphadenectomy in May 2012. Intraoperatively, the arterial pulse in the liver hilum appeared weak, but flow increased after test clamping of the GDA. Therefore, resection was completed. The dissection of the mesopancreas was performed on the SMA. The pancreatico-jejunostomy was performed according to Warren & Kartell using 4–0 PDS and 6–0 PDS sutures for the duct-to-duct anastomosis. About 15 cm distal to this anastomosis, the hepatico-jejunostomy was done with 5–0 PDS interrupted sutures. The intestinal passage was reconstructed by a gastroenterostomy (3–0 PDS) and a Braun anastomosis using 4–0 PDS.
The final histology revealed a 3.2 cm poorly differentiated adenocarcinoma of the pancreatic head with infiltration of the distal bile duct and the peripancreatic tissue. Moreover, the tumor had spread to 4/18 lymph nodes, and perineural and vascular infiltration were detected (pT3, pN1 (4/18), M0, G3, V1, Pn1, R0).
No further complications occurred in the postoperative course. In particular, no signs of intestinal hypoperfusion or anastomotic leak occurred. The patient was discharged 2 weeks after the operation in a very good condition.
Discussion and conclusions
Splanchnic vascular stenosis or occlusion can be caused by a variety of diseases. One of the most frequent causes of a stenosis of the celiac trunk is a hypertrophic arcuate ligament resulting in an extrinsic obstruction of the artery [3, 7, 8], which can usually be solved intraoperatively by dissecting the ligament . Angiographic studies revealed asymptomatic severe stenosis of celiac or superior mesenteric arteries in up to 50% of patients with atherosclerosis, and synchronous severe stenosis of both arteries are present in up to 5% of these patients [7, 10]. A percutaneous transluminal stent placement or even a vascular bypass surgery may be performed to improve the perfusion of the celiac trunk. If these interventions are not feasible, a Whipple procedure is considered impossible. In contrast, the hypertrophic pancreatico-gastroduodenal arcade may be preserved during distal pancreas resection [11, 12].
In this case, the arterial collaterals as consequence of the arterial occlusion were misdiagnosed as venous collaterals during the preoperative conference. Upon postoperative CT scan, the late arterial phase clearly demonstrated the occlusion of both vessels. Due to the chronicity of the arterial occlusion, hypertrophic collaterals, e.g. through the anastomosis of Riolan, had been formed and prevented severe complications. In contrast, the resection of the celiac trunk or the SMA without development of collaterals may have fatal consequences.
In summary, the synchronous chronic occlusion of the celiac trunk and the SMA, as reported in this case, is extremely rare, while cases of occlusion of one of both is well known in the literature. If this arterial situation would have been detected preoperatively, a bypass procedure would have been performed during pancreas resection in order to prevent serious complications, or surgery would have been denied. Although our patient tolerated major pancreas surgery well, procedures impairing the IMA (i.e. left hemicolectomy) could have been lethal for her. Since this arterial situation was well documented, the IMA was preserved during the emergency treatment of an aortic rupture 24 months postoperatively.
Although chronic arterial occlusion can be compensated through collateralization, cases as the above emphasize the importance of proper arterial imaging prior to operations of the upper abdomen. Moreover, careful assessment of the available imaging by trained radiologists is mandatory.
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ET conception and writing of the manuscript as well as assessment of the data. FJ carried out the reconstruction of radiological images and contributed to the radiological findings of the case. HL conception and critical discussion of this case report. SH conception and coordination of this case report. All authors read and approved the final manuscript.
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