Functioning arterial or venous riolan arch in localized pancreatic cancer. how it can change tactics?

Abstract

Background: CT are obligatory before pancreatic surgery. Discovery of functioning arterial or venous Riolan arch (FRA) can have substantial influence on tactics. Aim: To assess importance of FRA discloser for decision making before pancreatic surgery. Patients: Retrospective analysis of 554 patients' consecutive preoperative CT data revealed arterial(n2) and venous(n5) FRA in 7 cases. Modification of treatment were assessed. Results: Arterial FRA was found in pancreatic body cancer(n2). 1.atherosclerotic occlusion of CA and SMA with symptomatic abdominal ischemia; 2.tumor involved CA on the background of endoluminally unreсonstructable SMA occlusion. In the first case CA stenting before distal pancreatectomy eliminated symptoms fully. In the second case after FOLFIRINOXn12 R0 DPCAR without SMA reconstruction was done because of good collateral supply. Uneventful postop period, discharge on days 10 and 13. Venous FRA in all the cases of PDAC of the head±body were the sign of full block of all SMV tributaries and already formed outflow through the splenic(SV) and/or inferior mesenteric(IMV) vein. In all these cases efficient neoadjuvant therapy and venous FRA were the weighty argument for pancreatic resection. Thrice it was done without venous reconstruction, twice with IMV transposition in SV, once with SMA resection. Uneventful postop period, discharge on days 10-19. One patient died 44 month (distant mets), the second died 19 months disease-free (MI), others alive 21,18,13,12 and 11 months after treatment. Conclusion: Delineation of FRA before pancreatic surgery is the indication for tactics change: endovascular treatment for arterial FRA and more aggressive surgery in case of venous FRA.