One visceral artery is enough. Pancreatectomy in a patient with total occlusion of the celiac and superior mesenteric arteries

Abstract

Background: The blood supply of the liver is very 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 obstruction of one artery exists in approximately 10-20% of patients, but can often be compensated and therefore usually remains asymptomatic due to this double blood supply. Methods: We report the case of a patient with complete atherosclerotic obstruction of the celiac and superior mesenteric arteries (SMA) who required a resection of the pancreatic head due to cancer. This vascular anomaly was missed on the preoperative imaging and became known postoperatively. A collateral circulation from a hypertrophic inferior mesenteric artery (IMA) to the celiac trunk and SMA compensated the blood supply to the visceral organs. Results: The postoperative course was complicated by an elevation of the liver function tests, 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 IMA was preserved. Conclusion: CT scanning should always include a proper arterial phase in order to evaluate the arterial blood supply to the liver and bowel preoperatively in patients with atherosclerosis.