A novel case report of hepatic artery bypass following pancreaticoduodenectomy in the setting of median arcuate ligament-associated celiac artery stenosis

Abstract

Background:

Median arcuate ligament-associated celiac artery stenosis (CAS) is a vascular occlusive condition that is asymptomatic in most individuals. However, it can result in hepatic ischemia in patients undergoing pancreaticoduodenectomy (PD), necessitating advanced surgical intervention. Here, we present the surgical management of a patient with CAS and significant vessel tortuosity prior to PD.

Case presentation:

A 76-year-old White male presented to the emergency department with painless jaundice and was diagnosed with stage 1B pancreatic ductal adenocarcinoma requiring a PD for management. Preoperative imaging revealed CAS secondary to chronic median arcuate ligament compression with significant vessel tortuosity not amenable to endovascular stenting. In anticipation of gastroduodenal artery ligation during the PD, concern for hepatic artery ischemia prompted the need for concurrent vascular intervention.

Discussion:

This case presents a unique situation as concurrent or pre-treatment of CAS was not feasible due to the tortuosity of the celiac artery, precluding the possibility of angioplasty. The use of a reversed autologous great saphenous vein graft to create an aorto-hepatic bypass from the supra-celiac aorta to the common hepatic artery to preserve adequate liver perfusion is an effective solution for patients undergoing PD with CAS and significant vessel tortuosity.

Conclusion:

The presented case illustrates the successful implementation of an aorto-hepatic bypass as an effective technique for performing a PD in the presence of CAS when stent placement is not possible.

Introduction

Celiac axis stenosis (CAS) is an occlusive artery disease that affects nearly 7.3% of patients with hepatic tumors and is primarily caused by median arcuate ligament compression and atherosclerosis[1]. CAS rarely causes complications due to a rich collateral network. However, during a pancreaticoduodenectomy (PD), ligation of the gastroduodenal artery (GDA) disrupts collateral blood flow, potentially making CAS symptomatic. Surgeons must effectively manage the CAS and pancreatic cancer to avoid organ failure from hypoperfusion[2]. CAS in patients undergoing PD has been associated with increased postoperative complications, including hepatic and gastric ischemia, pancreatic fistulas, biliary leaks, prolonged ICU stays, and increased overall morbidity[2]. Classically, treatment options for this condition include decompression through release of surrounding ligaments, angioplasty, stent placement, and bypass grafting[3]. Here, we discuss the case of a patient diagnosed with pancreatic adenocarcinoma and CAS, in whom severe celiac artery tortuosity precluded preoperative endovascular stent placement. He underwent a PD with planned aorto-common hepatic artery (CHA) bypass.

HIGHLIGHTS

• Median arcuate ligament stenosis complicated pancreaticoduodenectomy due to the potential risk of hepatic ischemia.

• Severe celiac artery tortuosity precludes endovascular stent placement prior to pancreaticoduodenectomy.

• Aorto-common hepatic artery bypass ensured adequate hepatic perfusion during pancreaticoduodenectomy.

• Autologous reversed great saphenous vein graft provided durable revascularization.

• Multidisciplinary approach allowed for safe pancreaticoduodenectomy with vascular reconstruction.

Case presentation

Details of the case have been reported in line with the Surgical CAse REport (SCARE) guidelines[4].

A 76-year-old man presented to the outside hospital emergency department with painless jaundice and nausea. Significant past surgical history included an inguinal hernia repair ten years ago. The patient was vitally stable with a soft, non-tender abdomen and no other pertinent physical exam findings. A computed tomography (CT) of the abdomen with contrast revealed dilation of the pancreatic and biliary ducts with an abrupt cutoff at the pancreatic head, raising suspicion for a pancreatic head mass, which was then confirmed by magnetic resonance cholangiopancreatography. Due to symptomatic obstructive jaundice and evidence of biliary obstruction, the patient underwent endoscopic retrograde cholangiopancreatography (ERCP); this identified a malignant-appearing stricture in the common bile duct (CBD) with moderate dilation of intrahepatic and extrahepatic bile ducts. For decompression, a biliary sphincterotomy and stent placement in the CBD were performed. After referral to our facility for further evaluation, the patient underwent repeat ERCP with endoscopic ultrasound, confirming the staging as 1B (cT2, cN0, cM0), and cytology confirmed pancreatic adenocarcinoma. Imaging showed no metastases, and the patient was deemed a candidate for a PD.

Management

This case was discussed at a multidisciplinary tumor board meeting, where a consensus management plan was devised. The patient underwent four cycles of neoadjuvant chemotherapy with gemcitabine and abraxane. Following this, a preoperative CT with pancreas protocol revealed a tortuous celiac artery with severe narrowing at its origin, consistent with chronic median arcuate ligament compression and diagnostic of CAS. The primary hepatic blood supply was through collateral flow from an enlarged GDA and accessory right hepatic arteries (ARHA). Here, it was discussed that either a reno-CHA or an aorto-CHA bypass would be needed, and the risks and benefits of each were discussed with the patient.

Surgery was performed in three stages: tumor resection, aorta-CHA bypass, and reconstruction. Intraoperatively, proper hepatic artery flow was confirmed before ligating the GDA. The pancreatic head was dissected off the superior mesenteric artery (SMA), superior mesenteric vein, and portal vein, with the tumor encasing the ARHA, which was transected for clear margins. Post-resection, the vascular team (two vascular surgeons) came in to inspect the CHA, which did not have a pulse but had sluggish monophasic flow. In lieu of this, the aorto-CHA bypass was chosen as the more appropriate option for bypass. First, the patient’s great saphenous vein (GSV) was dissected using a combination of electrocautery and sharp dissection. The vein branches were ligated with 4-0 silk ties. After a 15 cm segment of vein was harvested, it was doubly ligated at the proximal and distal ends, and the specimen was placed in heparinized saline for the bypass. Following this, attention was directed to the patients’ supra-celiac aorta. Electrocautery was used to take down the right crus of the diaphragm, following which the supra-celiac aorta was dissected, taking care to ensure adequate lateral mobilization. The aorta appeared healthy and was appropriate for vessel bypass. The CHA was then dissected from surrounding structures to expose 4 cm of the vessel. Intravenous heparin was administered and allowed to circulate for 3 min, and an activated clotting time was checked to ensure adequate heparinization. Following this, a side-biting clamp was placed on the supra-celiac aorta, and an arteriotomy measuring 1–1.5 cm was created. The reversed right GSV was anastomosed to the aorta in a running fashion using 6-0 Prolene sutures. Subsequently, a 2 cm arteriotomy was created on the CHA, and the vein bypass was then sewn in using a running 6-0 Prolene suture. After completing the aorto-CHA bypass, pulsatile flow within the CHA was confirmed using a Doppler. Finally, the PD was completed with reconstruction via pancreaticojejunostomy, hepaticojejunostomy, and gastrojejunostomy. The total time for the procedure was 8 h and 34 min and the total blood loss amounted to 650 ml. See Figure 1.

Figure 1.

Series of postoperative coronal CT scans with contrast demonstrating the bypass created between the aorta and the common hepatic artery. (A) Shows the proximal anastomosis of the great saphenous vein graft (red arrow) to the supra-celiac aorta. (B) Demonstrates the proximal bypass graft (red arrow) along with the stenosed origin of the celiac axis (blue arrow). (C) Highlights the mid-portion of the bypass graft (red arrow). (D) Shows the distal anastomosis of the graft with the common hepatic artery (green arrow). CT, computed tomography.

Recovery was uneventful, and the patient was discharged after a 6-day postoperative stay. The patient completed two cycles of adjuvant chemotherapy with gemcitabine and abraxane post-resection, currently takes daily aspirin, and remains well 1-year post-surgery. CT imaging at 1- and 8-month post-surgery confirmed bypass patency without hepatic ischemia and no disease recurrence. Lab results, including liver panels, remained normal.

Discussion

This case demonstrates the successful creation of an aorto-CHA bypass using a reversed autologous GSV graft to maintain hepatic perfusion to be safe and effective during a PD in a patient with CAS due to median arcuate ligament compression and severe arterial tortuosity.

Although CAS remains asymptomatic in healthy individuals, it poses a great risk in patients with pancreatic tumors[5]. Common etiologies of CAS in the general population include median arcuate ligament compression, as in this case, atherosclerotic obstruction, and congenital or idiopathic variations[5]. In the absence of CAS, hepatic arteries arising from the celiac trunk primarily perfuse the liver; however, in CAS, retrograde blood flow through the pancreaticoduodenal arcades and GDA provides arterial perfusion to the liver[6]. During surgical resection of a pancreatic tumor, the GDA is ligated, putting an individual with CAS at risk for hepatic, splenic, and gastroduodenal ischemia[6]. In standard scenarios, the first-line approach to the management of CAS includes MAL release, which can decompress the celiac origin and restore antegrade flow. However, the MAL release still runs the risk of restenosis or thrombosis and necessitates the preservation of collaterals[7]. In prior reports, Yoshida et al and Miyata et al described the use of intraoperative MAL release occasionally combined with arterial reconstruction when flow remains insufficient^[8,9^]. These reports have included anastomoses between the middle colic artery and hepatic artery or the use of a splenic-SMA reimplantation technique to restore perfusion^[8–10^].

Alternatively, preemptive strategies to manage CAS patients scheduled to undergo a PD include treating the CAS beforehand to avoid causing hepatic ischemia^[9,11^]. Endovascular stenting of the celiac axis, either preoperatively or intraoperatively, has been utilized in cases where the stenosis is not due to extreme tortuosity or unfavorable anatomy^[11,12^]. In their report, Guilbaud et al described using an endovascular stent following a failed MAL release, which avoided the need for an open arterial reconstruction[13].

However, the anatomical features in our patient present a unique situation, as concurrent or pre-treatment of CAS with MAL release or endovascular stenting were not feasible due to the patient’s celiac artery tortuosity. This anatomical variation required an alternative intraoperative approach to address both the CAS and the pancreatic tumor concurrently. The decision to create an anastomosis via aorto-celiac bypass using the GSV was made to ensure adequate hepatic perfusion after GDA ligation. This strategy ensured that circulation to the liver was maintained during the PD, thereby preventing postoperative hepatic ischemia. After the specimen resection was completed, the CHA was pulseless and showed sluggish monophasic flow. This, along with prior imaging, which showed a severe extent of stenosis, reaffirmed the need for a more durable solution: revascularization via a planned aorto-CHA bypass using a reversed autologous GSV graft.

Few reports have described this specific approach in the context of PA with CAS. While Balakrishnan et al described an aorto-left gastric artery to CHA bypass in a similar setting, the anatomical configuration in our case warranted direct supra celiac aorta to CHA reconstruction[14]. To our knowledge, very few case reports have detailed this specific bypass strategy using a reversed autologous GSV graft for arterial revascularization during a PD, making this case a meaningful contribution in the rare scenario in which CAS cannot be managed conservatively during a PD.

This case report has a few important limitations to consider. First, 3D vascular reconstructions and intraoperative photographs were not available, which limits the ability to visually convey the technical aspects of the bypass procedure. While postoperative CT imaging provides useful anatomical detail, additional visual documentation could have enhanced the educational value of the report. Second, this is a single-center, single-patient case, and therefore, the generalizability of the findings is limited. Third, long-term outcomes remain unknown, which restricts the assessment of graft durability or oncologic recurrence beyond the immediate postoperative period. Lastly, the absence of direct flow measurements or intraoperative Doppler waveforms at each phase of the procedure limits the objective quantification of perfusion improvement.

Patient perspective

When I was first told I had pancreatic cancer, I was naturally scared. But what I didn’t expect was the added complexity of a vascular issue that made surgery even riskier. The doctors explained everything clearly, and I appreciated the team approach. After the surgery, I was surprised at how quickly I began recovering. It’s been a year now, and I’m thankful to be doing well. I’m especially grateful for the careful planning that went into making sure my liver continued to get proper blood flow.

Conclusion

Here, we highlight the critical importance of preoperative vascular assessment and surgical planning in patients with concurrent CAS and pancreatic head adenocarcinoma. The successful outcome supports that the combined approach of a PD with aorto-CHA bypass using a reversed GSV autograph provides adequate liver perfusion and is an effective solution for CAS, underscoring the importance of a multidisciplinary approach to managing higher risk surgeries for optimal oncologic and vascular results.

Ethical approval

Ethical approval was not required for this case report. It was deemed exempt.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

EAJ was responsible for collecting the data, reviewing patient notes, analyzing images, drafting the article, and revising the final case report. RA and MMMK were responsible for drafting the article and revising the final case report. CJA and VSS were responsible for collecting the data, reviewing patient notes, analyzing images, drafting and revising the case report, and approving the final draft.

Conflicts of interest disclosure

The contributor and authors have no conflicts of interest to disclose.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Edward A. Joseph.

Provenance and peer review

Not commissioned; externally peer-reviewed.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.