PMC5786235_01
(a) Enhanced abdominal CT showed a low-density tumor (red arrow), 30 mm in diameter, in the pancreatic head. The superior mesenteric vein (SMV, blue arrow) and gastroduodenal artery (GDA, yellow arrow) were involved by this tumor. (b) Stenosis of the celiac artery (CA) was shown (green arrow). (c) Preoperative 3D CT angiogram showed the development of pancreatic artery arcade and a saccular aneurysm (purple arrow) of the inferior pancreaticoduodenal artery (IPDA), 20 mm in diameter. CHA, common hepatic artery; PHA, proper hepatic artery; SMA, superior mesenteric artery; MCA, middle colic artery.
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Enhanced abdominal computed tomography (CT) revealed a low-density tumor, 30 mm in diameter, in the pancreatic head, and involvement of the superior mesenteric vein (SMV) with the tumor was noted (Fig. 1a). CA stenosis was revealed (Fig. 1b). In addition, the developed arcade of the peri-pancreatic arteries and an aneurysm of the inferior pancreaticoduodenal artery (IPDA), 20 mm in diameter, were found (Fig. 1c).
(a) The median arcuate ligament (green arrow) compressed the CA. (b) Compression of the origin of the CA by the ligament was released. (c) The image shows that the GDA was clamped. (d) We checked the hepatic artery flow under GDA clamping, but the flow had not improved satisfactory.
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After laparotomy we identified the MAL, which had compressed the origin of the CA (Fig. 2a), and Doppler ultrasonography showed that the hepatic arterial flow was hepatopetal, but the common hepatic arterial flow was hepatofugal (no record available). First, the MAL was divided (Fig. 2b). After clamping the GDA (Fig. 2c), the hepatic arterial flow was not satisfactory (Fig. 2d).
(a) The purple arrow indicates the stump of the aneurysm. (b) The image was after reconstruction by end-to-end anastomosis of the GDA and the MCA (yellow arrow). The blue arrow indicates the anastomotic part of the SMV. (c) We checked the hepatic arterial flow after reconstruction, the hepatic arterial signal had increased.
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The IPDA and aneurysm were ligated and divided (Fig. 3a). Arterial reconstruction by end-to-end anastomosis of the GDA and MCA was performed by plastic surgeons (Fig. 3b). After reconstruction, the hepatic arterial signal was improved (Fig. 3c).