Abstract
Pancreatoduodenectomy (PD) also known as Whipple procedure is done for malignant lesions involving the distal CBD, duodenum, ampulla and pancreatic head. In the absence of peritoneal and distant metastases, resectability of the lesion is mainly determined by the relationship of the lesion with the vascular structures in the vicinity. Vascular variations of the celiac artery branches are common and PD, a complex surgical procedure, becomes more challenging if the vascular variations are present. In borderline resectable lesions advances in neoadjuvant therapies and refined surgical techniques are pushing the boundaries of resection. Extended PD is done in borderline resectable lesions when resection and reconstruction of portal vein involved by the primary mass and dissection of extended lymph nodal stations are intended. In this era where more borderline cases are undergoing surgery, it is essential for the radiologist to understand the procedure and the implications of variations in vascular anatomy. Though there are many radiology literatures available on the diagnostic and resectability criteria related to normal vessel anatomy there are very few on the importance of the variant arterial anatomy. The purpose of this review is to familiarize the readers with these variant vessels which can help the surgeons in their intraoperative identification and consequently improve surgical outcomes.
Similar content being viewed by others
References
Tumor-Vessel Relationships in Pancreatic Ductal Adenocarcinoma at Multidetector CT: Different Classification Systems and Their Influence on Treatment Planning | RadioGraphics [Internet]. [cited 2020 Sep 27]. Available from: https://pubs.rsna.org/doi/10.1148/rg.2017160054
Song S-Y, Chung JW, Yin YH, Jae HJ, Kim H-C, Jeon UB, et al. Celiac Axis and Common Hepatic Artery Variations in 5002 Patients: Systematic Analysis with Spiral CT and DSA. Radiology. 2010 Mar 10;255(1):278–88.
Winston CB, Lee NA, Jarnagin WR, Teitcher J, DeMatteo RP, Fong Y, et al. CT Angiography for Delineation of Celiac and Superior Mesenteric Artery Variants in Patients Undergoing Hepatobiliary and Pancreatic Surgery. American Journal of Roentgenology. 2007 Jul 1;189(1):W13–9.
Sahani D, Saini S, Pena C, Nichols S, Prasad SR, Hahn PF, et al. Using multidetector CT for preoperative vascular evaluation of liver neoplasms: technique and results. AJR Am J Roentgenol. 2002 Jul;179(1):53–9.
Furukawa H, Shimada K, Iwata R, Moriyama N. A replaced common hepatic artery running through the pancreatic parenchyma. Surgery. 2000 Jun 1;127(6):711–2.
Wang L, Xu J, Sun D, Zhang Z. Aberrant hepatic arteries running through pancreatic parenchyma encountered during pancreatoduodenectomy: Two rare case reports and strategies for surgical treatment. Medicine. 2016 Dec;95(49):e3867.
Lee J-M, Lee Y-J, Kim C-W, Moon K-M, Kim M-W. Clinical implications of an aberrant right hepatic artery in patients undergoing pancreaticoduodenectomy. World J Surg. 2009 Aug;33(8):1727–32.
Sitarz R, Berbecka M, Mielko J, Rawicz‑Pruszyński K, Staśkiewicz G, Maciejewski R, et al. Awareness of hepatic arterial variants is required in surgical oncology decision making strategy: Case report and review of literature. Oncology Letters. 2018 May 1;15(5):6251–6.
Shukla PJ, Barreto SG, Kulkarni A, Nagarajan G, Fingerhut A. Vascular anomalies encountered during pancreatoduodenectomy: do they influence outcomes? Ann Surg Oncol. 2010 Jan;17(1):186–93.
Goss CM. Blood supply and anatomy of the upper abdominal organs with a descriptive atlas. By N. A. Michels. xiv + 581 pages, 172 figures. $24.00. J. B. Lippincott Company, Philadelphia, 1955. The Anatomical Record. 1960;137(2):153–4.
Yang SH, Yin YH, Jang JY, Lee SE, Chung JW, Suh KS, et al. Assessment of hepatic arterial anatomy in keeping with preservation of the vasculature while performing pancreatoduodenectomy: An opinion. World Journal of Surgery. 2007 Dec;31(12):2384–91.
Pueyo-Périz EM, Sánchez-Velázquez P, De Miguel M, Radosevic A, Petrowsky H, Burdío F. Replaced right hepatic artery arising from the gastroduodenal artery: a rare and challenging anatomical variant of the Whipple procedure. J Surg Case Rep [Internet]. 2020 Jun 1 [cited 2020 Sep 27];2020(6). Available from: https://academic.oup.com/jscr/article/2020/6/rjaa136/5857465
Rammohan A, Sathyanesan J, Palaniappan R, Govindan M. Transpancreatic hepatomesenteric trunk complicating pancreaticoduodenectomy. JOP : Journal of the pancreas. 2013;
Zhang W, Wang K, Liu S, Wang Y, Liu K, Meng L, et al. A single-center clinical study of hepatic artery variations in laparoscopic pancreaticoduodenectomy: A retrospective analysis of data from 218 cases. Medicine. 2020 May 22;99(21):e20403.
Ha HI, Kim M-J, Kim J, Park S-Y, Lee K, Jeon JY. Replaced common hepatic artery from the superior mesenteric artery: multidetector computed tomography (MDCT) classification focused on pancreatic penetration and the course of travel. Surg Radiol Anat. 2016 Aug 1;38(6):655–62.
Chandramohan K, Abdulla FA, Thomas S. Periampullary Carcinoma Complicated by a Transpancreatic Hepatomesenteric Trunk-a Case Report of an Extremely Rare Vascular Anomaly. Indian J Surg Oncol. 2020 Mar;11(1):142-146. https://doi.org/10.1007/s13193-019-01001-9. Epub 2019 Oct 27. PMID: 32205984; PMCID: PMC7064650.
Miyamoto N, Kodama Y, Endo H, Shimizu T, Miyasaka K, Tanaka E, et al. Embolization of the Replaced Common Hepatic Artery Before Surgery for Pancreatic Head Cancer: Report of a Case. Surg Today. 2004 Jul 1;34(7):619–22.
Jah A, Jamieson N, Huguet E, Praseedom R. The implications of the presence of an aberrant right hepatic artery in patients undergoing a pancreaticoduodenectomy. Surg Today. 2009 Aug 1;39(8):669–74.
Yamamoto S, Kubota K, Rokkaku K, Nemoto T, Sakuma A. Disposal of Replaced Common Hepatic Artery Coursing Within the Pancreas During Pancreatoduodenectomy: Report of a Case. Surg Today. 2005 Nov 1;35(11):984–7.
Woods MS, Traverso LW. Sparing a replaced common hepatic artery during pancreaticoduodenectomy. Am Surg. 1993 Nov;59(11):719–21.
Müller P, Randhawa K, Roberts K. Preoperative identification of anomalous arterial anatomy at pancreaticoduodenectomy. annals. 2014 Jul;96(5):e34–6.
CreŢu OM, Hut EF, Dan RG, Munteanu M, Totolici BD, Andercou OA. Replaced common hepatic artery originating from the superior mesenteric artery and prepancreatic, anterior course in a patient with cephalic pancreaticoduodenectomy - case report. Rom J Morphol Embryol. 2017;58(2):553–6.
Peschaud F, El Hajjam M, Malafosse R, Goere D, Benoist S, Penna C, et al. A common hepatic artery passing in front of the portal vein. Surg Radiol Anat. 2006 May 1;28(2):202–5.
Volpe CM, Peterson S, Hoover EL, Doerr RJ. Justification for visceral angiography prior to pancreaticoduodenectomy. Am Surg. 1998 Aug;64(8):758–61.
Allendorf JD, Bellemare S. Reconstruction of the Replaced Right Hepatic Artery at the Time of Pancreaticoduodenectomy. J Gastrointest Surg. 2009 Mar 1;13(3):555–7.
Desai GS, Pande PM. Gastroduodenal artery: single key for many locks. J Hepatobiliary Pancreat Sci. 2019 Jul;26(7):281–91.
Chen J, Ramjit A, Ahmad N.Replaced gastroduodenal artery with continuation as accessory left hepatic artery: a rare anatomical variant. CVIR Endovasc. 2018 Dec; 1: 23.
Younan G, Chimukangara M,Tsai S, et al. Replaced gastroduodenal artery: Added benefit of the “artery first” approach during pancreaticoduodenectomy—A case report. Int J Surg Case Rep. 2016; 23: 93–97.
Song S-Y, Chung JW, Kwon JW, Joh JH, Shin SJ, Kim HB, et al. Collateral Pathways in Patients with Celiac Axis Stenosis: Angiographic–Spiral CT Correlation. RadioGraphics. 2002 Jul;22(4):881–93.
Arc of Buhler: Incidence and Diameter in Asymptomatic Individuals - Wael E. A. Saad, Mark G. Davies, Lawrence Sahler, David Lee, Nikhil Patel, Takashi Kitanosono, Talia Sasson, David Waldman, 2005 [Internet]. [cited 2020 Sep 27]. Available from: https://journals.sagepub.com/doi/10.1177/153857440503900407
Elbanna KY, Jang H-J, Kim TK. Imaging diagnosis and staging of pancreatic ductal adenocarcinoma: a comprehensive review. Insights into Imaging. 2020 Apr 25;11(1):58.
Gaujoux, Sébastien MD*; Sauvanet, Alain MD*; Vullierme, Marie-Pierre MD†; Cortes, Alexandre MD*; Dokmak, Safi MD*; Sibert, Annie MD†; Vilgrain, Valérie MD†; Belghiti, Jacques MD* Ischemic Complications After Pancreaticoduodenectomy: Incidence, Prevention, and Management, Annals of Surgery: January 2009 - Volume 249 - Issue 1 - p 111-117 https://doi.org/10.1097/sla.0b013e3181930249
Pancreatic.pdf [Internet]. [cited 2020 Sep 27]. Available from: https://www2.tri-kobe.org/nccn/guideline/pancreas/english/pancreatic.pdf
Papavasiliou P, Arrangoiz R, Zhu F, Chun YS, Edwards K, Hoffman JP. The Anatomic Course of the First Jejunal Branch of the Superior Mesenteric Vein in Relation to the Superior Mesenteric Artery. Int J Surg Oncol [Internet]. 2012 [cited 2020 Sep 27];2012. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3303700/
Rebibo, L., Chivot, C., Fuks, D., Sabbagh, C., Yzet, T. and Regimbeau, J.‐M. (2012), Three‐dimensional computed tomography analysis of the left gastric vein in a pancreatectomy. HPB, 14: 414-421. https://doi.org/10.1111/j.1477-2574.2012.00468.x
Kawasaki, Kentaro, Shingo Kanaji, et al. Multidetector computed tomography for preoperative identification of left gastric vein location in patients with gastric cancer. Gastric Cancer. 2010 Mar;13(1):25-9.
Brennan DD, Zamboni G, Sosna J, Callery MP, Vollmer CMV, Raptopoulos VD, et al. Virtual Whipple: preoperative surgical planning with volume-rendered MDCT images to identify arterial variants relevant to the Whipple procedure. AJR Am J Roentgenol. 2007 May;188(5):W451-455.
Author information
Authors and Affiliations
Corresponding author
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Appanraj, P., Mathew, A.P., Kandasamy, D. et al. CT reporting of relevant vascular variations and its implication in pancreatoduodenectomy. Abdom Radiol 46, 3935–3945 (2021). https://doi.org/10.1007/s00261-021-02983-3
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00261-021-02983-3