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Celiac Axis Stenosis Caused by Median Arcuate Ligament in Pancreaticoduodenectomy

Taiga Wakabayashi, Emanuele Felli, Patrick Pessaux

We present the images of a seventy-eight-year-old patient affected by a pancreatic head ductal adenocarcinoma with concomitant hemodynamically significant celiac axis stenosis by median arcuate ligament. During the preoperative planning, it was revealed that a proximal portion of the celiac axis was compressed extrinsically and pancreatic arterial arcades were dilated and engorged as a consequence of the acceleration of the collateral blood supply from the superior mesenteric artery. Since treatments for periampullary lesions such as pancreaticoduodenectomy involves resection of these collateral pathways, and the upper abdominal organs with a blood supply originally coming from the celiac artery, there is a risk of postoperative ischemic complications. As of today, routine multidetector computed tomography and three-dimensional arterial reconstruction could be ideal diagnostic options. Besides, if celiac axis stenosis by median arcuate ligament compression is suspected, an intraoperative gastroduodenal artery pre-clamping test can be the only recommended procedure to estimate its significance to assess intrahepatic arterial flow by means of doppler ultrasound. If the pulse or the velocity is unsatisfactory, dissection of median arcuate ligament should be conducted. If the dissection of median arcuate ligament does not improve the blood flow of hepatic artery, a vascular bypass procedure or endovascular stenting should be considered as a bailout procedure.