Disposal of Replaced Common Hepatic Artery Coursing Within the Pancreas During Pancreatoduodenectomy: Report of a Case

Abstract

A replaced common hepatic artery (RCHA) originating from the superior mesenteric artery (SMA) is a rare anomaly. We herein report such a case in a 62-year-old man who was scheduled to undergo a pancreatoduodenectomy for lower bile duct cancer. Computed tomography (CT) showed the RCHA to run along the ventral side of the pancreas. Abdominal angiography showed an RCHA originating from the SMA, which communicated with an aberrant left hepatic artery from the left gastric artery. No gastroduodenal artery was observed, but instead a direct ramification of a right gastroepiploic artery was seen. Similar cases from the English literature were reviewed. The RCHA was confirmed to course first along the ventral side of, and then within, the pancreas. Clamping of the RCHA did not influence the arterial flow in the liver, and the RCHA was subsequently divided without reconstruction. In three of the five reviewed cases in which the RCHA coursed either within or along the ventral side of the pancreas, no gastroduodenal artery was found, but instead a direct ramification of a right gastroepiploic artery was observed. A combination of CT and angiographic findings can help in both the diagnosis of an anomalous RCHA coursing either within or along the ventral side of the pancreas as well as in selecting optimal operative procedures. Pancreatoduodenectomy was performed with a curative resection according to our usual practice except for the fact that we preserved the aberrant left hepatic artery.

Clinical Implications of an Aberrant Right Hepatic Artery in Patients Undergoing Pancreaticoduodenectomy

“…A combination of CT and angiographic findings can help in both the diagnosis of an anomalous RHA coursing within or along the ventral side of the pancreas as well as in selecting optimal operative procedures [13]. In our cases, MRCA was the most commonly used method in detecting HA anatomy.…”

“…RHA from SMA may course behind, within, or along the ventral side of the pancreas [13]. In particular, Michels found that half of the RHA actually coursed through the pancreatic parenchyma, whereas the other half passed posterior to the pancreas [14].…”

Implication of the presence of a variant hepatic artery during the Whipple procedure

“…An improper vascularization may delay the restoration of liver function. Different authors recommend arterial reconstruction in case of tumor infiltration or in cases where the intraparenchymal course not ensure an R0 resection (5,10,20,21). There are many arterial reconstructive techniques for the RHA after section.…”

Aberrant Hepatic Artery in Patients Undergoing Pancreaticoduodenectomy

“…The CHA originating from the SMA is very rare, occurring in only one case in our study. Yamamoto et al [18] put forward five methods for preserving the hepatic arterial blood flow when planning a PD for patients with the RCHA coursing in, or along, the ventral side of the pancreas. PD was performed in a usual manner following a dissection of the artery from the pancreatic parenchyma in our patient, as the RCHA coursed along the ventral side of the pancreas.…”