A 64-year-old female patient suspicious of cancer of the pancreatic head with a recent history of acute pancreatitis and cholangitis was admitted to our department for further treatment in April 2012. The patient had had coronary artery bypass surgery, diabetes and arterial hypertension. Laboratory findings revealed cholestasis, and endoscopic retrograde cholangiopancreatography (ERCP) showed a stenosis in the distal bile duct which was highly suspicious of a pancreatic malignancy. Computed tomography (CT) scan and magnetic resonance imaging (MRI) images, 2 months and 3 weeks prior to surgery, were demonstrated by a radiologist in the preoperative conference: a double duct sign, but no signs of metastases were found, and the tumor had contact to the superior mesenteric artery without suspect of a vascular invasion. The patient underwent a classic Whipple procedure (partial duodenopancreatectomy) with regional lymphadenectomy in May 2012. Intraoperatively, the arterial pulse in the liver hilum appeared weak, but flow increased after test clamping of the GDA. Therefore, resection was completed. The dissection of the mesopancreas was performed on the SMA. The pancreatico-jejunostomy was performed according to Warren & Kartell using 4–0 PDS and 6–0 PDS sutures for the duct-to-duct anastomosis. About 15 cm distal to this anastomosis, the hepatico-jejunostomy was done with 5–0 PDS interrupted sutures. The intestinal passage was reconstructed by a gastroenterostomy (3–0 PDS) and a Braun anastomosis using 4–0 PDS. Postoperative transaminases were elevated and peaked on postoperative day (POD) 3 (AST 713 U/L, ALT 1222 U/L). Therefore, abdominal CT with intravenous contrast was performed and revealed a chronic occlusion of both the celiac trunk and the SMA. A large-caliber inferior mesenteric artery (IMA) had strong collaterals to the SMA and celiac trunk. Emergency angiography confirmed chronic occlusion of the SMA and celiac trunk without any possibility for interventional therapy. In the absence of treatment alternatives, continuous alprostadil (prostavasin™) infusion and anticoagulation with unfractionated heparin were initiated and continued over 7 days. During this treatment, transaminases decreased continuously and remained normal thereafter. The final histology revealed a 3.2 cm poorly differentiated adenocarcinoma of the pancreatic head with infiltration of the distal bile duct and the peripancreatic tissue. Moreover, the tumor had spread to 4/18 lymph nodes, and perineural and vascular infiltration were detected (pT3, pN1 (4/18), M0, G3, V1, Pn1, R0). No further complications occurred in the postoperative course. In particular, no signs of intestinal hypoperfusion or anastomotic leak occurred. The patient was discharged 2 weeks after the operation in a very good condition. The patient received 6-months of adjuvant gemcitabine chemotherapy and presented in excellent general condition for a follow-up 12 months after surgery. Two years after surgery, the patient required emergency endovascular treatment (EVAR) of an aortic rupture. The aortic rupture extended from the aortic bifurcation to the renal arteries. At that time, also tumor recurrence was found. The IMA was spared during stent placement in order to preserve intestinal perfusion. After this intervention, the patient received 5 cycles of palliative gemcitabine chemotherapy and later changed to FOLFOX4 in December 2014 due to tumor progression. The patient died 34 months after the pancreas resection.