case_images: PMC11419828_01
case_images: (A) Computed tomography angiography (CTA). The axial pre-surgical CTA view showed an inferior pancreaticoduodenal artery (iPDAA) (arrow) in close proximity to the pancreatic head (*). (B) Digital subtraction angiography (DSA). The DSA confirmed a complete chronic occlusion of the coeliac artery (CA), which appeared independent of respiratory movements (not shown). The endovascular revascularisation attempt failed. The DSA further confirmed the iPDAA with a variant arterial blood supply of the liver. The right hepatic artery (RHA) arises directly proximal to the iPDAA from the superior mesenteric artery (SMA).
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case_images: Nevertheless, in line with the computed tomography angiography (CTA) (Fig. 1A), digital substraction angiography revealed a complete chronic CA occlusion (unaffected by respiratory movements), a large-caliber PDA with an proximal iPDAA (Fig. 1B), and a variant arterial blood supply to the liver (Fig. 1B, Fig. 2A and B). The iPDAA was located in close proximity to the origin of the RHA, which originated directly from the SMA (Fig. 1B).
case_images: Schematic illustration of the anatomical conditions. (A) Schematic illustration of the normal anatomical conditions. The spatial position of the pancreas is shown by a hatched area. (B) Pre-surgical anatomical situation. The coeliac artery (CA) was chronically occluded. The right hepatic artery (RHA) arises directly proximal to the inferior pancreaticoduodenal artery aneurysm (iPDAA) from the superior mesenteric artery (SMA). The left hepatic artery (LHA) arises from the CA and is retrogradely perfused from the SMA over the inferior pancreaticoduodenal artery (iPDA) with its proximal iPDAA. (C) Post-surgical anatomical situation. An autologous reversed great saphenous vein aortovisceral bypass was placed to provide antegrade perfusion to the occluded CA. The bypass secured arterial liver perfusion for the time delayed interventional exclusion of the iPDAA by coil embolisation in case of coil associated complications. Red: aortovisceral bypass. GDA = gastroduodenal artery; sPDA = superior pancreaticoduodenal artery; iaPDA = inferior anterior pancreaticoduodenal artery; ipPDA = inferior posterior pancreaticoduodenal artery; saPDA = superior anterior pancreaticoduodenal artery; spPDA = superior posterior pancreaticoduodenal artery; SA = splenic artery.
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case_images: A bypass was created from the aorta to the LHA using a reversed great saphenous vein graft via a median laparatomy and a transbursal approach (Fig. 2C).
case_images: Coil embolisation of the of the inferior pancreaticoduodenal artery aneurysm (iPDAA). (A) Correct position of the coils in the iPDAA during a transfemoral approach for interventional coil embolisation. (B) Digital subtraction angiography (DSA) illustrates the perfusion of the right hepatic artery (RHA) which arises directly proximal to the now excluded iPDAA. DSA also confirmed no thromboembolic event during the procedure. The (inferior) pancreaticoduodenal artery ((i)PDA) was occluded intentionally (the guide wire remained in the vessel).
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case_images: Also, adequate liver perfusion via the open LHA and RHA was confirmed (Fig. 3).