A novel case report of hepatic artery bypass following pancreaticoduodenectomy in the setting of median arcuate ligament-associated celiac artery stenosis

Background: Median arcuate ligament-associated celiac artery stenosis (CAS) is a vascular occlusive condition that is asymptomatic in most individuals. However, it can result in hepatic ischemia in patients undergoing pancreaticoduodenectomy (PD), necessitating advanced surgical intervention. Here, we present the surgical management of a patient with CAS and significant vessel tortuosity prior to PD. Case presentation: A 76-year-old White male presented to the emergency department with painless jaundice and was diagnosed with stage 1B pancreatic ductal adenocarcinoma requiring a PD for management. Preoperative imaging revealed CAS secondary to chronic median arcuate ligament compression with significant vessel tortuosity not amenable to endovascular stenting. In anticipation of gastroduodenal artery ligation during the PD, concern for hepatic artery ischemia prompted the need for concurrent vascular intervention. Discussion: This case presents a unique situation as concurrent or pre-treatment of CAS was not feasible due to the tortuosity of the celiac artery, precluding the possibility of angioplasty. The use of a reversed autologous great saphenous vein graft to create an aorto-hepatic bypass from the supra-celiac aorta to the common hepatic artery to preserve adequate liver perfusion is an effective solution for patients undergoing PD with CAS and significant vessel tortuosity. Conclusion: The presented case illustrates the successful implementation of an aorto-hepatic bypass as an effective technique for performing a PD in the presence of CAS when stent placement is not possible.